Yes, we can raise the standard of people below the poverty line but how?
By: Simran Martha
Tags: Crisis, Solutions, India, Poverty

Healthcare:

Is health purely a function of human biology or available technology — one that stresses disease, diagnosis, cure, or management of symptoms — known as the biomedical perspective? Is it a function of our social reality as stressed by the social perspective of health, or is it a combination of both as is stressed in a holistic perspective of health? Health services by themselves are a highly complex entity. They operate either as clinical or as public health services. Clinical health services are individualized services to those who seek medical attention, where the provider offers the best technology available or within the means of the patient.

Public Health Services: Skewed And Crumbling

India has a mixed system of services which includes modern as well as traditional systems. The health providers range from modern-day medical professionals to practitioners of traditional medicine. Then there are the paramedical personnel and traditional providers. Modern medical services are offered by the State as well as by the NGO and private sectors.

Though there are more medical care institutions in the private sector, the public sector continues to have a greater number of beds, despite its slow growth. By the end of the 20th century, there were a total of 15,501 hospitals. Of these, 10,848 were private institutions, an overwhelming majority. But the private hospitals had only 2,53,437 beds out of a total of 6,81,643 beds. This shows that the larger institutions still remained with the public sector.

Critical Gaps in Health Services:-

According to the Health Information of India 2004 report, out of the 6,39,729 doctors registered in India, only 67,576 are in the public sector; as many as 5,72,253 doctors are either in the private sector or abroad. This creates a tremendous shortfall in the states where a large number of posts remain vacant. It is a similar story with general nurses and midwives and Auxiliary Nurse Midwives (ANM).

To fill in this gap the government is trying to integrate manpower from available alternative systems that constitute a significant number.

Health Indicators: Unable to Reach out to the Poor

When we compare the morbidity and mortality profiles in India against the infrastructure and investments in health, the picture is not very impressive. Marginal declines in morbidity and mortality or stagnation seem to be the only achievement. In fact, it seems to be an achievement fraught with poor recording and misreporting.

Vaccine-preventable infections of childhood flourish. Dengue, pneumonia, enteric fever, viral hepatitis, and other infections have not subsided, along with other communicable diseases.

Impact of Reforms: Making the Poor Expendable:-

The weakening of the food security system, unemployment, and loss of subsistence undermined the inter-sectoral approach to health planning; Primary health care was reduced to primary level care thus excluding the supportive responsibility of secondary and tertiary care institutions; Primary level care got further narrowed down to essential clinical and essential public health care. Its components were defined by the World Bank which had little to do with assessing the epidemiological needs of the people. A focus on reproductive health made women the agency for population control. Thus, reproductive technologies of fertility control and infertility cure got a boost. Medical care got into the hands of the private sector, which had no obligation to follow prescribed procedures for monitoring, data pooling, and standardized treatment. It disrupted national disease control programs. Access to services due to rising costs as well as the quality of care remained variable in the absence of any formal mechanism to monitor the expanding private sector — either laid down by the private sector itself or by the State. Family welfare and AIDS control programs acquired a major position in health planning that was now guided by the priorities of donors. Decentralization of services was imposed and interpreted as provisioning by several independent providers and not a delegation of responsibility and answerability to a central authority.

Non-Treatment on the Rise:-

The main cause for non-treatment remains economic, as people do not have the resources to afford treatment, and lack of finances as a reason for non-treatment increases from 10 % of the respondents to 26 % across deciles.

Non-availability of services is another key reason for not seeking services. The 60th round of NSS confirms the qualitative insights that the poor try their best to save their families and often resort to private treatment, but their use of it is largely restricted to general wards and free beds that are very limited.

The average expenditure per delivery in private and public hospitals is markedly different with the former charging three or four times more.

The Politics of User Fees: Serves The Rich, Keeps The Poor Out

Other than privatization, the single largest cause of pushing away the poor from public hospitals is user fees. User fees were introduced with the idea that middle-class users would rather shift to private hospitals if they had to pay a user fee at the entrance to public hospitals. This would leave public services more for the poor.

User fees are actually preventing the poor from accessing the only facilities that are somewhat within their reach. Many benefits of user fees are trotted out officially, one being that they contribute to resource mobilization.

First and foremost, there are no established norms about the utilization of the amount collected as user fees. In some states the amount goes to the state treasury fully or partially, in others, it is the Chief Medical officer who decides what is to be done with it.

In some others, it may be a wider group of the hospital committee that decides. Nowhere do representatives of different sections of the hospital staff contribute to this decision-making process. The competing needs of patient care, diagnostics, emergency requirements, facilities for attendants, and hospital sanitation are often overlooked by the need to beautify the hospital or its offices.

Hospitals that manage to collect substantial amounts are those that are in a position to offer good services. If at all they can reinvest, they further improve their services. This process completely bypasses those institutions that are resource-starved, have poor finances and are therefore not chosen by people who can pay. Thus, unless a system of sharing resources comes into being, institutions that function poorly shall continue to do so as their user fees collection would remain negligible.

Gender Justice:-

In assessing the status of health and health services, the health status of women and their access to health services requires special attention. Given the patriarchal structure of society and gender differentials in education, work opportunities, participation in labor, and decision-making powers, it is inevitable that when it comes to getting a share of scarce family resources, women are invariably left out at critical junctures.

The low sex ratio of the girl child, high maternal mortality (4–5/1,000 live births), and poor share of women in health expenditure of the family as they mostly go to the traditional healer or local practitioner and less often to the doctor, makes it clear that special attention needs to be paid by the health services to ensure their coverage.

Strategies To Meet The Challenges: The Way Forward

● Facing squarely the task of building infrastructure for public health in a way that comprehensive primary healthcare becomes a reality. This would mean developing an integrated health system that strengthens the primary, secondary, and tertiary level care and emphasizes inter-sectoral linkages such as food availability (public distribution systems), drinking water supply, sanitation, public transport, housing, etc. Tertiary level public services are critical not only to provide referral services to the deserving but also to set up basic minimum standards of tertiary care that are effective and efficient within the epidemiological requirements of the country. Without this monitoring or regulation of the private sector by the State is not possible.

● Given the experience with user charges, it is clear that they harm the marginalized sections and do not improve the overall efficiency of state institutions given their very low proportion in the total resource requirement. User charges therefore must be removed.

● The only way out is to increase the overall investment levels and not delay this already accepted principle. Instead of shifting subsidies to the private sector the same could be used to strengthen the public sector. For additional resources, the possibilities of health cess or a national insurance system need to be debated.

● The epidemiological basis of many of the vertical programs in existence needs a thorough re-examination as evaluation studies bring out their strategic weakness both in terms of their technological choices and their structural coherence. In other words, priorities need to be re-set.

● The commitment to integration must be fulfilled, especially in the case of vector-borne disease control programs. Organization and management according to the epidemiological need should be the guiding principle.