India's ailing public health services
Financial Express, 4 July 2006
The Eleventh Plan Approach Paper correctly notes that rural health
care in most states in India is marked by absenteeism of
doctors/health providers, low levels of skills, shortage of medicines,
inadequate supervision/monitoring and callous attitudes. There are
neither rewards for service providers nor punishments to
defaulters. As a result health outcomes in India are worse than
bordering countries like Sri Lanka and South East Asian countries like
China and Vietnam.
The failure of the health system is leading to a visible decline in
outomes. Immunisation rates in India were already low by international
comparisons, worse than even those for countries like Bangladesh and
Cambodia. A recent report shows that immunisation of children in India
declined sharply from an already low 52 percent in 1998-99 to 44.6
percent in 2002-03. The two rounds of household surveys on the state
of maternal and child health care, conducted by the Reproductive and
Child Health Program of the World Bank, show serious failures in
public health services in India. Out of 274 districts, child
immunisation declined in 197 districts. Routine polio, DPT and measles
declined in 191, 199 and 153 districts.
The data on antenatal care and assisted deliveries is apalling. Though
the pecentage of deliveries assisted by health workers went up from
39.6 percent in 1998-99 to 47.5 in 2002-03, the percentage of women
delivering in public health facilities declined from 24 percent to
18.5 percent. The increase took place in deliveries in the private
sector, where they rose steeply from 9.4 percent to 21.5 percent.
Ironically, women in "better placed states", which presumably have
better access to public health facilities, are using them less. In
Andhra Pradesh, the percentage of women delivering in public
institutions declined by 9.8 percent, in Kerala by 28.9 percent, in
Karnataka by 10.2 percent, in Maharashtra by 9.1 percent and in Tamil
Nadu by 15.3 percent. Further, the number of women who received post
natal care by public health workers (ANM) through home visits within 2
weeks of delivery also declined from 14.1 percent to 12.7 percent.
The maternal mortality rate in India -- 407 deaths per 100,000 live
births - compared with 56 in China and 46 in Sri Lanka. There may be
many factors that explain the evidence thrown up by the RCH report
such as literacy and empowerment of women, but as recent studies on
the health sector in India have shown, the biggest issue is the job
security of health staff, which leads to a lack of interest in doing
work for patients.
The Plan document notes that there is a shortage of health staff. But
does hiring more public sector health workers contribute towards a
more healthy population? A study in Udaipur titled 'Wealth, health and
health service in rural Rajasthan' by Banerjee, Deaton and Duflo
conducted between January 2002 and August 2003 shows high absenteeism
by public health workers. 45 percent of medical personnel are absent
in subcentres and aid posts. 36 percent are absent in the (larger)
Primary Health and Community Health Centres.
An absent nurse meant that the subcentre had to be closed because
subcentres are often staffed only by a nurse. Hence, subcentres were
closed 56 percent of the time during regular hours. Subcentres were
open not merely infrequently, but also unpredictably. Patients thus
often choose not to walk the approximate half an hour from the average
village to the closest public health centre.
The consequence is predictable. As the Planning Commission's midterm
appraisal of the 10th Plan observes, "when people first seek treatment,
an estimated 70-85 percent visit a private sector provider for their
health care needs". However, as the midterm appraisal says, "the poor
avail of the costlier services provided by the private practitioner,
even when they have access to subsidised or free public health care,
due to reasons of distance, but most importantly, on account of the
unpredictable availability and very low quality of health care
services provided by the rural public primary health sector."
The Plan Approach paper suggests that the way out may be to empower
Panchayati Raj institutions to manage, administer and be accountable
for health services in community levels. The success of this strategy
may hinge on whether health workers contintue to have permanent
government jobs or get paid by the health care they provide and
patients they see.
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