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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