Unhealthy State

Poor facilities India’s per capita healthcare expenditure is lower than that of Chile and Thailand Photo: AP

IN MUCH of the world, health authorities fear the spread of is bird flu the most. Not so much because birds become ill and die off in large numbers, worrisome though it is, but because the spread of bird flu carries with it concerns that these might be early signs of the next influenza-style pandemic. The point of killing sick birds is to control the spread of avian influenza, because scientists worry that the virus could mutate and gain the ability to spread from humans to other humans – which, mercifully it cannot yet do. This ability is the remaining precondition for the start of a pandemic.

The prospect of another pandemic is horrifying. The Spanish Flu of 1918-19 killed 40 to 50 million people within the space of a year. In fact, according to some estimates, it killed more than 10 million people in India, lowering agricultural production by more than three percent. Yet, in India, it’s hardly the single-most important concern for health authorities.

Quite the reverse, in fact. As a 2005 World Bank report highlighted, the lack of a proper public health system represents both a significant danger and a huge economic cost that often gets overlooked. The report details the costs of having poor systems to safeguard public health. Unlike the fee-for-service model that has mushroomed in India, as in many other countries, a public health system is geared toward preventing disease by maintaining sanitation and food standards.

If the economic cost of the lack of a public health system are not obvious, they can be calculated by looking at the loss sustained by the 1994 outbreak of the plague in Surat, estimated at around $1.7 to $2 billion. That outbreak was the result of poor sanitation, a health issue that costs India an estimated Rs 2 billion in treatment for related ailments and Rs 3 billion in terms of lost working days.

Even more important, the World Health Organisation (WHO) annual health report, published late last year, highlighted the problem of the commercialisation of healthcare. Originally an urban phenomenon, small-scale unregulated fee-for-service healthcare offered by a multitude of different independent providers now dominates the healthcare landscape, from sub-Saharan Africa to the transitional economies in Asia or Europe. Healthcare is, therefore, reduced to a commodity, bought and sold on a fee-for-service basis, without regulation or consumer protection.

As it is, India does not fare especially well, either in its per capita spending on health, nor even in the bang for its health buck, as shown by indicators such as mortality rates of children under five years of age. India’s total health expenditure per capita in 2006 was $109, compared to countries that had the most success in reducing mortality rates of children under five: Chile’s total health expenditure per capita was $697, Malaysia’s was $500 and Thailand’s was $346.

Even among countries with similar spending, India fared worse than, say, Mongolia, which had a total per capita health expenditure of $149. What is perhaps even more shocking is that India underperformed a country such as Tajikistan, with a total health expenditure of $71 — far less than India’s $109. In fact, Tajikistan has a Health-Adjusted Life Expectancy (HALE) that is 4.3 years less than that of Sweden. This figure is less than the difference between Sweden and the US.

An example from the WHO report is illustrative. A Delhi housewife needs to visit a doctor. She chooses to go to a clinic close to her home that advertises the services of a “Gold Medallist, MBBS”. But the doctor our Delhiite actually meets was trained in traditional ayurvedic medicine through a long-distance course, because the gold-medallist has ‘franchised’ out her name. The example is familiar to all of us, even those who pay hundreds of rupees to see doctors who, one finds out later, deign to meet only their VIP patients.

India now has the largest privatised health system in the world, with about 80 percent of treatments paid for by users. While India’s elite hospitals and clinics market themselves to medical tourists from developed countries, the poorest 20 percent of Indians have a mortality rate that is twice that of the richest quintile.

The sudden onset of serious illness in a family is one of the biggest reasons for indebtedness. Perhaps, the solution is not more loans for poor farmers, but better healthcare at the most basic level?

The costs of poor public conditions include reduced attraction for investors and tourists; continued expenditure on combating diseases which should have become history by now, such as dysentery and cholera; and labour productivity foregone, the World Bank report concluded. The poor pay a high price in debility, reduced earning capacity and death. The rich, who may not die as often from communicable diseases, nevertheless suffer repeated episodes of morbidity, which are reflected in high rates of stunting amongst their children, says the report.

“Generally, any family can take afford to take care of basic ailments. When it comes to surgery, that means multiples of ten thousand rupees,” says Kadaba Vasuki, General Manager of Narayana Hrudayalaya, the micro insurance program that would become Karnataka’s Yeshasvini Co-operative Farmers Health Care Scheme. For 10 rupees per person per month, cooperative farmers can get OPD consultations, discounted diagnostic tests and are covered for surgical treatment.

Perhaps the most surprising outcome of the micro insurance program is that the highest number of surgeries conducted under the program is hysterectomies, Dr. Vasuki said, noting that women play a trivial role in getting health facilities.

Diseases that should have been eradicated long ago include malaria: in the 1950s, India came very close to becoming malaria free, but that’s not something we discuss very often now, is it? Similarly, although India is making tremendous progress in eradicating polio, the fact remains that it is one of four countries in the world where polio remain endemic. The other three are civil warwracked Afghanistan, unstable Pakistan and Nigeria. Significantly, our smaller, poorer, neighbour Bangladesh is not on the list.

By some estimates, India has spent Rs 25 billion on the polio eradication campaign till 2005. But, as some pediatricians argue, the missing element in the campaign is the focus on public sanitation: the polio virus, which causes permanent paralysis, is spread through faeces and infected water, which is particularly problematic in a country such as India, where people have little access to proper toilets. There isn’t any cure for polio; the only way to curb the disease is to prevent it.

AS IF there weren’t enough bad news, UNICEF’s State of the World’s Children 2009 underscores the troublesome state of affairs in India. More than 99 percent of maternal deaths have occurred in developing countries and maternal mortality ratios strongly reflect the overall effectiveness of health systems, which in many low-income developing countries suffer from weak administrative, technical and logistical capacity, inadequate financial investment and a lack of skilled health personnel. Although half of maternal deaths took place in Sub-Saharan Africa, India stands alone, single-handedly accounting for 22 percent of the global total.

In contrast, Sri Lanka is a story of success against the odds of a protracted civil conflict as well as the devastation of the 2004 Tsunami: Sri Lanka’s maternal mortality ratio declined from 340 per 100,000 live births in 1960 to 43 per 100,000 live births in 2005. In fact, 98 percent of births now take place in hospitals. It’s enough to make one wish for our very own Michael Moore, although an Indian Sicko might make for some really difficult viewing.


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