Avoiding doctor-centric health solutions

The old adage ‘health is wealth’ was given legitimacy by no less a personage than Professor Jeffrey Sachs, who in 2000, chaired the World Health Organization’s Commission on Macroeconomics and Health (CMH). The CMH report brought forth indisputable evidence of the link between health, development and wealth, arguing that neglect of health entails real costs to the economy — in terms of household expenditures incurred on buying drugs rather than nutritious foods, investments for hospitals rather than factories that generate jobs and impair growth due to reduced productivity and so on. As these impacts are not as easily perceptible as say the closure of a factory, they are routinely forgotten in policy dialogues in India.

Immediate concerns

The Bharatiya Janata Party’s stunning victory raises two >immediate concerns: one, the focus on economic growth visualised in terms of physical infrastructure to the exclusion of the social sector, namely health and education; and two, the ideology of ‘minimum government and maximum governance’, so often stated by Narendra Modi in his election speeches. Such a formulation may be appropriate for economic sectors but in the context of health, it could imply a government reneging from its duty to provide primary health care, both preventive and curative, and universal access to public goods like piped water, nutrition and sanitation.

The economic growth and development dialogue needs to centre round the human capability dialogue — that it is the educated and healthy that create wealth, not the illiterate and sick. And given that health markets are plagued by failures due to asymmetry of information, state intervention becomes imperative for ensuring access to public goods. In other words, no country can be “shining” or “incredible” with a balance sheet that shows 40 per cent of its >children malnourished, 69 per cent defecating in the open and less than 30 per cent having access to piped water in rural areas, productive lives being cut short by tuberculosis and other infections, and emergence of non-communicable diseases affecting the rich and poor alike.

There is little doubt that the nation’s health is in a critical state and needs immediate attention. The compulsions of earlier coalition politics resulted in soft pedalling on substantive issues that directly impacted outcomes. As each crisis loomed, a knee-jerk policy response was provided. While the United Progressive Alliance government can legitimately take credit for having finally eliminated polio, reduced by half the incidence of HIV/AIDS and accelerated the reduction in maternal and infant mortality, it failed to take hard decisions on two vital issues: the availability and quality of human resources in health and forging intersectoral linkages with social deteriments viz water, sanitation and nutrition.

Doctor-centric approaches serve vested interests in opening more medical colleges in the absence of systems that make them accountable to the quality of the product they produce. The manner in which the private sector is given easy passage to open medical colleges is no less a scam than the 2G — the “presumptive loss” to be calculated in terms of the consequences an unsuspecting patient could face due a poorly trained doctor. In fact, the recent report of U.K. removing from its rolls a large number of Indian doctors due to inadequate training hardly behoves well for India claiming its place in competitive global health markets. Achieving aspirational goals of Universal Health Coverage and the more immediate ones of arresting disease and bringing down morbidity will be dependent on initiating reforms related to assuring the quality of our doctors, our ability to paramedicalise primary care, the effective utilisation of technology and the active engagement of the lay public in the governance of health.

The >new government has the onerous responsibility of making up for lost time. It is creditable that Mr. Modi seeks inspiration for his growth model from China and Japan >rather than the U.S., which is a high-cost, specialist-driven model. China and Japan did not jump into health rights or health security for all without first attacking the causal factors responsible for ill-health. China started its “healthy China” narrative by first ensuring simpler and more basic services like access to water and toilets, good nutrition, access to public health at the community level and promotive health for forming sanitary habits like drinking boiled water, bringing to mind Mr. Modi’s call for instilling the values of cleanliness and hygienic habits in his >thanksgiving speech in Varanasi. The difference in outcomes between China and India (in the table) will explain the importance of the paths we have chosen.

The question boils down to choices in resource allocations. Achieving universal access to the basket of public goods listed above requires an estimated Rs.10.8 lakh crore against which the Planning Commission has barely allotted 40 per cent during the 12th Plan period. Primary health care is itself underfunded — just meeting the National Rural Health Mission standards needs 3 per cent GDP against which hardly 1 per cent is being allotted.

The new government must undertake institutional reform to assign to the >different layers of governance their functional responsibilities.

Highest priority must be accorded to resource allocation for public goods and implementation must be monitored at the Prime Minister level. Attention to water and sanitation alone will bring down morbidity and mortality by half and improve public health in a manner that doctors, medicines and hospitals may not be able to do.

Issues such as pricing, patenting, international agreements, quality control and regulation of drugs must be integrated and a cohesive drug policy formulated.

Multiple >schemes related to nutrition — the Public Distribution System, food law, mid-day meal and Integrated Child Development Services programmes — must be revamped and integrated. This will reduce wastage and duplication.

The relationships between public and private sector in health, between the Centre and States, between the various hierarchies of human personnel such as doctors, nurses and paramedics, and between allopathy and other systems of medicine must be reworked through a broad and consultative process, which will reduce duplication and enable more cost-effective use of resources.

Finally, central funding must be provided to States (conditional to good governance) in terms of a State policy on human resources — training, recruitment and deployment and establishment of systems that ensure the synchronisation of all inputs.

India does not need any more reports. What is needed is sheer hard work to implement recommendations already available.

(Sujatha Rao is former secretary, Ministry of Health, Government of India.)

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Printable version | Sep 27, 2021 8:27:45 AM |

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