The neglect of the public health system in India and its fallout on successive generations have often been discussed. Health indices reflect painfully slow gains. Most Indians seem convinced by the recurring themes of being a poor nation and thus being unable to afford their own health. The word ‘afford’ has become part of the national health lexicon ever since the Bhore Committee (1957) submitted its report on the structure of health services that could benefit India. That determination of ‘unaffordability’ has pushed many people into the market to go and buy their own health.
The economy has multiplied in size many times over but we continue to remain a ‘poor nation’ when it comes to funding health. The dominant cause is the inability to translate non-economic, non-metric but strong human attributes such as empathy and sympathy into reasons for funding health. Ironically, the poor health of individuals is now held responsible for delivering an ‘underperforming’ economy, as if that were the purpose of health.
The economy is a composite and generated by the collective effort of all in various walks of life. Citizens pay directly and indirectly into national taxes, but allocating those revenues for the proven health needs of the population has many layers of difficulties. There is certainly no reverse-coercive mechanism available to citizens to increase budgetary allocation for long-established and proven interventions that are known to mitigate mortality or morbidity.
We thus remain in ‘developing nation’ status and will likely be so as long as we do not consider it respectable and honourable to prioritise the bio-health of those who generate the economy.
Unsatisfactory budgetary allocations have led to accumulated unmet needs over the decades in both the care-seeker and care-giver fraternity. Lack of capacity creation from under-funding has led to an inability to utilise funds, which argument is then used to deny additional resources. This institutionalised neglect manifests periodically as ‘freak’ disasters, while other forms of neglect continue to consume lives invisibly. Clearly, human biology cannot be put on hold awaiting economic logic, understanding and sanction to come on par.
Unfortunately there are no cut-and-paste models available that would allow us, or any other nation, to import and deploy an entire health eco-system solution. Nations that have large allocations do not provide equitable or cost-effective care.
There are diverse reasons why monetary allocation for health care has stagnated but a historical analysis of past allocating behaviour suggests it will continue to be so. It is not that our GDP needs to improve or health services should become cheaper. The health budget is deemed to be largely unproductive investment. This perception is false as the manner in which public health benefits are realised remain unquantifiable in traditional economic metrics. A one-year change in life expectancy or dip in the IMR (infant mortality rate) by one percentage point can cost sums that can potentially unbalance the sheet of the government exchequer.
The sense of despondency in those engaged in the health economy is a result of the same reason that is praiseworthy in other sections of the economy, namely, profit. Serious consideration must be given to creating a new financial institution to cater for national health needs and priorities -- an institution not driven by profit but built to be sustainable for those that seek care and those who provide it. Many sectors of the economy have special ‘vehicles’ built for their revival, but the health sector is merely allotted money. Activities in the proposed health eco-system would derive revenue from the diverse set of goods and services in the health sector that human populations currently consume but in a non-exploitative manner. Such a transparently governed system should be driven by the idea of continuity and sustainability rather than profiteering. Including investments from the formal economy with realistic growth expectations can serve as a driver rather than be the one and only source of expenditure. The challenge of making biological care equitable can be started and maintained in earnest by making it independent of economic vacillations.
T he author is an orthopaedic surgeon with a major hospital facility in Chennai.
