Indicators that matter: On the quality of public healthcare -Soumitra Ghosh
Governments must be judged on the quality and extent of the public health care they provide
The deaths of more than 70 children in one hospital in Gorakhpur and 49 in Farrukhabad, both in Uttar Pradesh recently, reflect the appalling state of public health in India. However, it needs to be remembered that India’s public health care sector has been ailing for decades. According to the latest Global Burden of Disease Study, which ranks countries on the basis of a range of health indicators, India has the 154th rank, much below China, Sri Lanka and Bangladesh.
Though ‘health’ is a State subject, — implying that the primary responsibility of providing quality health services to the people lies with the States — States have been reducing their health-care spending efforts in relation to total government spending. In 2013-14, the per capita public expenditure on health in U.P. was ?452. Such low spending cannot be expected to deliver much. The number of primary health centres, the first point of contact for patients in the rural areas of U.P. went down from 3,808 in 2002 to 3,497 in 2015. The gravity of the situation is understood better when we juxtapose this with the 25-30% increase in the State’s population during the same period. These statistics show that health has never been a political priority in the State. The patterns of public expenditure on health show that the provisioning of curative care through hospitals received disproportionate policy significance, ignoring overwhelming evidence that it is preventive health care and public health actions (for example, to prevent infection by providing clean drinking water) that have brought down periodic episodes of infectious disease outbreaks or epidemics. thus, prolonging the lives of people significantly in industrialised nations and elsewhere. Scientific discoveries, technological improvements that have occurred in the last century and government efforts to improve sanitation and hygiene, not only high and middle income countries but also many low income countries have successfully controlled infectious diseases. Today, in those countries, very few parents ever experience the death of a child unlike in most Indian States where people live with the misery of seeing some of their children die due to preventable causes. The government’s lack of understanding of the importance of public health has played the most important part in U.P.’s health predicament.
While the under-provisioning of health care including public health services continues in some States that were directly under the control of the British Raj, those that were once princely states such as Kerala and that had caught the attention of the world with their outstanding health achievements have not been providing enough resources to health since the late 1980s. It is no wonder then that the situation has gone from bad to worse. Health care continues to be treated like any other private good in this country, although it has certain features that make it on a par with a public good. That is why instead of leaving it to the ‘invisible hand’ of the market, governments around the world became deeply involved in health care. The prominent role of governments in health care goes back as far back as the 1880s when German Chancellor Otto Von Bismarck established a national health-care system to gain political advantage over the Socialist Party. After World War II, most governments in Europe became extensively involved in health care. A notable example is the National Health Service, a publicly funded health-care system in the U.K., set up in 1948. Government health spending now accounts for 80-90% of total health expenditure in most countries of the European Union and North America; public expenditure contributes to less than 30% of the total health expenditure in India.
As public health-care provisioning becomes more limited and the quality of services deteriorates, people are left with no option but to seek services from private providers, knowing well that the end result could be financially ruinous. Every year, around 60 million people become impoverished through paying health-care bills in India. Worse, more than a fifth of people do not seek health care, despite being unwell, because of their inability to pay for it.
What can we learn from the global experience? The experience from other nations that have done relatively well in health suggests that political commitment to health is a prerequisite for improving the health scenario of any country. Thailand, Cuba or Costa Rica have achieved universal health care, although they have taken different routes. While Thailandmay not be the best example to follow, it has some important lessons for India. For instance, Thailand has enacted a law to make quality health care a constitutionally guaranteed right. Unlike in India, where the Right to Education Act has been reduced to mere rhetoric, Thailand has undertaken structural reforms in the health sector to achieve the goals stated in the Health Act. Even before it started reforms to attain universal health coverage, it began massive investments to build public health facilities in rural areas. For about seven years, the Thai government channelised a greater amount of public resources to the rural areas than to in the urban places. Like Thailand, China, Ghana and other many low and middle income countries have also in recent years steadfastly augmented the public health-care system’s capacity through increased funding. Cuba did the same thing many decades ago. Health care is a right there and the government assumes the fiscal and administrative responsibility of ensuring access to free health care.
The Cuba story
The health indicators of Cuba are similar to that of developed countries. With an infant mortality rate of 4.2 per thousand births, this socialist country is among the top three performers in the world. But this was not the scenario five decades ago. In 1959, the infant mortality rate in rural areas was 100 per thousand live births and half of Cuba’s doctors and hospital beds were in Havana. The rural areas had all the problems that U.P. and other underdeveloped States in India still have. Besides poverty and mass illiteracy, undernutrition was rampant and health inequalities were pervasive. However, Cuba’s turn-around story is now acknowledged and its health-care system has become a model for other countries. This was made possible as the country’s leadership recognised the importance of public health, which essentially means addressing the social determinants of diseases (for example, improving the living conditions of the people) and developing a health-care system based on preventive medicine and not curative care.
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The Hindu, 9 September, 2017, http://www.thehindu.com/opinion/op-ed/indicators-that-matter/article19646168.ece?homepage=true