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, India has the 154th rank, much below China, Sri Lanka and Bangladesh.
Though ‘health’ is a State subject, 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 Rs. 452. The number of primary health centres, 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 that have brought down periodic episodes of infectious disease outbreaks or epidemics. Scientific discoveries, technological improvements and government efforts to improve sanitation and hygiene have successfully controlled infectious diseases globally. 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 had outstanding health achievements have not been providing enough resources to health since the late 1980s. It is no wonder then that the situation has deteriorated. 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. 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; 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.
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. Thailand has made quality health care a constitutionally guaranteed right, having undertaken structural reforms in the health sector to achieve 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.
The Cuba story
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 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. However, Cuba’s 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 and developing a health-care system based on preventive medicine and not curative care.
If we want the people of this country to enjoy a health status that is commensurate with that of their counterparts from other middle-income countries and in the region, not only should there be more resources available for health, but also the government’s approach towards health needs to be radically changed.
Soumitra Ghosh is Assistant Professor, Centre for Health Policy, Planning and Management, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai