With the introduction of the Structural Adjustment Policies in 1991 there has been a major shift in the government’s policy towards social sectors like health. These policies sought to — by way of fiscal austerity measures — cut Govt. spending and subsidies in social sectors, reduce direct taxes, increase administered prices, liberalise trade by reducing tariff rates and providing other incentives for foreign investments, privatise public enterprises, deregulate the labour market, etc. The policies were designed to clear the path for withdrawal of the State from the social sectors like health, education, food security, etc. The ideological barrage associated with the reforms package served to confer legitimacy to the virtues of the private sector and the market. This legitimisation of the state’s withdrawal is a signal contribution of the reforms era. In the process, the supposed inability of the state to sustain funding of education, medical care and public health, programmes for provision of drinking water, etc., seems to have gained acceptance.
Responding to the “Market”
Since Independence there has an been improvement in many areas, both in terms of growth in infrastructure and in terms of their actual impact on the health status of our people. The health services at the time of Independence were a function of the socio-economic and political interests of the colonial rulers. The post – independence era witnessed a real effort at providing comprehensive health care, and in extending the infrastructure of health services. However the improvements in our health delivery system have not kept pace with the needs of a vast majority of our people. So much so that the Govt.’s “Statement on National Health Policy”(1982) was forced to state “In spite of such impressive progress, the demographic and health picture of the country still constitutes a cause for serious and urgent concern.”
Neither the stated commitment of the Government nor its implementation has been able to make a significant dent in the status of health or in health care delivery systems. The major negative trends of an urban elitist bias in medical education and in administration continue and there seems to be no apparent remedy to the training and value orientation of health personnel. Continued emigration of doctors, rush for super specialities, development of corporate hospitals and polyclinics, and an incredibly large and near universal trend to irrational use of drugs are all trends that have intensified in the last 5 decades. The major disease-load of the population and their health status remains largely unaltered.
The major reason for this continued state of affairs is that health services and health care tends to respond to the existing ‘market demand’. The vast health needs of the majority of the people do not figure as part of this demand for there is neither the awareness nor the organization nor their participation in the making of these decisions.
One of the principal reasons for the state of health in India is related to inadequate resource allocation. Even the meagre resources allocated, are not equitably distributed — with a clear bias for urban and metropolitan centres. Of the over 11 lakh medical practitioners of different systems in the country, 60% are located in cities.
Effect of New Policies
It is in this background that the effect of the new policies, being pursued since 1991, need to be viewed. The immediate fallout of the new policies was a cut in budgetary support to the Health sector. The cuts were severe in the first two years of the reform process, followed by some restoration subsequently.
A perusal of Govt. spending on Health in the initial years of the reforms period show that while between 1990-91 and 1993-94, there was a fall, in real terms, of expenditure on Health care both for the Centre and the states, it was much more pronounced in the case of the states. In this period there was a compression of total developmental expenditure of state governments. Thus expenditure, in real terms, for state governments plummeted in 1991-92 and 1992-93, and just about touched the level of 1990-91 in 1993-94. This squeeze on the resources of states was distributed in a fairly secular fashion over expenditures incurred under all developmental heads. Health care was a major casualty as the share of states constitutes a major portion of expenditure. A similar kind of squeeze in resource allocation was felt in all programmes, largely financed by the states, including water supply and sanitation. In contrast even in the worst “resource crunch” years, the almost exclusively centrally funded family planning programme fared much better.
Compression of funds available with states is likely to have had a number of other far reaching effects. Generally, expenditures on salaries tend to take up an inordinately large part of total expenditure. Salaries constitute 70-80% of expenditure for most major programmes, and the trend is most distorted in the case of rural programmes, viz. rural hospitals and primary health centres. Faced with limited funds, while salaries still require to be maintained at previous levels, the burden of cutbacks are increasingly placed on supplies and materials. Ultimately a skeletal structure survives, incapable of contributing in any meaningful manner to amelioration of ill-health.
Expenditure patterns on health care are grossly skewed in favour of urban areas. Expenditure cuts further distort this picture with the axe on investment falling first on rural health services. As a result of this rolling back of state support to health care the first major casualty in infrastructure development has been the rural health sector. There has been a perceptible slowing down in infrastructure creation in rural areas.
The extent of cuts in health sector funding by the state and the consequent impact, as part of the reform process, are in a sense peripheral issues. The central issue that needs attention is the theoretical underpinning of the reform process vis a vis state involvement in social sectors like Health. It is important to note that structural adjustment policies are geared to restructure the economy in a certain manner and not to improve welfare measures. Reforms initiated in this country and elsewhere start from the premise that present levels of subsidies to the social sectors are unsustainable. So prescriptions for restructuring of the health sector are designed, not to provide the best possible health care but to maximise outputs from greatly reduced state support.
India’s situation in terms of spending of Health Care is different from most developing countries on two counts. At 6% of GDP spent on health care, India spends more on health care in percent terms than most developing countries. At the same time, at 21.7%, government spending of the total expenditure on Health Care, India is one of the lowest in the world, both in actual terms as well as in percentage terms. Health spending in India is thus already heavily distorted in favour of the private sector. It should be understood that the extremely low level of public funding in India is not a new phenomenon. In fact successive Five Year Plans have shown a fall in percentage terms, in budget allocation for health care.
There has been little effort towards sustained investments to build up health care infrastructure in the country. To be fair, periods of stagnation have been punctuated by sporadic efforts to enhance public health funding. Mention may be made in this context of the National T.B. and Malaria programmes of the fifties and sixties and the Primary Health Care Programme in the late seventies and early eighties. In the case of all these programmes, much of the earlier gains were frittered away as the initial infrastructure created was not supported in later years by matching investment. In fact between 1985-86 to 1990-91 there was already a major slow down or decline in State expenditures on Medical and Public Health. This was more glaring in the case of capital expenditures for setting up of new infrastructure.
Misplaced Emphasis on Vertical Programmes
This is not to suggest that optimal use has been made of public health expenditure in the country before the reforms process. In fact, quite to the contrary. Much of the blame for what is today being termed the “resurgence of communicable diseases” lies in strategies adopted well before the reforms programme in the country. These strategies relied on various centrally administered programmes (vertical programmes) for disease control and prevention. Such programmes included the National programmes on Tuberculosis, Malaria, Leprosy, Immunisation, Diarrhoeal diseases, Blindness and Family Planning. With no integration at the level of delivery, these programmes were insensitive to local conditions, unresponsive to local needs, highly bureacratised and inefficient. These programmes were accountable to officials situated in the national and state capitals, and had little or no scope for flexibility based on local conditions. Local populations were indifferent and in some cases hostile to such programmes, resulting in fair measure to the very poor utilisation of Government health facilities in many areas.
Family Planning Programme – Targeting Women
The prime example of vertical programmes undermining the Health Care programme in the country has been the country’s family planning programme. This programme has been a major obsession for planners in this country. However, a dispassionate assessment of the programme in its four and a half decades of existence raises many interesting issues. Female sterilisation accounts for about three-fourths of contraceptive prevalence in India. Male methods account for only 6 percent of current contraceptive use. Only 5.5 percent of couples use reversible modern contraceptive methods. Total acceptors of contraception constitute just 43% of couples in the child-bearing age group. Even this is likely to be a major overestimation, linked to over reporting – a bane of the target oriented approach – and to the fact that a large part of this figure is made up by tubectomies conducted on women towards the fag end of their reproductive life.
Indirect evidence too indicates that the programme can hardly be held responsible for the few success stories in population planning in the country – Kerala and Tamil Nadu. Kerala’s success in achieving results comparable to the developed world – vis-à-vis both demographic and health indicators – have been widely attributed to factors such as high minimum wages, land reforms, high literacy rates and access to universal health care. Much of Tamil Nadu’s success in pegging down birth rates in recent years is being attributed to improved child survival due to the massive statewide feeding programme for undernourished children and improved communication facilities. Both experiences strengthen the maxim that “development is the best contraceptive”.
Family planning strategies have tended to be paternalistic, prescriptive and coercive. It is a strategy which starts from the belief that the poor breed prodigiously and it is the nation’s duty to cap their unbridled fertility. Such programmes are inappropriate not only because they victimise women, but also because they do not work. Such a strategy has undermined the effectivity of the general health care infrastructure as well as the faith that women have in this infrastructure to address their real concerns. Most programmes, have tended to view women as assembly line appendages required to produce babies. Thus a woman’s health becomes important only when she is pregnant or lactating. But in India 65% of deaths in women are due to infection related causes and only 2.5% of deaths are related to childbirth. Even among women in the reproductive age group only 12.5% of deaths are due to childbirth associated causes. Gender discrimination starts very early. Girls are more likely to die than boys, between the ages of 1 and 5 years. The risk of dying at that age is 43% higher for girls — one of the largest sex-based mortality differences in the world.
India’s new population policy talks of a new Reproductive and Child Health (RCH) package, which shall replace earlier mechanisms. As the name itself suggests, the concerns are with reproduction and not health. The gaze of the programme is still firmly fixed at women as targets. Nomenclature notwithstanding, the new policy carries within it the basic core of earlier policies, which made them unacceptable to large sections of women in this country. Women need access to family planning services because of their own health needs. But such access has to ensure that women have a choice, that women are in a position to make decisions about their choice. In order for a policy to centre-stage women’s concerns and needs, it should revolve around a package that addresses women’s health in all its dimensions and not just their wombs.
There is basic assumption that women’s health status in India is low because they bear too many children. But figures clearly show that developing countries from S.America, Asia and Africa with significantly higher fertility rates are able to demonstrate much better health conditions for their women. In India the bogey of population is a convenient ploy to hide the class and social bias of the Indian state, which discriminates against poor women, both because they are poor and because they are women.
The Ugly Face of Malnutrition
A major determinant of the morbidity and mortality load in the country is malnutrition. 63% of children in India suffer from some form of malnutrition — this adds up to a staggering 75 million children, that is more than 40% of the estimated 170 million children in the world suffering from malnutrition. Of these, 30 million suffer from severe malnutrition. Probably because the statistics are so staggering, we have developed a defence mechanism towards an unpleasant reality. While Infant mortality and Under Five mortality rates are reported to be on the decline, these rates conceal the ability of the modern State, armed with the tools provided by modern science, to maintain a much larger number of people at a level of bare subsistence.
Oblivious to the trends discussed earlier, the government has geared itself towards the show-casing of the “market orientation” of health care policies. Investment in the private hospital sector was very low in the 1970s, but since then it has grown at an exponential rate. This was fuelled by a slowing down of investment by the State and simultaneous incentives given to the private sector in the form of soft loans, subsidies and tax exemptions. In recent years new medical technologies have further added to the impetus, with increasing participation from the Corporate sector. This coupled with the impending entry of insurance multinationals, has cleared the path for the Indian health care sector being taken over by forces that control the global “market” for health care. In the process, the health needs of an overwhelming majority of Indians are being increasingly ignored.