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Resource centre on India's rural distress
 
 

That Healthy Feeling by SL Rao


Monica Das Gupta is a senior social scientist at the World Bank. Her field research in Punjab, when she was at the National Council of Applied Economic Research, established that sex differentials in child mortality in rural Punjab persisted despite relative wealth, socio-economic development including rapid universalization of female education, fertility decline, and mortality decline. Amartya Sen’s writings drew attention to female foeticide and infanticide in Asia that led to “missing” female millions in the population totals of Asian countries. He calculated that excessive female mortality accounted for a six to 11 per cent deficiency in the total number of women. This gender bias should be reflected in household health expenditures on females.

The NCAER used its large (at that time 500,000 households) sample that studied purchase and ownership of household consumer goods to find out. It found evidence of discrimination against females, a reluctance among the rural poor to use free government health centres except for illnesses requiring hospitalization, a lack of doctors and medicines in the centres and bribing by the poor. The rural health provision was ineffective and, while ostensibly free, also expensive. But was poor medical delivery the only reason for the worse health outcomes in India as against many Southeast Asian countries? Das Gupta’s work showed that Southeast Asian countries, unlike India, emphasized preventive aspects of healthcare like safe drinking water, sanitation and so on.

Two recent well-researched papers by her and five others for the World Bank give insights into the gaps in the total healthcare in India, examine how Tamil Nadu achieved superior health outcomes, and suggest policy and systemic changes to achieve the Tamil Nadu results in other states. The essence of her findings is that Indian Central government policies since the 1950s, though well-intentioned, have inadvertently weakened the capacity to deliver population-wide preventive health services. India in the 1950s amalgamated medical and public health services. Keeping these services separate gives better results as is illustrated by the paper on healthcare in Tamil Nadu.

Successive decisions at the Centre have diminished the health ministry’s capacity for stewardship of the nation’s public health. At the state level, they have introduced policies and fiscal incentives which have inadvertently de-prioritized public health systems and the public health workforce’s capacity, at both managerial and grassroots levels. There are many possible ways of organizing effective public health systems. Das Gupta’s suggestions require the least modification of existing structures and systems.

She finds that Central government health policies have marginalized public health services. There has been undue emphasis on single-focus programmes. These erode public health systems.

Single-focus programmes started with malaria eradication. Such programmes (however well-intentioned) have encouraged state governments to put public health services primarily to such use. The other major mistake was to amalgamate all male grassroots health workers (Das Gupta says they are most suitable for such work) as multi-purpose workers.

The Union health ministry has to build its capacity to support public health systems across the country. A simple step would be to establish a focal point for public health in the health ministry. The ministry staff would require some training in managing health systems. This focal point must be supported by institutions with the autonomy to function effectively. They could be the Indian Council of Medical Research or the National Institute for Communicable Diseases, but with more power to give incentives to the staff and to hold it accountable.

This focal point could help the ministry to encourage state governments build up their public health systems. A basic requirement is a public health act. A blueprint exists. The ministry must encourage innovations in public health approaches, create a platform to encourage, discuss, reward and replicate innovations, and engage in continuous advocacy for public awareness.

Inter-sectoral coordination mechanisms at both federal and local levels must work as well in normal times as they seem to do in responding to public health emergencies. They must therefore regularly assess potential health threats and plan actions for averting them. The health sector could, for example, help ensure that urban development projects ensure adequate arrangements for drainage, sanitation, and solid waste management. The health agencies at all levels could also facilitate and monitor services provided by other agencies that are essential for good health, such as drinking water and sanitation.

State governments could re-establish separate services for public health distinct from medical care, each with its own budgets and workforce. They must each be oriented to population-wide public health and clinical services respectively. Each service must have its own career opportunities and incentives. Tamil Nadu and Sri Lanka have done this to great effect.

This change would cost little. In Tamil Nadu, training to revitalize the public health managerial cadre is required for only one per cent of government doctors. New public health training schools being opened by the Public Health Foundation of India could draw on the good models available (including Tamil Nadu and Sri Lanka) for training public health managers. The training is to enable managers respond to routine health hazards as well as freak events like a tsunami. They will need periodic updating with new technical information.

The government must revitalize the grassroots male health worker cadre. Its duties must focus on ensuring environmental health and other population-wide health services. States where this cadre is dying could establish a new cadre of well-trained and well-managed health inspectors, with a standardized training curriculum. Detailed job descriptions, manuals, and supervisory guidelines, scope for progress, rewards to those who obtain additional educational qualifications in public health will help to build an effective cadre.

The use of public funds for health needs re-evaluation. Tamil Nadu, by better administration and management of resources, makes better use of grassroots male health workers and thus enhances public health outcomes.

Much is possible, especially given the scope for innovation offered by the large Central outlays for rural and for urban health. The National Rural Health Mission and the National Urban Health Mission can significantly increase the utilization of health facilities. Thus, in urban areas, much can be achieved to improve urban health outcomes, by focusing on environmental and public health, and not only on expanding the network of public clinics.

The Central government could link its fiscal support to states’ health budgets to phased progress in enactment of state public health acts, the establishment of separate public health directorates, the revitalization of grassroots public health workers, and health department engagement in assuring municipal public health. The proposed strong focal point for public health at the Centre would help support the states in setting up robust public health systems. Tamil Nadu has separated medical and public health services. There are enormous synergies from an integrated approach to addressing public health threats, not distracted either by the requirements of managing hospitals or by the fragmentation of public health services into single-issue programmes.

Tamil Nadu has a separate directorate of public health staffed by professional public health managers with firsthand experience of working in both rural and urban areas, with its own budget, and with legislative underpinning. This system has a full workforce including non-medical specialists and labourers. Tamil Nadu’s health department, with a specialized cadre and a clear, focused mandate, is much better placed to protect public health than a more generalized cadre distracted by other (clinical) activities.

To earn the demographic dividend that India eagerly anticipates, we must implement Das Gupta’s recommendations for improving healthcare.
 
The author is former director-general, National Council for Applied Economic Research