The Indian Express (Delhi Edition)
Wanted: A Fairy Godmother
India’s development story does not include its healthcare system. A detailed analysis of what ails it and how it can be put back on track
THE LOUD band accompanying the Indian development story has one conspicuously missing element — the health sector. The exclusion of a large section of our citizenry from even minimal access to the so-called “growth story” is generally not noticed in public discourse. Against this depressing background, Sujatha Rao’s magisterial study of the Indian health system — Do We Care? India’s Health System — is a courageous attempt to force back our attention to issues which are routinely ignored, even though they are central to the sanctity of our social contract.
India’s health system today is not just complex, it is incomprehensibly tangled. To capture the contours of this structure, and to prescribe suggestions for repairing the broken system, is a hugely challenging assignment. Rao (and I must, at this juncture, disclose that she is my former colleague in the Union Ministry of Health) by virtue of her professional experience, uniquely fits the skill set required for undertaking such a challenging study.
In Part I of the book, the author outlines the significant features of the health system, and its challenges and constraints. In one section of this part, the author also gives a very lucid and detailed analysis of the vexed issues relating to health financing. Health financing in India has always been a “black box”, revealing no useable data for drawing up a health system policy. The analysis of the budgetary features set out in the book demystifies many troubling conundrums. In its totality, the data in the book clinically delineates, almost without any relief, the critically broken-down condition of the system. The author gives us all the dismal numbers of inadequate financial and human resources in a reader-friendly way. Drawing upon these statistics, the author argues passionately and convincingly, that the gross under-funding is principally on account of lack of political commitment. This situation is peculiar to India. By comparison, in all the developed countries, regardless of the ideological underpinning of their system of governance, the responsibility towards the health sector is considered to be irreducible. In the course of the narrative, the author presents interesting and significant statistics. For example, in the USA, the public funding in the health sector amounts to 9 per cent of GDP, as compared to 1 per cent of GDP in India. To put the set of numbers in perspective, it is necessary to recall that the per capita GDP of USA is nearly 35 times that of India!
The author’s analysis of the financing system leads her to the inevitable conclusion that persistent political neglect of the health component of the social sector constitutes a grave and progressive risk to societal stability. She observes, with palpable regret, that the policies of governance rely almost exclusively on the inputs and perceptions of the economic advisors. The belief system in a democracy requires that government policies reflect the various societal aspirations, which would include not only “economic growth”, but also many other elements which are greatly valued by large sections of society who may not be very audible in the national discourse. A quick totalling of the mortality figures presented by the author indicate that not less than three million human beings (nearly half of them being infants under the age of five years) succumb to easily preventable/treatable diseases. Rao’s book focuses the arc light on the ambivalence displayed by people like us when facing these disturbing facts; and, we can only hope that, at least, some people will recognise this blind spot in their attitude, and use their leverage as opinion-makers, to reverse the policy of neglect towards the health system.
In Part II of the book, amongst other engaging issues, the author narrates the experience gathered in implementing an important initiative undertaken in the public sector — the National Rural Health Mission (NRHM). This programme was basically designed to revamp the rural primary healthcare system, which had virtually broken down, by adding some new supplementary modules, particularly in the area of project management. The outcomes of the NRHM programme showed up as very promising. During the programme period, the infant and maternal mortality rates have dropped dramatically, and, at least, some of the reduction can be attributed to the impact of the NRHM on the primary healthcare system.
It is apparent that a storm of intellectual passion has driven Rao to undertake the gigantic task of writing this book. While every page of the book impressed and informed me, I was particularly struck by the title: Do We Care? I am happy the author took courage in her hands to adopt this mildly provocative title; most commentators would find it politically incorrect to do so. But, in truth, we need to ask ourselves, at least in our rare honest moments — “Do we care?” And, if we were to attempt an answer in the same honest moment, we would have to say — “No; not very often.”
The oppressed princess in the romantic folk tale, Cinderalla, seems an apt metaphor for our neglected health system. Can we also, possibly, hope that, with the help of a benevolent fairy godmother, a dashing Prince will arrive in the near future, to set free our own shackled health system?
The writer is a retired civil servant and former Health Secretary, Government of India