India, the second most populous country in the world, is a bewildering collection of contradictions. If the people in some regions live in abysmal conditions, and thousands die from preventable and treatable illnesses, islands of good health such as the southern state of Kerala have health indicators comparable to those of developed countries.
Faced with massive problems of ill-health (the burden of disease), Indians have had to address the question of how to provide a health infrastructure that is accessible to the people. A number of critical health issues have been raised in this context. The question is: what are the solutions, and what is being done to change the health system and the quality of health of the people?
HEALTH INDICATORS: WHAT CAN THE BILLIONTH INDIAN BABY EXPECT IN THE 21ST CENTURY?
Around June 2000, India turned one. One billion, that is. The Census of India 2001 (www.censusindia.net) counted 1,027,015,247 Indians as of March 1, 2001: 531,277,078 men and 495,738,169 women.Can this child -- and the many more born the same year -- hope for a good life?
The good news:
Life expectancy at birth and infant mortality are two important indicators of a society's health. And the billionth Indian baby is less likely to die in childhood, more likely to live a long life. She can expect to live beyond her 60th year, twice as long as her great-grandfather did.
If in 1947, 146 of every 1,000 babies born died before their first birthday, the infant mortality rate (IMR) is half that today, at 68/1,000.
National averages of all indicators of health and health care are looking up:
For example, couples are having fewer children. In 1998-99, the total fertility rate was 2.9 per woman, down from 3.4 in 1992-93.
More deliveries take place in health facilities (34 per cent in 1992-93, compared to 26 per cent in 1992-3) or with the help of trained support (42 per cent from 33 per cent), reducing the risk to both mother and child.
More children receive the essential vaccines protecting them from tuberculosis, diphtheria, pertussis, tetanus, measles and polio --- 42 per cent, up from 36 per cent.
However, such averages hide wide variations, from the populous northern state of Uttar Pradesh (with an IMR of 88/1,000) to the southern state of Kerala (16/1,000) whose health indicators rank among those of developed countries.
So, the bad news is:
More than one-third of married Indian women have chronic energy deficiency; more than half of them are anaemic.
Forty-five per cent of children under three are severely and chronically malnourished..
Only 42 per cent of children between the age of 12 and 24 months have completed their immunisation schedule; a massive 14.4 per cent have not received a single vaccine.
Only 31 per cent of the rural population has access to potable water supply and only 0.5 per cent enjoys basic sanitation.
In 2001, people continue to die for the same reasons they did when India became independent in 1947: infectious diseases.
Babies continue to die every day of treatable respiratory infections, diarrhoea and other illnesses either preventable through clean water, nutritious food and cheap vaccines, or treatable with basic drugs.
AIDS is one more infectious disease in the landscape today.
As the entire Indian population ages, many more people are being struck down by non-infectious ailments. Some people believe that cancers, diabetes and heart disease will soon overtake infectious diseases as the number one killer.
(For more information see: 1991 Census of India, National Health Policy, 1983 www.mohfw.nic.in, PRB 2000 World Population Data Sheet, www.worldpop.org/prbdata.htm, National Family Health Survey-II, 1998-99, www.nfhsindia.org.)
THE BURDEN OF DISEASE: WHAT AILS INDIANS?
At present, infectious and parasitic diseases dominate. They killed 2,121,000 people in 1998. The killers include tuberculosis and other infections including sexually transmitted diseases, AIDS, tropical diseases, respiratory infections and maternal conditions. In fact, press reports indicate a resurgence of diseases once believed to be on their way out. Epidemics of deadly cerebral malaria have been reported in many parts of the country. Every year, scores of children in the rural areas die of measles, exacerbated by malnutrition.
Tuberculosis kills 500,000 Indians each year. One in two Indians is infected with the TB bacillus, and 1.5 per cent of the population has radiologically active TB. Between one and two million new cases occur ever year, with a case load of over 11 million patients. India has more TB cases than any other country in the world.
TB affects the poorest sections of society. An estimated 26 per cent of all deaths in the economically most productive section is due to TB.
The TB pandemic is further complicated by the spread of HIV/AIDS. It is estimated that there are 250,000 HIV-related TB cases annually by 2000.
It is estimated that the economic cost of TB to India is more than US $2 billion (Rs 8,000 crore) each year.
Almost 100,000 people died from respiratory infections in 1998.
Some 1,25,000 women died from complications of pregnancy, in 1998.
100,000 deaths in 1998 could be attributed to nutritional deficiencies, more than half of which were simple protein-calorie malnutrition.
HIV affected 3.5 million Indians in 1998, according to UNAIDS estimates, though the overall prevalence of HIV in India is still low. Official surveillance data suggest that the epidemic is progressing rapidly.
One in two new HIV infections takes place in people below the age of 25; one in four HIV infections in India are amongst women, most of whom have no risk factor other than being married.
However, doubts have been expressed on the quality of epidemiological data. It has also been argued that the HIV epidemic should be seen in the context of other conditions such as diarrhoea, respiratory infections and tuberculosis, which have a higher morbidity and mortality
Malaria affects 2.6 million people each year, and killed at least 20,000 people in 1999.
India has the largest burden of leprosy patients in the world, with a caseload of over 4 million patients.
(For more information see: World Health Organisation: World Health Report, 1999, www.who.int/home/reports.html, TB: http://www.httpcity.com/indiatb/revntcp2.html., http://w3.whosea.org/prsrls/pr17feb2000.htm, http://www.trc-chennai.org/Rntcp/rntcpmain.htm, HIV: National AIDS Control Organisation www.naco.nic.in; UNAIDS http://www.infochangeindia.org/www.unaids.org; WHO Global burden of disease and disability, 1995)
As Indians live longer, chronic diseases, related to aging, are expected to take a greater toll.
Cancers killed 653,000 people in 1998, the single largest type being mouth and oropharynx cancer. An estimated 1.5 million new cases occur each year.
Cardiovascular diseases, which includes those with an infectious origin, such as rheumatic heart disease, killed 2,820,000 people in 1998
Diabetes: In 1994 there were 20 million diabetics in India; there will be more than 33 million in 2005, according to World Health Organisation estimates. One in four diabetics will be Indian. Diabetes was responsible for 102,000 deaths in 1998. Up to 75 per cent don't even know they're diabetic. Studies over the last three decades show a rising prevalence of non-insulin-dependent diabetes, which affects Indians earlier than in the West. Diabetic retinopathy, the most common cause of blindness in urban, middle-class Indians, is on the rise, though most of it is preventable. Diabetes is also the most significant cause of end-stage kidney disease and of amputations in India. The costs of drugs for diabetes, already high for the average Indian, are expected to go up in the near future..
The 2001 Census for the first time records people with visual, hearing, locomotor and mental disabilities.
A benchmark survey was carried out by the National Sample Survey Organisation in 1991. It estimated that 1.9 per cent of Indians are disabled. Other estimates suggest that between 6 and 10 per cent of the population in any developing country is affected by disability, which means 60-100 million Indians are affected by disability.
According to various estimates, between 4 million and 14 million Indians are blind. The most common causes of blindness is cataract, which is treatable by surgery; the next most important cause was refractive error which is treatable with glasses.
The 1991 NSSO survey estimated 3.2 million people with hearing impairment in India. According to a 1980 WHO report, the underlying causes are low socio-economic status, poor health care and nutrition, which deprives people of immunisation against infections and adequate treatment for infection.
Approximately 1.6 per cent of the Indian population, or over 16 million people, are affected by locomotor disabilities. The two most common causes are poliomyelitis and cerebral palsy.
The 1991 NSSO survey estimated that 3 per cent of India's children have delayed development (mental retardation), of whom one in four is moderately to severely retarded. The problem is more common in rural areas. The problem can be reduced with access to prenatal screening, immunisation, nutrition and health services. Early identification, assessment and intervention will help bring down the burden of disability.
Ten per cent of the child population -- or 30 million children up to the age of 14 -- have special educational needs of various kinds. Unfortunately, in the absence of comprehensive support services, not more than 3-4 per cent of children with disability have access to education.
(For more information see www.rehabcouncil.org).
Indian women often tolerate ill health without complaint. A number of community-based studies are bringing to light the extent of women's health problems.
In a study in rural Maharashtra, researchers found that one in two women interviewed reported an illness in the previous month. They spoke of chronic, non-infectious, long-standing problems, related to their reproductive health, to various aches and pains, or to mental health. Illnesses were often linked to their working and living environment, childbearing and contraception. Almost half tolerated their illnesses without treatment -- either they couldn't afford the treatment, or they felt it couldn't be treated, or health facilities were inaccessible.
A considerable proportion of women suffer silently from a range of gynaecological problems -- reproductive tract infections (RTIs), menstrual problems, cervical erosion, infertility, uterine prolapse, and so on. The most frequent complaint is of vaginal discharge. RTIs are acquired through sexual transmission, medical procedures such as IUDs, tubectomies, abortion and childbirth, or from overgrowth of the body's own bacteria. Numerous studies have demonstrated that gynaecological morbidity is a serious problem in India.
100,000 Indian women die of pregnancy-related causes each year. The maternal mortality ratio (number of deaths for every 100,000 live births) is 50 times higher than developed countries and six times higher than neighbouring Sri Lanka. The six major causes -- haemorrhage, anaemia, eclampsia (pregnancy-related hypertension), infection, abortion and obstructed labour -- account for 85 per cent of pregnancy-related deaths. There are also a number of background factors: nutrition and health status, age, number of children, marital status, gender disparities, lack of information, socio-economic conditions and poor access to health services all influence maternal mortality and morbidity.
Abortion, which has been legal in India since 1971, accounts for at least 12 per cent of maternal deaths. Only ten per cent of the estimated 5 million abortions ('medical termination of pregnancy' or MTP) that take place in India annually, are performed in approved health services.
Authorised MTP centres are concentrated in the urban areas, and in a few states. Many approved centres may not be providing services, many are inadequately equipped, with poorly-trained or insufficient staff. The private sector provides a large proportion of services.
A rural community-based study in the state of Maharashtra found that one out of six women who underwent an abortion did so to abort a female foetus. Two out of three suffer health consequences serious enough to affect their daily lives. Less than one-third of women are counselled about the procedure's risks, but more than half are given contraceptive advice, and many are forced to accept contraception in order to get an abortion.
However, women's health problems extend beyond their reproductive health. While maternal mortality and morbidity have been the focus of women's health efforts, public health specialists have argued that mortality data from the government's model registration scheme indicate that communicable diseases are the most significant cause of death for women
More than one-third of all deaths take place in children under the age of five. In 1999, 98 of every 1,000 children died from an infectious disease before their fifth birthday, placing India 49th out of 187 countries in the under-five mortality rate.
As many as 429,000 children died of diphtheria, pertussis (whooping cough), tetanus, measles or polio, in 1998. One in two polio deaths in the world occurs in India. All of these are preventable.
733,000 children under the age of five died of diarrhoeal diseases in 1990 (250 million cases annually).
777,000 children under the age of five died of respiratory infections in 1990 (nearly 500 million cases annually).
333,000 children died of complications following low birth weight in 1990.
These deaths are preventable through adequate nutrition to mother and child, clean water supply and sanitation, effective immunisation and an accessible health service to provide prompt treatment.
HEALTH INFRASTRUCTURE IN INDIA
Public health services. India has a vast health care sector, estimated at Rs 126.27 billion in 1998. This health care sector is broadly divided into the public and private sectors. Public health services consist of the following 'step-up referral' network of sub-centres, primary health centres, community health centres and district hospitals:
140,000 sub-centres manned by two multipurpose health workers; 23,000 primary health centres (PHCs) with a medical officer, 14 staff and 4-6 patient beds, with each PHC acting as a referral unit for six sub centres; 3,000 community health centres (CHCs) with four medical specialists, 21 staff, 30 beds and basic surgical and lab facilities, with each CHC a referral unit for four PHCs; 550 district hospitals and 1,012 at the sub-divisional level.
In the urban areas, the network consists of urban family welfare centres for contraceptives, urban health posts and hospitals.(Figures as of June 1999, according to the health ministry: http://mohfw.nic.in)
Doctors, nurses, hospitals and dispensaries: In 1998, about 523,000 allopaths and 115,500 practitioners of other systems of medicine provided health services to the Indian population. Institutional services were provided by 17,000 hospitals and 28,000 dispensaries (mostly privately owned and in the urban areas), with 95,000 beds, and supported by 566,000 nurses. Health providers are trained at 165 medical colleges, which turned out 12,000 graduates and 3,140 postgraduates in 1991. However, more than 80 per cent of out-patient services and a smaller proportion of hospital services were provided in the private sector.
This infrastructure is primarily in the private sector, which provides at least 80 per cent of health services in the country. The role played by non-governmental organisations working in health is also significant.
Indigenous medicine: India has perhaps the world's largest community-based tradition of indigenous systems of medicine.
Every rural community has its own local health tradition, using thousands of plants for medicinal purposes. As many as 700,000 traditional dais (midwives) conduct the majority of rural deliveries, 60,000 bone-setters treat orthopaedic problems, 80,000 herbal healers provide primary health care for various conditions. Millions of people use home-based remedies.
The classical systems include Ayurveda, Siddha (www.mohfw.nic.in/ismh/frwho.htm), Tibetan medicine, Unani-Tibb (www.unanimedicine.org/nnnntbrdiums.htm) and Homoeopathy (www.ccrhindia.org). Some of these date back thousands of years, and depend on a codified system of knowledge, some documentation, and institutions of teaching, research and manufacture. Medical practice is largely not institutionalised.
Yet only four per cent of the national health budget is devoted to these systems. There have been very limited efforts to evaluate these systems. Most Ayurvedic colleges do not have the required infrastructure and faculty. The Central Council of Research in Ayurveda and Siddha has 80 research centres, but there is a general lack of perspective on the proper research design to validate the claims of ayurveda based on its own theoretical formulations rather than isolating active principles for allopathic medicine. Overall, there has been no effort to strengthen these systems.
THE CRUX OF THE PROBLEM: ISSUES AND DEBATES IN HEALTH CARE
The 1983 National Health Policy was meant to arrive at "an integrated, comprehensive approach towards the future development of medical education, research and health services… to serve the actual health needs and priorities of the country." Critical of the curative model of health care, it emphasised a primary health care approach to prevent illness and promote good health. It envisioned an inexpensive but decentralised system of health care, depending on volunteers, paramedics and community participation, with an expanded private curative sector to reduce the government's burden, and a network of epidemiological stations to support health programmes.
The next decade saw the rural health infrastructure develop with a massive expansion of primary health care facilities (described in Infrastructure). However, this effort was sabotaged by a combination of poor quality facilities, inadequate supplies, ineffective managerial skills, poor planning, monitoring and evaluation.
There was no community participation in building up the health services. Various national health programmes function almost independently of each other. Public health experts have suggested that allocation for disease control programmes is driven more by donor organisations than the country's epidemiological realities. Health services concentrated on targetted programmes like family planning and immunisation. Primary health services were never really established in the country.
The private health sector has grown phenomenally, thanks to state subsidies in the form of medical education, soft loans to set up medical practice, etc. accounting for 70-80 per cent of all primary care treatment sought, and over 40 per cent of all hospital care -- in a country where over three-fourths of the population lives at or below subsistence levels.
"Universal, comprehensive, primary health care services" are a distant dream. Public health experts suggest that current trends in health care, and the policies demanded by the structural adjustment programme, have sharpened inequities in health. Selective health interventions have become even more focussed after the World Bank's 1993 World Development Report recommended limiting government health money to the most 'cost-efficient' interventions. "Efficiency scored over the severity of health care problems, as well as equity and social justice."
Problems of access
One in three Indian women did not receive an antenatal check-up during their pregnancy. Fifty-four per cent delivered their babies without the support of trained personnel. Fifty-eight per cent of children have not completed their immunisation schedule and 14 per cent have not received a single vaccine. Only one in two women seeks treatment for illness, usually because the nearest health service is too far away, or it's too expensive. These examples are only meant to illustrate the fact that people's access to health care is limited by their ability to pay, as well the availability of services.
The private-public debate
India is believed to have one of the largest private health sectors in the world. Varying estimates place private expenditure at between 75 and 85 per cent of health care expenditure. One out of two people seeking hospitalisaton go to the private sector, which handles a larger proportion of out-patients than of in-patients.
In 1991, the Indian government's health care expenditure was less than two per cent of its gross domestic product, and just 21.7 per cent of total health expenditure -- one of the lowest proportions in the world. Over the years, it has made further cutbacks in its commitment to public health services. Total expenditure on health is 5.2 per cent of the GDP, but out of this, only 13 per cent is spent by the government. Health accounts for only 3.9 per cent of total public expenditure.
What does this mean in a country where at least 26 per cent of the population are still fighting for subsistence (below the poverty line)? Poverty and ill-health go hand-in-hand, and limited income means a limited capacity for health spending. For the poor, therefore, health care is often the last priority, affordable only if there is money left over after paying for more immediate needs such as food. In such a situation, what is the government's responsibility in providing health services for the people?
Sri Lanka, with health indicators comparable to many developed countries, spends only 3 per cent of its GDP on health, but 45.4 of this is spent by the government. Or take the example of Cuba, with similar health status, which commits as much as 10 per cent of all public expenditure to health.
Private services: not the privilege of the rich
In the absence of accessible government clinics and hospitals, private health care is not the privilege of the rich but often the only option of the poor as well. Studies of household expenditure have shown that health care can use up to 40 per cent of a poor family's budget. Even using public services costs money: fifty per cent of the patients in Mumbai's public hospitals spend more every day than the daily income of their entire household. In private hospitals, average costs for medicines, doctors' and hospital fees can amount to twice a family's monthly income. No wonder health care is becoming the second most common cause of debt in rural areas.
User charges in government hospitals
For some years now, the government has been advocating user charges in public hospitals, arguing that while it is commited to basic health care (family planning, immunisation and selected disease programmes) people should pay for other services. This has been opposed by many health activists on the grounds that user charges actually reduce the poor's access to essential services.
A small fraction of India's population is covered by insurance schemes of any sort, whether private or employees' schemes. The vast majority of Indians must either make out-of-pocket payments for health services in the growing private sector or go to the public sector which is both small and increasingly demanding compensation.
One of the consequences of structural adjustment programmes in the health sector was to open up health insurance to private companies. Will the entry of private insurance companies provide relief to the poor who cannot afford to pay for care? The private sector has an estimated premium potential of over Rs 4,500 crore. But the private sector will target only those who can afford its premiums. Private insurance companies are unlikely to provide coverage to the poorest of the poor in the rural areas, who need it the most.
Quality of care
The quality of health care available in India is extremely variable -- from corporate hospitals with the latest equipment, highly-qualified doctors and patient-friendly services, to small outfits with unqualified staff, lacking even basic equipment or a continuous supply of water and electricity. General practitioners in slums charge for injections of limited efficacy and possible harm. Traditional health practitioners -- many providing allopathic medicines -- serve a large proportion of the population, many of them practising allopathic medicine for which they are not trained.
All these practitioners thrive free of regulation. Unethical practices such as unnecessary investigations and surgeries and kickbacks for referrals are rampant. Many private hospitals over-charge and deny the patient information about diagnosis and treatment. Though medical services were recently brought under the Consumer Protection Act, there are no enforceable standards for private hospitals. Regulatory bodies such as the medical councils are unwilling to fulfil their responsibilities, the legal system is ill-equipped to handle the burden of medical litigation, and aggrieved patients and their relatives cannot afford the costs and long delays of the battle.
The global economy and Indian people's health
In 1991, India began instituting a structural adjustment programme (SAP), as a condition of a loan from the International Monetary Fund to bail it out a financial crisis. The SAPs were supposed to discipline a wasteful planned welfare state, and required that India reduce government spending, privatise state-owned enterprises, and open up its markets to outside investment and a 'global economy'.
In the health sector, this meant cuts in public health spending, the introduction of service charges in public services, and handing over even more responsibility to the private sector which already accounted for three-fourth of health expenditure.
Many senior public health experts feel that the SAPs increased the rich-poor gap, and increased the international debt burden. The result: cuts were forced in an already inadequate public expenditure on health and other social sectors. At the same time, rising unemployment and food prices as a result of liberalised industrial policies makes people even less able to maintain good health. As investment in health services gets more and more driven by profit rather than need, 'five star' hospitals flourish even as tribal children weakened by chronic malnutrition die in measles epidemics every year.
FUTURE STRATEGIES AND POSSIBLE SOLUTIONS
If Indian people face a myriad health problems, hundreds of individuals and organisations are looking for the way forward. Academic academic and research institutions such as the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi (http://http://www.jnu.ac.in/sss/csmch.html ), and the Centre for Enquiry into Health and Allied Themes (CEHAT), Mumbai (www.cehat.org) -- whose publications are the basis for a number of the points made in Section IV -- have provided vital documentation and analysis of the health scene.Voluntary organisations (see Stories of Change in this section) have provided services as well as demonstrated the effectiveness of innovative strategies and inexpensive models of health care. Some have promoted the value of indigenous systems of medicine which are both more accessible and perhaps less harmful. Others have provided support services for disability groups. Networks of health professionals, academics and activists such as the Medico Friends Circle (www.mfcindia.org) have enriched the many ongoing debates. Larger movements such as the National Health Assembly (www.chennaionline.com/tnsf/short/pha/) have brought together organisations from all over the country to influence the direction of health policy.