IF HEALTH IS LOST...........?

Health is currently a privilege in India. Not a right. Maternal & child health neglected even after countless plans, programmes & political proclamations. Every year, nearly 60,000 women die in pregnancy & childbirth, while approximately 1.7 million children less than five years of age also die. In absolute numbers, India outranks all other countries in both regards. Sadly, most deaths can be prevented with available technologies. Many diseases such as tuberculosis & pneumonia kill thousands every year. While infectious diseases are very much a concern, chronic diseases are now rapidly catching up. India has become the capital of diabetes, high blood pressure & heart diseases. Health targets in plan after plan have not been achieved, yet there has been no systematic analysis of why health systems fail to achieve these targets.

     The fundamental reason why our health targets are not achieved & will not also be achieved, unless we radically change our strategies, is that we set targets without setting strategies; without understanding what is preventing progress; & without putting adequate human & financial resources toward achieving targets.

     First we equate the number of buildings to available health services. The Planning Commission & Central & State governments only count the number of health centers, without bothering to find out what is happening at these centers. Many are without staffs, electricity, a telephone, water medicines or an ambulance. No wonder these centers do not have patients - mothers or children to take care of. Surveys have shown the inadequacy of our health infrastructure & that health workers are not staying where they are posted. There are good reasons why health staff do not stay in villages. But health departments have not bothered to study this problem or remedy it. Not only are workers not staying, studies have also shown that they are frequently absent without reason. Such unaccountability is treated as routine & not discussed in health policy forums.

    The second reason for a lack of service is underfunding & poor management of medicines, leading to a lack of availability. How can an army fight without ammunition? The lack of medicines forces poor patients to buy medicines from private pharmacy shops, which can be expensive. Often times, the quality of medicines available from these shops & government health centers is poor due to government's weak oversight on pharmacies & poor procurement policies. Patients do not want to go to clinics where they do not get medicines or where they are of poor quality.

    MANAGERS

    

    While planning & funding are major problems, the root of the health problem in India is the lack of adequate numbers of well-trained managers. Many national health programmes cover millions of beneficiaries, yet they are managed by just two or three technical managers who are general & specialist doctors.

    Most of the time these individuals are without any public health or management training. They learn this on the job. This is also true for health secretaries & ministers - they all learn on the job. We are obsessed with training an eight standard-passed village health worker with six to seven modules - but there is no training or even orientation for top policymakers & managers in the health department before they take up such important managerial & policymaking jobs. Why isn't health systems management made compulsory  before an officer takes up the job of director or secretory in the health department?

    THE WAY OUT

    Fortunately things can rapidly change in the next few years, if government & society pay a little more attention to health. During the last five years, the govt. has put in significant resources into the National Rural Health Mission (NRHM). At the same time, many States are also using local solutions to various problems. Preparations are underway for the 12th five year plan (FYP), & thus we should be looking at what radical changes are needed in the public health system.

    Budgets for health services will need to increase by a factor of three to five times. The national govt. is committed to take health funding from less than one percent to two to three percent of the GDP. This is critical. The govt. must chart out how the Center & State will increase these budgets over the next five years. This will also require advocacy on behalf of the health community. And we must also be more smart in how to spend the money that is already available. Money remains unspent in health because the regulations around spending are so complicated & confining that doctors & health works can not spend the money. Many times money does not arrive in time for it to be useful.

    Health care is provided by humans. Not by buildings & physical infrastructures. We need to get doctors & nurses to go to remote & rural areas & work there. This means paying them much higher wages, providing much better housing & other amenities & making the working environment conducive to their lives.

    Appreciation of the doctors & nurses who work in remote areas will ensure that younger doctors go to rural areas & serve the poor. Another solution could be to contract private providers, where govt. providers are unavailable & unwilling to provide services. Gujarat did just this through its much acclaimed "Chiranjeevi Scheme". Here, the govt. pays private doctors a fixed fee for conducting child birth services for poor woman in their private hospitals. "Rashtriya Swasthya Bima Yojana" also provides financial access to care in private & public services to the poor throughout the country. This is truly innovative & revolutionary.

    TECHNOLOGY & DRUGS

    While improving health system is critically important, we can not afford to wait until such changes are made before also improving the technological base for health systems. This means better machines & newer drugs & vaccines. For example, new vaccines & diagnostic techniques that can prevent or diagnose early some of the diseases among children & woman are currently available in the private sector, but these technologies remain out of reach for the poor. The health department must have a division of technology assessment that is responsible for identifying & rigorously evaluating potentially useful & cost effective technologies for adoption in national health programmes in India.

    All this can happen if there is a high level of political commitment & the Prime Minister & Chief Ministers take personal interest in health improvements.

    Of course, more resources need much better management in order to deliver results. Health departments must have an adequate number of qualified programme managers & health planners to ensure better programme design & effective implementation which can be proved as a big step towards universal access to health, because if health is lost then something is lost.