India’s health care system is in crisis. Health indicators are dismal. One quarter of the world’s total maternal deaths every year occur in India. 47 per cent of all children in India are underweight. This is more than the number for the entire continent of Africa. India’s health system failures are usually attributed to the chronically low levels of health spending. In most countries of the world, government spending on health care constitutes a significant proportion of total health spending partly because health care constitutes a “public good” and also because health spending enables poverty reduction and greater social equity.
Despite increases in spending in recent years, total yearly health spending in India as a percentage of GDP is approximately 4.5 per cent, thereby contributing to India’s rank of 153 out of 193 countries with respect to total expenditure on health per capita. However, government expenditure on health is only a quarter of total health spending with the bulk of the expenditure being private expenditure. The impact of this spending inequality has severe consequences in a country where 42 per cent of the population lives below the international poverty line of $1.25 per day and an even greater proportion of the population relies on public health facilities.
Today, there is recognition that the government must increase health spending in India. The stated goal of the National Rural Health Mission launched in 2005 was to increase health expenditure from 0.9 per cent of GDP to 2-3 per cent of GDP in the next 5 years. However, despite increases in government health spending, this target has not been met so far.
While India’s neglect of health spending is significant, India’s health policy failures are graver because they mean that whatever little is spent on health is not used effectively to ensure better health service delivery. Within India’s federal constitutional framework, state governments possess primary responsibility for public health and sanitation, including both the funding, programmatic and structural development of health care systems, hospitals and dispensaries. Yet the central government significantly influences health policy through its “Five Year Plans” and centrally sponsored schemes.
India’s health policy since independence has been marked by three chief failures that have contributed to the current health care crisis. First, there has been an absence of a political commitment to realise universal health care. Second, the shift in budgetary and policy priorities toward the creation of vertical disease eradication programmes and family planning during the 1960s and 1970s, which gained even greater impetus during the emergency, have resulted in a decline of institutional health capacity and prevented the creation of an integrated health infrastructure in India. Third, where piecemeal disease eradication programmes as opposed to universal health care programmes have in fact been implemented, they have proved to be both ill conceived and cost ineffective.
On the few occasions (first in 1946 following the publication of the Bhore Committee Report and later in the 1983 National Health Policy) when the central government articulated a commitment toward the provision of universal health care, such policies were opposed by international organisations like the World Bank and the WHO. In line with the idea championed by the WHO and UNICEF that “poor countries” should focus their limited resources on specific disease eradication programmes, the government focused on vertical programmes for eradication of diseases like malaria, tuberculosis, etc.
Such disease eradication programmes have been acknowledged by the National Health Policy, 2002 (NHP) as both ill-conceived and cost ineffective. This is because most diseases targeted have not been eradicated and the creation of separate infrastructure for each programme has proved extremely costly. Following liberalisation in 1991, health sector reforms introduced at the state level by international and bilateral funding agencies have again advocated piecemeal strategies that favoured commercialisation of healthcare, including the adoption of user fees in public hospitals, privatisation of health services, and the promotion of public private partnerships via franchising and contracting out of services.
The NHP 2002, which remains in effect today acknowledges previous policy initiatives such as vertical programmes and lack of an integrated health infrastructure as responsible for India’s poor health care system. Despite such acknowledgement, it has carefully steered away from a commitment to universal access to health services on grounds of financial viability.
Similarly, the National Rural Health Mission (NRHM) launched in 2005 has made important contributions to health service delivery but it has failed to integrate existing state health systems and private health care in rural areas. Another important problem has been the failure of the poorest states to expend the funds allocated to them under the NRHM due to an over-arching lack of capacity. Moreover, the failure to prescribe long-term goals and targets and lack of correlative data makes it difficult to measure the efficacy of the NRHM.
Similar capacity and execution problems have delayed the launch of the National Urban Health Mission (NUHM) that was announced in early 2008. Four years after its announcement, the fate of the mission is uncertain.
The need of the hour is a serious rethink of health policy in favour of establishing a universal and integrated health care system. Toward this end, government health spending must in fact be increased to 2-3 per cent of GDP. The NUHM must be launched as soon as possible and integrated with NRHM. Both the NUHM and NRHM must become a permanent feature of our Five-Year Plans and not dependent on the budgetary priorities of future governments. However, serious, transparency, accountability and bureaucratic failures plague health service delivery in India, particularly in the poorest states. Continuous monitoring and audit of health schemes is imperative for India’s health care system. PDS, ICDS and the mid day meal schemes should be integrated with the NRHM and NUHM.
(Views expressed in the column are the author’s own)
Namita Wahi is a lawyer and current doctoral candidate at Harvard Law School.