Cycle of Illness
In the past few years, diseases such as dengue fever, viral hepatitis, tuberculosis, malaria and pneumonia "have returned in force or have developed a stubborn resistance to drugs," according to a report on health care in India by consultancy PricewaterhouseCoopers. "This troubling trend can be attributed in part to substandard housing, inadequate water, sewage and waste management systems, a crumbling public health infrastructure, and increased air travel." Pylore Krishnaier Rajagopalan, who was head of the government Vector Control Research Centre in the southern city of Pondicherry between 1975 and 1990, blames policies that concentrate on the latest scientific techniques and not enough on basic controls. "Field work is almost dead," Rajagopalan says. "These mosquitoes are sun loving. How can a shade-loving, lab-bound, white-coated scientist control the mosquitoes through research? It may be the future but millions of people in India are suffering and dying now because we're not doing the basics."
If all that explains why Indians are so sick, look to public hospitals and medical services to understand why they are not getting better. In many parts of the country, but especially in rural India, where two-thirds of the population lives, health services are poor to nonexistent. Clinics are badly maintained and equipped. India needs hundreds of thousands more doctors and more than a million more nurses. Current staff often don't turn up for work. "It is a well-recognized fact that the system of public delivery of health services in India today is in crisis," begins the paper "Understanding Government Failure in Public Health Services" published in the influential Economic and Political Weekly last October. "Recent analyses show that high absenteeism, low quality in clinical care, low satisfaction with care and rampant corruption plague the system."
Such dire conditions force millions of people to head to the better public hospitals in India's cities. The Dr. Ram Manohar Lohia Hospital (RML) in New Delhi is well maintained, relatively clean and is probably one of the best. Unlike most hospitals, which get their funding from state governments, the RML is financed directly by the central government and caters to the thousands of public servants and senior government officers, including members of Parliament, who are lucky enough to have state-funded medical insurance. But its high standards are also a magnet for sick people for hundreds of miles around. About 60% of the 4,500 patients the hospital sees every day travel not from the New Delhi area but from neighboring states. Some of them are complicated cases that have rightly been referred to a tertiary-care hospital, but many are simple cases of malaria or dengue fever that other hospitals should treat easily. "The challenge is that our facilities are totally at saturation point," says Dr. Nishith K. Chaturvedi, the hospital's medical superintendent. "If states were doing a better job it would cut our case load by 35%."
The crush of numbers means that the RML is sometimes forced to have patients share beds. "For a short period only," Dr. Chaturvedi says, looking slightly sheepish. "But it happens." A tour of the emergency and outpatient departments brings the problem into stark relief: the crowds of patients and visiting relatives are as thick and suffocating as the heady fug of chloroform and the sounds of children screaming. A few cases on trolley beds wait outside under a small awning. Though generally well kept, "it's very hard to maintain cleanliness even if you clean every half an hour," says the head of the outpatient department, Dr. P.K. Misra, waving his hand at a heap of bloodied sheets in a corner. "I have visited a few hospitals in the U.S. They are like five-star hotels for us. But we can never match that. It's the population load."
Later, taking a break in an unoccupied office, a tired Misra laments the state of public health. "This place is one of the good ones," he says. "I have seen hospitals with dogs below the beds." After graduating, Misra spent a few years in India's northeast, one of the poorest parts of the country. "I went to the rural area to serve the people but the government doesn't recognize that," he says, explaining that classmates who went to big cities "are now professors and earning big bucks." The system, he says, is set up so that rural areas will never have good doctors or other medical staff, tens of thousands of whom leave to work in cities or abroad. "It's better to start a practice in the city than go to the country and ruin your life."
With such problems in the public system, it's little wonder that private operators have boomed. Some 80% of all spending on health care in India is now private, some of it by large companies insuring their staff, some by nongovernmental groups running health programs, and a bit by rich Indians using the best private facilities. But the overwhelming majority of the spending is by poor citizens. Money is so tight that many rural Indians skip doctors and rely on advice from local pharmacists, who too often prescribe cough syrup or tablets that do nothing to help. Because only one in 10 Indians has any form of health insurance, out-of-pocket payments for medical care amount to 98.4% of total health expenditures by households, according to the PricewaterhouseCoopers study, which estimates that 20 million people in India fall below the poverty line each year because of indebtedness due to health-care needs. In Brazil and China, both countries India often compares itself with, the public share of health-care spending is around 40%, while the average for G7 countries is 70%. In India it is just 17%.
The good news is that the current Indian government seems to get it. "Health is slowly becoming an important focus," says Krishna Rao, who heads health economics and funding for the Public Health Foundation of India. The organization was set up in 2006 by the government, NGOs like the Bill and Melinda Gates Foundation and private health providers to influence policy and research, and to set up world-class public-health schools around the country. The government has also promised more money for rural health through its ambitious National Rural Health Mission. The Congress Party, which leads India's coalition government, says it will increase public-health spending from the current 1% of India's GDP to up to 3% by 2010, but that's still just half the rate at which countries with comparable per capita incomes such as Senegal and Mongolia fund their health sectors. "What has been a fatal flaw in our approach is that we have gradually abandoned comprehensive health care and a public-health perspective for focused attention on selective diseases," Prime Minister Singh said at the April 2005 launch of the National Rural Health Mission. "We have grievously erred in the design of many of our health programs. We have created a delivery model that fragments resources and dissipates energies. Most importantly we have paid inadequate attention to the public-health issues and the possibilities of social and preventive medicine."
If that is to change, one of the first myths that need to go is the idea that economic growth alone will lead to better health. Though health indicators vary widely across India, the link between wealth and good health isn't clear cut. Poor states such as Orissa and Chhattisgarh that have made efforts in child immunization over the past few years now have better coverage than richer states, where immunization has actually slipped.
Other sacred cows will need to be challenged. India's old socialist system may have had its problems, says Imrana Qadeer, one of India's foremost public-health experts, but the belief that private enterprise can cure all of India's woes is dangerously misguided. "The private sector doesn't want to do basic things like treating diarrhea, improving nutrition, immunizing babies because that's not where the money is," says Qadeer. "In India we cannot live without a strong public sector."
In the end that will mean spending hundreds of billions of dollars more on public health, perhaps even creating a basic national insurance scheme. "Unfortunately there may not be any low-cost solutions," says public-health expert Kumar, who believes current government promises do not go far enough. "India needs to be prepared to spend on health but whenever it's mentioned there's always this debate about cost. Why don't we have the same debate when we spend tens of billions on new arms? It's totally unacceptable to shortchange a system that will save lives." And it's hard to be an economic superpower if you're too sick to work.