Having worked in 11 different countries, both developing and developed, I have harboured a long-term interest in the different healthcare systems around the globe and their comparisons have always intrigued me. The Indian healthcare system has always been of special interest not just because of my origins but because of the special challenges it presents in every sphere.
Therefore it was with a great deal of anticipation I commenced my perusal of Rajendra Pratap Gupta’s recently released book ‘Health Care Reforms in India: Making up for the Lost Decades‘. Gupta, as the blurb points out, has very impressive credentials. He is a public policy expert with interest in global healthcare and has been very active on the healthcare policy making circuit delivering lectures in several prestigious international fora.
I was somewhat astonished to learn that this is his first book! The wealth of information that he has attempted to condense in almost 450 pages (mainly small print) is staggering. Despite the avalanche of information, I found the book a gripping and a compulsive read — and the author should be commended for this.
I certainly consider myself much better informed on the subject now. Clearly the author has undergone a process of painstaking research from varying sources. There were times I was overwhelmed with the statistics presented but the author always made it a point to explain the point he was attempting to make either through text or statistical diagrams — which of course made it easier for the likes of myself who are intimidated by overpresentation of figures.
I came to know of hundreds of committees that that government has appointed since independence. Many have come up with very meaningful suggestions but there are others that have suggested solutions that are nothing short of bizarre! For instance, I am not sure what to make of the Shetty Committee recommendation that student nurses should be asked to provide an undertaking that they would not get married during the training! Or Mudaliar Committee recommendation that public defaecation should be made a cognizable offence! Equally puzzling is the Sokhey Committee recommendation that women should be prohibited from consuming alcohol not just during pregnancy, but not men! Needless to say these recommendations were not accepted but it is regrettable that public exchequer had to fund these useless projects. Siddhu Committee came into existence during my last year in India and I know it was widely believed that the chairperson was appointed as he was a kin of a senior bureaucrat. He came up with even more impractical suggestions which were comprehensively rejected.
But I am grateful to the author for acquainting me with the recommendations of the Bajaj Committee and the Shrivastava Committee, the latter making stellar recommendations which were more or less replicated by the Mehta Committee.
We all know that the Indian healthcare system is in a very poor shape. If Amartya Sen is to be believed, it is the worst healthcare system in a democratic world both in terms of accessibility and affordability as well as the facilities available. I know some people have taken issues with Sen’s inference but it cannot be contested that the healthcare statistics in India are unflattering.
Perusing the text of the book, it was therefore astonishing to appreciate that nearly all the points that concern me about Indian healthcare have received bureaucratic attention but the decisions have not percolated down to the ground level. Readers may find it amazing that some healthcare programmes named after political leaders and launched with much fanfare have remained obscure and ineffective. I was, for instance, not aware of the Indira Gandhi Programme for helping pregnant mothers.
The author has dwelt extensively on health economics therefore I was somewhat surprised not to find reference to Partha Dasgupta’s work. It does not relate to India but does provide some very valuable insights.
And while the entire picture appears gloomy, the most notable public heath achievement in the last 50 years, i.e. eradication of smallpox, I felt deserved elaboration rather than adumbration that was provided. I was a medical student at the time preparing for the preventive medicine examination. It was a day prior to my practicals that we suddenly learned that smallpox had been eradicated from India. For many families, including my own, which had its share of smallpox survivors, it had come as a pleasant surprise. But more importantly it served to establish that given the will and determination, the Indian healthcare system can work wonders — and sadly, it is the will that is missing. What else can explain more than 25,000 infant deaths owing to Japanese encephalitis in Gorakhpur, my own mofussil town? And the shocking state persists while the policy makers continue to battle whether opening up a new AIIMS in the town is a feasible proposition. Even the Fourth Estate (the News Media) has displayed apathy; infants continue to die!
The Chapter 5 of the book is the most instructive in which the author deals with the possible solutions. I agree with him in toto when he indicates that while under-spending in the health sector is a reality, the main problem is effective resource utilization and lop sided planning. Before any further fiscal resources are allocated, it would be prudent to ensure that they are being properly utilized. That does not seem to be happening now.
The author has provided a timeline of the history of Indian healthcare. The striking feature is that after the composition of Sushruta Samhita in 500 BC, the next notable landmark was the appointment of the Chief Medical Officer by the East India Company in 1644. It would seem that Indian healthcare has lost centuries, not just decades — which indeed is a pity as India was better endowed with medical systems in the medieval era than most other civilizations. And as the author has mentioned Clara Swain, I would have liked a reference to Anandibai Gopalrao Joshi, India’s first female medic as well as Upendranath Brahmachari who was responsible for saving millions.
The author has also mentioned the problems with statutory regulation of healthcare. He has not dwelt in as much detail as I would have liked. The Medical Council of India — and for that matter the Nursing Council as well as the Dental Council — have been in a state of turbulence which has led to steady ethical erosion clearly having a major impact on healthcare. One can only hope the situation improves.
Many important diseases that have played a role in healthcare planning have been mentioned. The tuberculosis and leprosy programmes have received a special attention. The author has also not shrinked from stating that many of the chronic health problems in India are not related to under-spending but neglect of sanitation concerns. There was a minor error in one of the governmental papers concerned. Sandflies cause kala-azar but have nothing to do with malaria. Most gratifying for me was a competent discourse on the disarray in the mental health provision in the country — despite the reports of several committees. A mention of lack of medical genetic facilities would have been appropriate.
The author has extensively narrated statistics from different countries as a contrast. Therefore it was all the more surprising not to find mention of Cuba’s remarkable successes in the healthcare field. I have written about that in the portal here. While the model may not be entirely applicable in the Indian context, it certainly had some very valuable lessons for us. The country has disproportionately concentrated on developing super specialty hospitals and completely ignored primary healthcare which has resulted in major problems. Cuba is woefully short of specialists but by concentrating on primary healthcare has earned praises for its healthcare successes which are nothing short of a revolution. All the successful healthcare systems have followed this two-tier system, e.g. Denmark, Switzerland, Sweden and Norway. That is the only way we are going to achieve the goal of Universal Health Care.
The author has very appropriately mentioned the constitutional provisions for healthcare in India. I would like to contrast that with the following article from the Cuban Constitution:
“Everyone has the right to health protection and care. The state guarantees this right by providing free medical and hospital care by means of the installations of the rural medical service network, polyclinics, hospitals, preventative and specialized treatment centres; by providing free dental care; by promoting the health publicity campaigns, health education, regular medical examinations, general vaccinations and other measures to prevent the outbreak of disease. All the population cooperates in these activities and plans through the social and mass organizations.” — Article 50 of the Cuban Constitution.
The distressing reality though is that in India healthcare has never been an election issue despite its colossal importance. Senior politicians and bureaucrats who have attempted to bring about revolutionary reforms have been prevented from doing so for expedient reasons. Most of us would remember what happened to a minister when he tried to take on the tobacco lobby.
And unless healthcare does become an election issue, we cannot expect any major changes.
But an information packed book like this has the potential to spur this debate in the right direction — and I sincerely hope it does.
I would like a copy of this book to be available in every public library and medical school libraries.
Health Care Reforms in India: Making up for the Lost Decades Hardcover
Author: Rajendra Pratap Gupta
Hardcover: 468 pages (Rs 995)
Publisher: Elsevier (Jan 2016)
by Dr Ashok Prasad