Friday, September 01, 2006

Punjab Loses Sight of Public Health

I came across this interesting article/op-ed about the state of Punjab's public health system:

Death due to AIDS, blood cancer, numerous malignant neoplasias, death from bird flu, SARS (Severe Acquired Respiratory Syndrome), or genetic disorders like hemophilia are inevitable to a certain extent. But death from malaria, tuberculosis, miscarriage (due to anemia) and from many more general diseases at the hands of unregistered medical practitioners is a common and wide-ranging phenomenon prevailing in Punjab, the land of the Green Revolution, a state that boasted the highest per capita income for approximately three decades from the 1960s onwards.

But today's public health system in Punjab has practically collapsed, largely coincident with the introduction of the Punjab Health System Corporation. Large buildings belonging to good hospitals are now crumbling, owing to negligence by the state government. These are the same buildings covering hundreds of hectares, including two state medical colleges, that produce doctors and provide health care at the primary, secondary, and tertiary levels to Punjabis. Even basic infrastructures, which were maintained until recently in these state-run institutions, are now nearing dilapidation.

The Punjab Health System Corporation was introduced in the mid 1990s, funneling millions of dollars from the World Bank into the healthcare infrastructure of Punjab. The deterioration of health services rapidly increased after its introduction. According to one survey report, "a 20-40 percent reduction in outpatient cases was recorded after the introduction of the PHSC -- even hospital occupancy has been reduced by 20 percent."Once there was not a single rupee charged to people with an income of just Rs 1,000 (US$21.50) a month. Additionally a charge was not made to recover at least a third of the costs from those with an income of Rs 2,000 a month, nor one to recover at least half the costs from those with an income of Rs 3,000 a month.

But after the introduction of the PHSC, this tiered system was no longer applied."Even now, Punjab does not have a building for 70 percent of subcenters, 67 percent of subsidiary health centers, 62 percent of primary heath centers, and 5 percent of community health centers," according to the Punjab Development Report for 2002.

Even today, when a large number of different diseases and their remediation have been identified, along with the need to revolutionize the primary (preventive) and tertiary (curative) levels of the healthcare infrastructure, the Punjab government is busy spending more for arms, building police barracks occupying thousands of hectares of land, and spending millions for a large share of the additional police force which is now surplus after the end of the decade-long period of Khalistan terrorism (Sikh militancy, late 1980s and early 90s) in Punjab.

In 1980-81, spending on health comprised 5.49 percent of the state budget in comparison to 8.28 percent on police and administration; in 1990-91, corresponding figures were 4.61 percent and 20.83 percent; and in 2003-04, the figures were 3.86 percent on health and 23.18 percent on police and administration.

The basic need and right of people for healthcare sees only a 3.86 percent share of the total state budget. Even during the tenth five-year plan (2002-2007) state spending on healthcare amounted to only 2.28 percent, but this is no surprise, as India nationally spends only 1.5 percent on healthcare. The question is, can anyone enjoy a better life expectancy if such a small amount is allocated to healthcare?

Even the statistical abstract of Punjab from 2005 contains its own ironies as the infrastructure deteriorates rapidly. The number of outpatients was 13,237,447 in 1980, as compared to 11,994,693 for 2004. The total number of beds in the medical facilities of Punjab was 24,179 in 1990, as compared with 25,192 for 2005 -- only a thousand more beds for a state with a population of 2.42 crores (24,200,000) (2001 census).

Further, we can see the importance of primary, or preventive, health care, which has been ruthlessly distorted by Punjab state policies. The progress of preventative care against nutritional anemia in Punjab in 1990-91 was 84.5 percent for children and 145.1 percent for expectant mothers, declining to 65.1 percent and 95.9 percent respectively in 2004-05. A similar situation obtains with immunization programs, which underwent a 101.1 percent increase for expectant mothers and a 125.94 percent increase for children (3-8 years); the respective figures for 2004-05 are 87.5 percent and 93.11 percent.One other precarious and shameful development occurring in the health system is the mushrooming number of private heath institutions and medical colleges in the state, though the phenomenon is nationwide.

Some of the bigger corporate sector firms like Escorts, Fortis, (owned by pharmaceutical giant Ranbaxy), and Apollo, are transforming healthcare into a business and reaping huge profits. Even individual entrepreneurs are setting up private nursing homes and multi-specialty hospitals. Consistent with this, we see a large number of doctors taking early retirement in recent years. A surgical procedure in these private hospitals will cost a minimum of Rs 1 lakh (i.e., Rs 100,000 or US$2,151) unaffordable even by middle class Indians or Punjabis. For the same reason the number of patients using public health institutions annually was 13,200,000 in 1980, but by 2004 this had decreased to 11,900,000, despite a population increase and a relative lack of heath awareness in 1980.

A recent move by the Punjab government, in which doctors would be appointed on a three-year contract and monitored by panchayat (village level governing body) under the "Alternative Service Delivery System," utilizes the 73rd Amendment to the Indian Constitution, which accommodated the Panchayati Raj institutions (1,300 doctors have been appointed so far). But a problem has been the absence of a body to implement the services in a better way. Feudal relations and the hegemony of the sarpanch (chairman of panchayat) may hinder the working-in of newly-graduated doctors appointed on a three-year contract, as the contract will be renewed only after the sarpanch delivers a favorable appraisal. This move gives the state government a pretext for withdrawing its support for the delivery of primary healthcare to the people.

Finally, there is concern about the character, quality, and moral fiber of the new doctors produced by these institutions and their concern for and emotional attachment to society. They become neither good doctors, even after spending lakhs of rupees in privately owned medical institutes, nor good healers for society. Even newly graduated doctors want to make crores of rupees by working in private corporate hospitals, instead of serving society. According to one survey, nearly two years ago 60 percent of students in Punjabi medical colleges were eager to run their own private hospitals. We can see the institutionalization of the profit motive from the mindset of current trainees in the healthcare system, something that should not obtain in the sphere of health in any event.Governments and private firms are actively promoting the privatization of healthcare in the West and other developed countries. But where is the range of insurance plans that could fund preventive care for people together with whatever treatment is necessary? This is the quandary of the Indian system, in which insurance is necessary for motor vehicles to use the roads but not for the health of its people. Health is not a profit-oriented business but the right of people without regard to religion, caste, or country. Nations waving the flag of development provide free health care to every citizen. How can we expect athletes, scientists, engineers, doctors, intellectuals, writers, and even politicians to come from an ailing and diseased society?

1 comment:

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