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AN IIPM THINK TANK & GREAT INDIANDREAM FOUNDATION JOURNAL

Dream

GreatIndian

R E T H I N K E D I F Y D E L I N E A T E

Te

POISONEDPOLICIES22POISONEDPOLICIES 22

How despite of law reforms femalefoeticide is still prevalent in India?

ow despite of law reforms feSELECTIVEDISCRIMINATION 18ELECTIVE DISCRIMINATION 18

Why pricing is a Red Herring inhealth-care access?Why pricing is a Red HerrinBILLSOVERPILLS 10

Lack of central planning is deprivingIndians of equitable access to health-care

HOW THE FAULTY

HEALTH POLICIES

COULD NEVER MAKE

IT UNIVERSAL

SURVIVING ONVENTILATOR!

R

AB&EMONTHLYSUPPLE

MENT,DEC-2011;ISSN

2249-5215

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THE INDIA

ECONOMY REVIEW

THE GREAT INDIANDREAM

A N I I P M T H I N K T A N K & G R E A T I N D I A N

D R E A M F O U N D A T I O N J O U R N A L

TO TAKE

FORWARD THEPHILOSOPHYOF COMMITMNETTO OUR GREATNATIONEPITOMISEDIN THE PATH

BREAKING BOOKTHEGREATINDIANDREAM

is now

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PRAISES FOR THE GID

DreamGreatIndian

R E T H I N K E D I F Y D E L I N E A T E

Te

S Chinnam ReddyDean,

Faculty of Management

Joelle BurbankAssociate,

The Fund for Peace

R Vishal OberoiCEO,

Market Xcel

Marcin MenkesAnalyst,

PISM, Poland

The Great Indian Dreamis one of the mostintelligently writtenexecutive grade academicJournal. It offers latest andseminal updates in mattersrelated to economicpolicies and their effects inIndia as well as the rest ofthe world. The Journalfeatures the most concise,globe-encompassingwrap-ups of business andeconomies. The Novemberissue of the GID providesan insight on the geo-

political shifts happeningthrough out the globe. Inmy opinion, the GID is avery well writtenpublication with valuableinsights for readers. Iwould like to congratulatethe IIPM Think Tankteam for bringing out sucha brilliant issue. All thebest for the future issues.

The November issue of theGreat Indian Dream hasexposed the failed statesand how they couldpotentially disrupt worldpeace at large.

The Great Indian Dreamjournal as a whole looksexcellent and intellectual.As far as the content andcoverage of topics go, Ifind the journal quitefascinating to read. Widerange of topics coupledwith sleek design is trulyunmatchable especially ifwe compare it with otheracademic journals in thesame league. In a way, it isan articulate journaladdressing the germaneissues in India. The

journal comprises ofanalytical and cohesivearticles which provideuninhibited globalperspectives. I wish theentire IIPM Think Tankteam all the success fortheir journal and hope thatthey continue to providereaders with candidinformative platforms.

As an aspiring academicfrom the West, it is alwaysrefreshing to read contentconcerning Asia. The GIDdoes a great job blending adiverse mix of topics.

Rok SprukEconomist,Slovenia

Amartya MukhopadhyayProfessor,

University of Calcutta

Congratulation for trulyhigh-quality editions ofthe GID that are of theprime importance to thefuture of Indias thrivingeconomy.

With its gloss and colourthe GID is a welcomechange in the tradition ofacademic publishing. Thelist of contributors covers awide area.

ANIIPMTHINK TANK

&GREATINDIAN

DREAM FOUNDATION

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GAMESNATIONSPLAY

Dream

GreatIndian

Te

THEGLOBALCIRCUS

PAIR INGWEAKS28

Theriseof India and Chinais

challengingthe supremacy of

theUSEMERGIN

GEAST24

Thehurdles inthe tradenego

tations

that hauntIndiaand EU

INDO-EURIFT20

Why small countries have to

kneel

before theworldssuper-pow

ers?

AB&EMONTHLYSUPPLEMENT,

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FOUNDER :Dr. M. K. ChaudhuriEDITOR-IN-CHIEF: Arindam Chaudhuri

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CREDITS(F)ACT SHEET

Continuous Learning in Medical Profession should be

Made Mandatory!

Prasoon S. Majumdar........................................................................................ 05

Entry Prohibited

Shivaji Sarkar....................................................................................................... 06

Why Pricing is a Red Herring in Healthcare Access?

Ashok Jinghan.................................................................................................... 10

Burning a Hole in the Pocket

Brijesh C. Purohit ............................................................................................... 12

Cash Crunch

Gautam Chaktraborty & Arun B Nair ........................................................... 16

When will Womb be Safe for our Girls?

Sukhamay Paul ................................................................................................... 18

Cashing on the Tourist

K R Bolton ............................................................................................................. 22

Making Health Insurance a Reality

Akash Acharya..................................................................................................... 26

Health and System Challenges

Sarit Kumar Rout ................................................................................................ 30

Health Programmes : A Soft Insight to why We Fail

S C Mohapatra & Archisman Mohapatra ..................................................... 34

UHC could be the Nex t Big Social Trump Card

Mohsin Wali Khan .............................................................................................. 38

How much does AIDS Add up to?

Vinod B. Annigeri ............................................................................................... 40

Cover Design: Satyajit Datta

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5T H E G R E A T I N D I A N D R E A M

The First Words and The Last WordEditorial

CONTINUOUS LEARNING IN

MEDICAL PROFESSION SHOULDBE MADE MANDATORY!

Acouple of days back, one of my colleagues

went to Delhis one of the best nursing homesto consult a physician for his ulcer problem.

The doctor during consultancy told him that ulcersare not curable and there is no permanent solution.

However he was not very convinced and did a Goog-le search and found that in 2004 two scientists wereawarded Nobel Prize for their breakthrough solutionfor this so-called incurable disease. The moot pointhere is not that how the doctors are ill-informed butabout the very mechanism that keeps or rather shallI say, forces the docs to keep themselves updated.

Today, after completing their MBBS (or MD), mostof the doctors rarely go back to books for updatingtheir knowledge base. Most of the doctors in Indiaare still relying on medicines and treatment theycame across during their initial days of practice!Thus, the new discoveries and health research that

are changing the very DNA of medicine and medicaltreatment are kept alien to the Indian masses. Con-

ventionally, Indian doctors bank upon the medicalrepresentative and the brochures that they carry(again self-advertised) as source of information. Ivecome across several occasions wherein doctors di-rectly pick up these brochures and pen down medi-cines without referring back to medicinal develop-ments that are taking place around the world.

Medicine is one of those professions where thesociety believes that the person at the giving endwould always uphold his professional competencyand would serve his customers with best of treatment

available. Given the pace of scientific research andbreakthrough happening, it is impossible for a doc-tor to remain proficient without undergoing a com-prehensive and regular training module. Keepingthis concept in mind, the Medical Council of Indiahas proposed a bill to make continuous medicallearning compulsory in India, but the law makersare yet to give it a nod. In the same light, Society for

Prasoon S. Majumdar, Executive Editor

Academic Continuing Medical Education ensuresthat such facility is extended to medical practitionersin the West and UK and some parts of Europe.Many states in the US have made it mandatory formedical practitioners to attend continuous medical

education programs in order to keep practicing andmaintain their licenses. The duration of the programvaries from 40 hours to 60 hours and needs to beattended every 2-4 years. The old breed of doctors,

who understand diseases and symptoms within sec-onds, all thanks to their years of experience, end upsuggesting decade-old treatments rather than expos-ing Indian masses to the latest state-of-art healthcare updates!

Given the fact that agencies across the world areinvesting millions in such researches, keeping mass-es bereft of these developments is nothing less thana crime. Medical fraternity and the health ministry

should make continuous medical examination com-pulsory (every three years or so) and organise medicalseminars across India every six months. Doctors whoskip these exams should be legally and profession-ally prosecuted as well! This is more important incase of India, where majority of patients are suffer-ing from diseases that are highly contagious and fewof them have even been eradicated from the otherparts of the world. Thus, continuous learning be-comes more important for these strata of docs whoserve this pocket of population, so that these patientscan receive best available treatment and not remaina carrier of inflections for long!Happy reading.Best,

Prasoon S. Majumdar

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SURVIVING ON VENTILATOR

15 per centof the Indianpopulation

does not haveaccess to health

care due tounavailability of

resources

ENTRY PROHIB

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S E L E C T I V E D I S C R I M I N A T I O N


The sudden deaths of scores ofnew-born and infants in onecase 45 deaths in a week - atgovernment hospitals in West

Bengal exposed the chinks in the healthcare. Have we achieved nothing in 64

years since the country became inde-pendent? Thats possibly not true. Lifeexpectancy has increased from an aver-age of 38 years in 1950 to 63.2 yearsnow. The government can claim that ithas been able to take care of manyuniversalised immunisation pro-grammes, countered many infectiousdiseases and better health care inbroader terms. Some of the diseaseslike small pox have been eradicated,polio incidence reduced to the mini-mum and many other killer diseases

virtually eliminated. Despite this, infantmortality still remains high and accord-ing to Unicef, every fourth infant to diein the world is from India.

The health sector is a contrast. Poorand average Indians find access to medi-care difficult, consultations expensiveand medicines beyond their reach. Onthe other hand India is developing intoa hub of medical tourism as it has theadvantage of highly qualified profes-sionals, varied health care programmes,and an affordable cost-effective treat-

ment for foreigners. Indian medicaltourism income is expected to reachupto Rs 8,000 Crore by 2012 on back ofits low-cost medical treatment and a vastpool of well-qualified medical profes-sionals, according to Associated Cham-bers of Commerce of Commerce andIndustry of India (ASSOCHAM).

But in terms of life expectancy, India

remains far behind Japan, US and Eu-rope. Even China has leaped forwardand is now only two years behind Eu-rope. India remains eight years behindChina, which has a life expectancy of 72

years. The private expensive healthcare sector has grown phenomenally. Itcaters to the affluent and some middleclass people who can afford health in-surance, an expensive proposition. Thesilver lining is Rashtriya Swasthya BimaYojana (RSBM), presently restricted tothe poor people and ensures healthcare upto Rs 30,000 for a premium ofRs 30. It has helped a large rural popu-lace and women in particular, who gofor medicare rarely in Indian homes.

Statistically, India has one of the besthealth systems spread all over the coun-try. As per health ministry, there are137,000 sub-centres, 28,000 dispensa-ries, 23,000 primary health care (PHC),3,000 centralised health care (CHC),and about 12,000 secondary & tertiaryhospitals. The whole administrative setup may appear large but most of thehealth care facilities are under-staffed,and under-staffing is most prominentin the rural health care sector. It is alsothe worst administered and stated to beleast honest.

About 15 per cent of Indian popula-

tion does not have access to health caredue to reasons of unavailability or dueto economic reasons. Expansion ofhealth care in India has been mostlyurban oriented while major part ofpopulation lives in rural or semi-urbanlocations. Mushrooming of privatehospitals in India has been in the urbanareas, and is highly profit oriented.

SHIVAJI SARKARSenior Journalist;Ex-Sr. Editor, The Financial ExpressITED

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8 T H E I I P M T H I N K T A N K


Public health care systems are becom-ing extinct by the day. Insurance sys-tem, often tried to be promoted bygovernment officials do not suit Indianconditions since a very large section ofrural and urban population would not

be able to afford it, and the governmentmay not find the required budget tosubisidise it.

The allocation for the health sectorin 2011-12 budget is Rs. 26750 crore. Inreal terms, it is a little over one per centof the GDP calculated at Rs 89,80,860crore. A survey by the Organisation forEconomic Co-operation and Develop-ment says only seven countries in theworld spend less money than India onpublic health. It is an irony that whileengineering colleges have proliferatedalmost everywhere, there are not manymedical colleges. It has created a short-age of doctors, hospitals and madehealth care difficult. The 12th plan pa-per, despite acknowledging the malaise,does not try to solve it. It has come outwith a programme for free universalhealth coverage despite the experiencethat the government hospitals have notbeen able to provide it to most patientsduring the last many decades.

It has also led to a thriving parallelmarket promoting corrupt practices inthe government hospital system. Theproblem is so deep-rooted that it hasled to murder of two chief medical of-ficers in Uttar Pradesh during the lasttwo years. As a policy, giving anythingfree from a government-run systemmay have populist value to garner votesbut in real terms it has always been adisaster. The planning commissionsconcern is welcome but the prescrip-tion has least practicality. The malaiseis deeper. It is not restricted to provi-sion of free medicare. Even now stateslike Delhi is supposed to have the bestsystem with New Delhi Municipal

Committee (NDMC

) and MunicipalCorporation of Delhi (MCD) runningmany free dispensaries, but doctorsoften do not visit the dispensaries andthe prescribed medicines are rarelyavailable at the dispensaries. Similarlythe primary health care centres aredysfunctional in most states. In placeslike UP and some other states, some-

times these are used as cattle sheds.The state government-run hospitalshave lost credibility. Everyone wants toavoid these. The complaint is often notwith doctors, but para-medics rarelygive the service. Doctors may be con-

science but they are far fewer in termsof the number of patients. The govern-ment-run systems are also facing exo-dus of top doctors as per a Delhi gov-ernment statement. Specialists ingynaecology, anaesthetics, ophthalmol-ogy, ENT, paediatrics, neurology andpulmonary medicines are quitting asthey do not find service conditionsconducive. The gain is that of privaterun hospitals. To our despair, Health-care is ailing. It has become extremelyexpensive and it is not only makingpoor poorer, even cash rich Indiancompanies are grappling with an aver-age of 10 per cent rise in costs over thelast three years. While private spendingon health in India is 4.2 per cent ofGDP, public expenditure is estimatedat a mere 0.9 per cent, among the low-est in the world and ahead of only fourcountries Pakistan, Burundi, Myan-mar and Laos.

According to a Planning Commis-sion paper, private spending on healthis 4.2 per cent of GDP. More than 70per cent of all health expenditure in thecountry is paid for by people from theirown pocket. This expenditure has beenrising, particularly for the poorest. Theplan panel estimates that it has pushed3.9 crore people into poverty due toout-of-pocket medical payments. Acorporate survey conducted by WatsonWyatt, a global consulting firm special-ising in insurance, financial services,human consulting and employee ben-efits, has found that most Indian com-panies providing health care cover totheir employees are grappling with anaverage of 10 per cent rise in premiums

over the last three years. The mainreasons for this are, the emergence ofnew medical technologies and over-recommendation of services, the surveysaid. A related discomfort is the risingcost of medicines. With multi-nationalcorporations taking over Indian phar-maceutical companies, the healthministry is expressing concern of mo-

nopolisation of the sector and furtherrise in drug prices. The governmentpolicies vary from ministry to ministry.Drug farms, though cater to the healthministry causes are controlled by min-istry of industry and ministry chemicals,

who have different concerns and pro-moting foreign investment in the sec-tor. The health minister speaks for theailing populace and other ministersboast of bringing in more investment.

The World Congress of the Interna-tional Health Economics Associationheld in Beijing in July 2009 stated thatIndia figures at the bottom if one takesthe government share in total healthexpenditure. It is less than 25 per centin India against 76 per cent in Europeand 34 per cent in South-East Asia.

The ILO has called upon Indiangovernment to rectify this as poorhealth care leads to lost years of incomedue to short and long-term disabilityfamily members, lower productivity,and the impaired education and socialdevelopment of children. The ILOstates that poor health care conditionshave given rise to micro-insurers, whopurchase products from state-runhospitals and facilities to provide serv-ice to deprived poorer sections. The

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poor have to bear cost of transporta-tion and loss of earnings as add-ons toillness. In reality, despite many pro-nouncements, health has been a lowpriority area for the government. Itcalls for a complete re-look, including

recasting the central ministry of health.It remains a service-oriented ministry.Even its remote arm Medical Councilof India, is a toothless wonder. Theministry suggests policies but these areeither implemented by other ministrieslike industry or chemicals or even con-sumer affairs or if insurance it is thefinance ministry. Some other functionsare left to the states. The bias is alwaysagainst the health ministry.

As corporate enter the area, it is seenas a profitable market and patients arenothing but a commodity for them.Corporate hospitals do not adhere toHippocratic Oath. They function morelike hotels catering also to health careneeds and charge as per norms in theluxury hotel industry. The immediateneed for the health sector is to takecare of how it could be affordable foreverybody. Higher cost is detrimentalnot only for the causes of health but italso mounts cost on entire economy.The government hospitals all over the

country need serious treatment to bringthem back to health. But private busi-ness interests come in the way. So doesthe insurance companies. Low costgovernment hospitals are not goodbusiness models for them. It calls forintroduction of a low-cost universalisedhealth model. It does not need to ex-clude the private sector. It should alsonot be subservient to it. It is also truethat the government alone cannot runthe show countrywide. The universalhealth system has to begin with largeinvestment in medical education andcreate a network of medicos that couldspread to all over the country. There isno reason to restrict medical educationto help the monopolies of many kinds.It also needs to allow proliferation ofhospitals and dispensary systems tocreate a competition on the price front.Today a caesarean section surgery costs

Rs 3500 to Rs 50,000 or more. A com-petitive medicare system could reducethe same and help the poor.

Regulatory mechanism in India andChina for drugs, hospital services orinsurance has been one of the worstproblems. In some cases the regulatorsare found to act not in favour of thesufferer. While considering health,physical culture, nutrition and variousdifferent systems indigenous, orien-tal and occidental need to be

brought under one policy umbrella.Now many of these are away from theambit of health ministry. Expecting amiraculous solution in a short spanshould not be the idea. But it must be atargeted approach to create a low-costuniversalised overall health care to allIndians in a decade. A good healthprovider nation could hope to becomethe super power it has been aiming forthe last many years. The solution in acountry with such a vast expanse is noteasy. Mere cosmetic increase in budg-etary allocations would not solve theproblem. The government has to initi-ate steps to resuscitate the system anddelivery mechanism that it has built upand act ruthlessly so that the benefitcould reach the people. It should desistfrom promoting insurance business andprovide direct relief to the people sothat the nation could have healthy andproductive people who would add tothe GDP.

(SHIVAJI SARKAR is a is a seniorjournalist, ex Sr Editor with The Finan-cial Express, Delhi. He writes on socio-economic and politico-economic issuesand is an expert commentator.

The views expressed in the article arepersonal and do not reflect the officialpolicy or position of the organisation.)

RISING MEDICAL COST IN INDIA

IS NOT ONLY DETRIMENTAL FOR

HEALTHCARE FACILITIES BUT ADDS

PRESSURE ON THE ENTIRE ECONOMY

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Healthcare authorities should stop flogging the dead horse ofpricing and focus on issues such as inadequate infrastructureto make healthcare access an accomplished mission

WHY PRICING IS A

RED HERRINGIN HEALTHCARE ACCESS?

ASHOK JINGHANChairman, Delhi DiabetesResearch Centre

Unlike most nations, in India, theresa general tendency to pass thebuck. Over generations, this hasbecome second nature, especially

for people in positions of power. One way ofpassing the buck is by introducing a red her-ring something that diverts attention awayfrom the real issue.

A classic case is the Governments inabilityto ensure universal healthcare access even 64years after Independence. Therefore, eachtime criticism swells about the sorry state ofhealthcare access, the authorities simply di-

vert attention by introducing red herring high drug prices. Had high drug prices notplayed spoilsport, the official refrain goes,healthcare access would have been a groundreality. The so-called solution: price controlof drugs.

The truth is pricing neither drives norhinders healthcare access. Just as there isactually no fish species called red herring,pricing being liable for the lack of healthcareaccess is an absolute myth. If pricing couldpropel access, India would never have had ahigh percentage of anaemic women par-ticularly since iron supplements are availablefor free in Primary Health Centres (PHCs)

across India.Clearly, pricing is not the problem. The

actual issue is that India suffers from lack ofavailability of medicines, an insufficientnumber of doctors or absence of healthcarepersonnel, and inadequate healthcare infra-structure. In other words, even if the officialpolicy dictates free distribution of iron tablets,they first need to be in stock. Doctors are thenrequired to prescribe these for patients. Fi-nally, PHCs need to be located within strikingdistance of rural or urban centres for patientsto procure these free iron supplements.

Therefore, though the official policy of freesupplements exists on paper, the ground real-ity of the other three conditions is rarely ful-filled in tandem. Even if one of the three re-quirements is missing availability ofsupplements, doctors on duty, PHC in the vi-

cinity the chain is broken and delivery offree iron supplements never occurs.An analysis of prices of 53 drugs based on

purchasing power parity revealed that Indiahas cheaper drugs than other countries suchas Pakistan, Philippines, Malaysia, China,Thailand and Indonesia.

To quote specific rates, consider the pricesof Diclofenac Sodium 50 mg (10-pack): in


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B I L L S O V E R P I L L S

India it costs Rs 3.50; in Pakistan, Rs 84.71;Indonesia, Rs 59.75; US, Rs 674.77, UK, Rs60.96. Similarly, prices for Omeprazole, 30 mgcapsules (10-pack): India Rs 38.40; Pakistan,Rs 578.00; Indonesia, Rs 290.75; US, Rs2,047.50, UK, Rs 870.91.

Moreover, inflation for pharmaceuticalproducts is much lower than that of other es-sential commodities. While, pharma pricesincreased barely 0.5% in 2010, food inflationduring the same year was 14.4%.The price riseindex for essential commodities between 2006and 2010 also bears this out. While oilseedsrose 11.2%, sugar 14.9%, onion 36.0%, pota-toes 11.0%, salt 17.0% and food 9.4%, phar-maceuticals only showed a nominal increaseof one of percent.

It should be clear by now that since pricesof medicines in India are amongst the lowestworldwide, pricing is not a barrier for health-care access. In order to access medicines,Indias poor are largely reliant on the Govern-ment Healthcare Systems represented byPHCs. But with the system plagued by inad-equate infrastructure, poor availability ofdrugs in PHCs and shortage of doctors,nurses and pharmacists, it is these issues thatneed to be addressed.

To elaborate, it is estimated that across In-dia, theres a cumulative shortfall of approxi-mately 17,000 PHCs. Due to this, patients donot have an easy access to medical help, sincethe nearest PHC could be too far away to bereached on foot. Across PHCs in India, theresan estimated shortfall of 8,500 doctors, while41% PHCs do not have health workers.

As long as the authorities flaunt the redherring of drug prices and keep bandyingdrug price control as an ostensible solution,healthcare access will always remain a miragein India. The sooner they focus on the realissues by improving and augmenting health-care infrastructure, increasing the number ofmedical personnel and ensuring year-roundavailability of drugs, the faster will India beable to fulfill its mission of universal health-care access.

(DR. ASHOK JINGHAN is the Chairman,Delhi Diabetes Research Centre and is a mem-ber of IHPs Expert Panel.

The views expressed in the article are personaland do not reflect the official policy or positionof the organisation.)

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BRIJESH C. PUROHITProfessor, Madras School ofEconomics, Chennai



The growing medical expenditure due to surfacing of private players isposing a threat to completely deny access to health care to the poor

It is now universally recognized thathealth of the people plays a signifi-cant role in the overall develop-ment of a nation. Ever since Inde-

pendence, Indian planners have aimedat achieving an efficient health system.Since the beginning, the Bhore Com-mittee (Government of India, 1946)formed the basis for adopting a modelof the health system which mainly re-

lied on the States investment which inturn is determined by outlays allocatedto health in the Five Year Plans.

The three major players catering tothe health of the countrys populationinclude public sector (comprising Cen-tral, State and local governments andtheir institutions), private sector andNGOs. The public sector health serv-

ices are further categorized in terms ofprimary, secondary and tertiary care.

The primary responsibility of healthcare in the Indian Constitution, how-ever, rests with the States. In general,a major chunk of the public expendi-ture (almost 90 percent) on the healthcare sector in the country comesthrough the States budget. However,there is also a certain degree of finan-

cial dependence of States on the Cen-tre with regard to the health sectorexpenditures. First, Central fundinghelps the States to run the family plan-ning programmes and centrally spon-sored schemes like national diseasecontrol programmes (including leprosy,

malaria, tuberculosis), immunization,nutrition schemes and the components

of primary healthcare, rural water sup-ply and sanitation which fall under theminimum needs programme of theCentre. The funding from the CentralGovernment to the States comes eitheras cent percent grants or partly throughmatching grants. In the latter, theStates have to contribute through amatching contribution from theirbudgets. Secondly, the Central Gov-

ernment provides the total funds formedical research and education in theCentrally-funded institutions.

At present, however, in the overallspending on health in the country, theshare of all governments (Central, State

and local) comprises nearly 23.8%. Amajor chunk comes from the householdsector (68.8%) and others (including

BURNING A HOLEIN THE POCKET

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corporate sector) comprise the rest. Thehealth sector is indeed grossly underfunded. The overall public sectorspending on health in India, which onthe revenue account was 0.22% ofGDP in 1950-51, has remained merely

around 0.9% of GDP.

EVOLUTION OF SYSTEM

The investment in the health sector hasbeen through each of the five year plansin the country. From First Five YearPlan (1951-56) which emphasizedhealth-related issues like: malaria con-trol, preventive care in rural areas,maternal and child health (MCH) serv-ices, family planning and populationcontrol, and water supply and sanita-tion and vertical programmes pertain-ing to preventable diseases; the subse-quent five year plans had their focustuned to suit the contemporary require-ments of the nation. Thus a major shiftin focus from preventive programmesto family planning was witnessed in theThird Plan (1961-66). The strengthen-ing of the rural PHCs and existing

vertical programmes received the at-tention in the Fourth plan (1969-74). Aslight shift in the Fifth plan (1974-79)occurred with an attempt towards inte-gration of the peripheral staff engagedin vertical health programmes. Further,the Alma Ata declaration in 1978 andICMR/ICSSR report (ICSSR, 1980)shaped the health sector priorities andhad an impact on health priorities inthe Sixth Plan (1980-84) which envis-aged to integrate the development ofthe health system with the overall mi-lieu of socio-economic and politicalchange in the country.

A major guideline for the healthsector in the country evolved with theformulation of the National HealthPolicy in 1983. This policy reflectedthe commitment of India to attain the

goal of Health for All by the Year2000 AD. The Seventh Plan (1985-90)and the Eighth Plan (1992-97) had anotable shift with major focus beingput on rural health programmes andprivate sectors contribution to thehealth sector. The structural adjust-ments and less expenditure on healthin the initial Plan years coupled with

international funding of vertical pro-grammes changed the focus of the fiveyear plan priorities towards increasedprivate sector participation in thehealth sector. The subsequent planperiods of 1997-2002 (Ninth Plan) and

2002-07 (Tenth Plan) emphasized pri-mary care, referral services and decen-tralization in the health care sector.Again in 2002, GOI brought out a newNational Health Policy (NHP 2002)

which listed the achievements in thehealth sector between the years1951-2001. Based on achievements sofar and keeping in view new threatsfrom diseases like HIV and AIDS,NHP 2002 listed the new goals to beachieved between the years 2000-15.Some of the other notable features ofNHP 2002 were: the need for: en-hanced health facilities, organiza-tional restructuring, more equitableaccess to health care facilities, empha-sis on control of diseases contributingto high mortality (e.g., Malaria, HIV/

AIDS) and designing of separateschemes tailor made to the healthneeds of women, children, aged per-sons, tribal and other socio-economi-cally backward sections of society.

MAJOR CHALLENGES

Notably, India has achieved importantmilestones due to sustained plannedefforts. As a result, during 1947 to 2011,life expectancy has more than doubledfrom 32 years to 66.8 years. Diseaseslike smallpox and guinea worm arenon-existent. Leprosy and polio willsoon be eliminated. Despite all theseachievements with the prevailing Na-tional and State health policies and thesystematic five year plan health sectorpriorities, there are numerous discon-certing features and new emerging is-sues in the health care sector in India.The distressing facts that emerge are:

our total population (16.5% of globaltotal population) accounts for one fifthof the worlds share of diseases; a thirdof the diarrhoeal diseases, TB, respira-tory and parasitic infections; a quarterof maternal conditions; a fifth of nutri-tional deficiencies, diabetes, venerealdiseases; and the second largestnumber of HIV/AIDS cases after SouthAfrica (GoI 2005).

Besides this high disease burden, theoverall state financing of health caresector in India, as noted earlier, hasbeen inadequate resulting in an unsat-isfactory distribution of infrastructureand resources in the health care sector.This has lead to undesirable outcomes

ENHANCING EFFICIENCY IN THE

PUBLIC SECTOR OR ACHIEVING

AN OPTIMAL MIX OF PUBLIC AND

PRIVATE SECTOR IS A MUST


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To achieve better health outcomes and reduce catastrophic healthexpenditure, the government is infusing hefty amount. But is it enough?


Health Financing deals withthe sources of funding thehealth expenditures. At themacro-economic level, the

pattern of financing the health ex-penditure determines whether the ar-rangement is efficient and equitable. Ahigher out-of-pocket (OOP) expendi-ture on healthcare, especially by ruralpopulation, accompanied by lowerproportion of public funded healthcaredelivery, is considered to be inequita-ble. As reported by a WHO technicalbrief in 2005, every year, approximate-ly 44 million households throughoutthe world face catastrophic expendi-ture, and about 25 million householdsare pushed into poverty by the need topay for services. India is a typical caseof lopsided financing of healthcare, asis evident from the National HealthAccounts (NHA) report pertaining tothe year 2004-05. As per the NHA(2004-05), the total health expenditurein India, from all the sources was Rs.1,337,763 million, constituting 4.25%of the GDP. Of the total health ex-penditure, the share of private sector

was the highest with 78.05%, publicsector at 19.67% and the external flowscontributed 2.28%. The provisionalestimates from 2005-06 to 2008-09shows that health expenditure as ashare of GDP has come down to 4.13%

in 2008-09. Though health expenditurehas increased in absolute terms, theproportionately higher growth of GDPhas resulted in a moderate increase inthe share of health expenditure to GDPover the years.

Kerala has the best achievementscores for HDI, IMR and for life ex-pectancy, three related indices of

CASH CRUNCH

health outcomes. The OOP in the gov-ernment hospital is twice as much asTamil Nadu has but certainly muchlower than the other states. Punjab hasthe next highest HDI and life expect-ancy but an IMR significantly higherthan both Kerala and Tamil Nadu, andmany other service indicators of healthcare where it is not within the first fouror five. Also, like Kerala, it achievesthis health outcome for a much higherpublic and private expenditure onhealth, the latter representing 84% ofthe total health expenditure. What ismuch more important is the huge OOPon hospitalization in the public sector ,almost nine times the Tamil Nadu fig-ure. Tamil Nadu and Maharashtra havealmost similar figures on life expect-ancy, HDI, and even on IMR. Howev-er, in Tamil Nadu, the per capita privateexpenditure on health is significantlyless and forms only 76% of the totalhealth expenditure as compared to80% for Maharashtra. Also, the totalout-of-pocket expenditure in the publichospital is the lowest for the nation inTamil Nadu.

Looking at the significance of publichealth expenditure in achieving betterhealth outcomes and reducing cata-strophic health expenditure, the centraland state governments in India havebeen increasing their expenditure on

health, especially since 2005-06, coin-ciding with the launch of the NationalRural Health Mission (NRHM). Thecentral government budgetary ex-penditure for health increased by 21.45per cent per year (compounded annu-ally) in the post NRHM phase (2005-06to 2009-10) as compared to 10.85 percent per year in the pre-NRHM period

GAUTAM CHAKTRABORTYAdvisor Health Care Financing,NHSRC, New Delhi

ARUN B NAIR

Consultant Health Economist,NHSRC, New Delhi


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I N A D E Q U A T E A L L O C A T I O N

with an increase from 40.7% in 2001-02to 90.3% in 2004-05 and to 95.1% in2007-08. The increasing trends in gen-eral health expenditure, and more sig-nificantly, the capital expenditure, re-flects an increased capacity of states innot only absorbing funds, but also make

significant improvement in assets crea-tion in the public health sector. This isa welcome trend that addresses thedecades of neglect faced by the publichealth sector, especially since the dec-ade of financial crisis and structuraladjustments in the 90s.

Apart from increasing public ex-penditure on direct provision of health-

care, the central and state governmentshave also initiated various innovativeschemes to increase access and choiceof healthcare provider (public or pri-vate) to the people, especially in theform of various subsidized health insur-

ance schemes. In order to reduce theout-of-pocket expenditure of poor sec-tions of the society especially the unor-ganized sector which constitutes 93%of the total work force, the XI Planenvisages effective risk pooling arrange-ments at the state level. A lot of healthinsurance schemes have been launchedin the recent past, with RashtriyaSwasthya Bima Yojana (RSBY) beingthe most important one announced inthe Union Budget 2007-08. The schemealso has a provision of smart card to beissued to the beneficiaries to enablecashless transaction for health care.The cost of smart card would also beborne by Central Government.

Many state governments have initi-ated health insurance schemes for theBPL population and unorganized

workers. The major focus of theseschemes are to cover identified tertiarycare diseases which involves cata-strophic expenditure and are not cov-ered under any other pre-existinghealth programmes.

Thus, together with increased healthoutlay for direct (public) provisioningof healthcare services to the people, theinnovative and subsidized health financ-ing and insurance schemes launched bycentral and state governments aim atincreasing the total proportion of publichealth expenditure and reduce the out-of-pocket expenditure by the people forenhanced access, equity and financialprotection along with achieving betterhealth outcomes.

(GAUTAM CHAKRABORTY is cur-

rently working as an Advisor, HealthCare Financing, NHSRC, New Delhi.

ARUN B NAIR is currently working as aConsultant - Health Economist, NHRSC.


(2001-02 to 2004-05). The increase wasfrom 9650 crores in 2005-06 to 20,996crores in 2009-10 and this includes theNRHM. In 2009-10, the NRHM re-lease was Rs. 11,225 crores and thiscomes to 53.46 % of the central govern-ment health budget.

It can be seen from the RBI (study ofbudgets) data for the state health ex-penditure details that the utilization ofrevenue expenditure of state healthbudget for all states increased from91.4% in 2001-02 to 93.8% in 2004-05and marginally declined to 92.1% in2007-08. Utilization of capital expend-iture for all states is more significant

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WHEN WILLWHEN WILLWOMB BE SAFEWOMB BE SAFEFOR OURFOR OUR GIRLS?GIRLS?

Reforms and law enforcements claimtheir strong foothold in the society

but ground reality is way belowexpectations and the situation is justgetting worse by every passing year



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Ultrasound scanning, being a non-inva-sive technique, quickly gained popularityand is now available in some of the mostremote rural areas. Both techniques arenow being used for sex determinationwith the intention of abortion if the foetusturns out to be female. These methods donot involve manipulation of genetic mate-rial to select the sex of a baby.

Recent preconception gender selec-tion (PCS), however, includes flow cy-tometry, preimplantation gender deter-mination of the embryo, and in vitrofertilization to ensure the birth of ababy of the desired sex without under-going abortion. Ironically, it is beingused in India to avoid giving birth togirl children.

The killing of women exists in variousforms, in societies, the world over. How-ever, Indian society displays some uniqueand particularly brutal versions, such asdowry deaths and sati. Female foeticideis an extreme manifestation of violenceagainst women. Female fetuses are selec-tively aborted after pre-natal sex determi-nation, thus avoiding the birth of girls. Nomoral or ethical principle supports sucha procedure for gender identification.The situation is further worsened by alack of awareness of womens rights andby the indifferent attitude of Govern-ments and medical professionals. Thepregnant woman, though often equally

anxious to have a boy, is frequently pres-surized to undergo such procedures.Many women suffer from psychologicaltrauma as a result of forcibly undergoingrepeated abortions.

As a result of selective abortion be-tween 35 and 40 million girls and womenare missing from the Indian population.

United Nations says an estimated2,000 unborn girls are illegallyaborted every day in India. Inmost parts of India, sons are

viewed as breadwinners who will lookafter their parents and carry on the fam-ily name, but daughters are viewed as fi-nancial liabilities for which they will haveto pay substantial dowries to get marriedoff. Increasing female feticide in Indiacould spark a demographic crisis wherefewer women in society will result in a risein sexual violence and child abuse even as

well as wife-sharing.Demographers warn that in the next

twenty years there will be a shortage ofbrides in the marriage market mainlybecause of the adverse juvenile sex ratio,combined with an overall decline infertility. While fertility is declining morerapidly in urban and educated families,nevertheless the preference for malechildren remain strong. For these fami-lies, modern medical technologies are

within easy reach. Thus selective abor-tion and sex selection are becomingmore common.

Some of the worst gender ratios, indi-cating gross violation of womens rights,are found in South and East Asian coun-tries such as India and China. In India,the available legislation for prevention ofsex determination needs strict implemen-tation, alongside the launching of pro-

grammes aimed at altering attitudes, in-cluding those prevalent in the medicalprofession. Most of those in the medicalprofession, being part of the same genderbiased society, are steeped in the sameattitudes concerning women. It is scarce-ly surprising that they are happy to fulfillthe demands of prospective parents.

SUKHAMAY PAULChairman, Coochbehar Jan ShikshanSansthan (Institute of Peoples Education)under Ministry of H.R.D. Govt. of India

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Medical malpractice in this area is flour-ishing. In many states, these acts havehad little effect.

Female infanticide was prohibitedthrough legislation in pre-independentIndia. However, the law was toothless andthere were few, if any, convictions.

The Act has a central and state levelSupervisory Board, an Appropriate Au-thority, and supporting Advisory Com-mittee. The function of the SupervisoryBoard is to oversee, monitor, and makeamendments to the provisions of the Act.

Appropriate Authority provides registra-tion, and conducts the administrative

work involved in inspection, investiga-tion, and the penalizing of defaulters. The

Advisory Committee provides expert andtechnical support to the Appropriate

Authority. Contravening the provisionsof the Act can lead to a fine of Rs 1,00,000and up to five years imprisonment for thefirst offence, with greater fines and longerterms of imprisonment for repeat offend-ers. The Appropriate Authority informsthe central or state medical council totake action against medical professionals,leading to suspension or the striking offof practitioners found guilty of contraven-ing the provisions of the Act.

Women and Developments in Repro-ductive Technology Abortion was legal-ized in India in 1971 (Medical Terminationof Pregnancy Act) to strengthen humani-

tarian values (pregnancy can be aborted ifit is a result of sexual assault, contraceptivefailure, if the baby would be severelyhandicapped, or if the mother is incapableof bearing a healthy child). Amniocentesiswas introduced in 1975 to detect foetalabnormalities but it soon began to beused for determining the sex of the baby.



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In some parts of the country, the sex ratioof girls to boys, has dropped to less than800 : 1000. The United Nations has ex-pressed serious concern about the situa-tion. The impact on society should not beunderestimated. According to India esti-

mates, by 2020 there are likely to be 40million unmarried young men.

STATUS OF INDIAN WOMEN LINKED

WITH SEX RATIO

The adverse sex ratio has always beenlinked with the low status of women inIndian communities, both Hindu andMuslim. It is deeply influenced by thebeliefs and values of the society. Islampermits polygamy and gives women fewerrights than men. Among Hindus, prefer-ence for the male child is likewise deeplyenshrined in belief and practice. TheRamayana and the Manusmriti (the Laws

of Manu) represent the ideal woman asobedient and submissive, and alwaysneeding the care of a male: first father,then husband and, then son. The birth ofa son is regarded as essential in Hinduismand many prayers and lavish offerings aremade in temples in the hope of having amale child. Modern medical technologyis used in the service of this religion-driven devaluing of women and girls.Religion operates alongside other cul-tural and economic factors in loweringthe status of women.

FEMALE DESELECTION

The practice of female deselection inIndia could be attributed to socio-eco-nomic reasons. There is a belief by cer-tain people in India that female childrenare inherently less worthy because theyleave home and family when they getmarried, a system known to anthropolo-gists as patrilocality.

Studies in India have indicated threefactors of female deselection in India,

which are economic utility, socio-cultural

utility, and religious functions. The factoras to economic utility is that studies indi-cate that sons are more likely than daugh-ters to provide family farm labor or pro-vide in or for a family business, earnwages, and give old-age support for par-ents. The socio-cultural utility factor offemale deselection is that, as in China, inIndias patrilineal and patriarchal system

of families is that having at least one sonis mandatory in order to continue the fa-milial line, and many sons constitute ad-ditional status to families. The final factorof female deselection is the religious func-tions that only sons are allowed to provide,

based on Hindu tradition, which mandatethat sons are mandatory in order to kindlethe funeral pyre of their late parents andto assist in the soul salvation.

The most important task is to controlpopulation and increase awareness on thebenefits of controlled human populationwhich includes better lifestyle, education,environment, health and well being ofevery individual. We two, ours one.Girl or Boy, let there just be one childare awareness campaigns started by thegovernment of India, but there is lack oflaws that enforce single child.

The British medical journal, The Lan-cet reported in early 2006, that there mayhave been close to 10 million female fe-tuses aborted in India over the past 20

years. This is extrapolated partly on thebasis of reduction of female-to-male sexratio from 945 per 1000 in 1991 to 927 per1000 in 2001. Ultrasounds are meant tomonitor the health of unborn children, sodoctors always know their sex, but they

inform the parents, a practice that is il-legal in India, yet common.

SEX-SELECTIVE ABORTION

Sex-selective abortion has been seen asworsening the sex ratio in India, and thusaffecting gender issues related to sex

compositions of Indian households.It has been argued that by having aone-child policy. India has increased therate of abortion of female fetuses, therebyaccelerating a demographic decline. AsIndian families are allowed only onechild, they would end up preferring atleast one son over a daughter, thus pre-venting the formation of a greater number

of families in the next generation.

ASSISTANCE TO

PREVENT FEMALE FOETICIDE

There is a need to encourage and moti-vate the population and specially farmers

for being interested in having the girlchild birth by assistance, mainly for themarriage of their daughters. The Minis-tries of Govt. of India has launched dif-ferent schemes favouring the same .Ladli Scheme Rules, 2005 is applicablethroughout the State of Haryana. Theaim of this scheme is to combat the men-ace of female foeticide which has devas-tating demographic and social conse-quences, to restore the demographic sexratio imbalance, to facilitate the birth ofmore girl children and to meet the feltneeds of women and girl children for

which these rules have been framed spe-cially for Hariyana State. There are manyother supports to facilitate girl childthrough different Govt. schemes by cen-tral and different state Governments.But the support status is very poor interms of need.

Within the framework of a democraticpolity, our laws, development policies,Plans and programmes have aimed at

womens advancement in differentspheres. In recent years, the empower-ment of women has been recognized asthe central issue in determining the statusof women. The National Commission forWomen was set up by an Act of Parlia-ment in 1990 to safeguard the rights and

legal entitlements of women. The 73rd

and 74th Amendments (1993) to the Con-stitution of India have provided for res-ervation of seats in the local bodies ofPanchayats and Municipalities for wom-en, laying a strong foundation for theirparticipation in decision making at thelocal levels.

The evolution of property rights in a

WITH DWINDLING SEX RATIO,

HOW WOULD THE FAMILIAL LINECONTINUE? WE NEED TO WAKE UPUNTIL ITS TOO LATE FOR US



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patriarchal system has contributed to thesubordinate status of women. The Policy

would aim to encourage changes in lawsrelating to ownership of property andinheritance by evolving consensus in or-der to make them gender just.

But in some of the cases, the hard actsof Indian Penal Codes are misused andreceive the highest media attention thesedays. Two of these famous acts are theDowry Prohibition Act of 1961 and 498aof IPC . The Dowry Prohibition Act is arelated law which defines giving, abettingand taking of dowry as criminal acts, andit also prescribes many rules as to theexchange of gifts, expenditure at the timeof marriage and declaration of the sameto the Government. The purported aimof the Act is to curb the practice of dowryand to prevent extravagant marriages.498A of IPC refers a husband or relativeof husband of a woman subjecting her tocruelty. Whoever, being the husband orthe relative of the husband of a woman,subjects such woman to cruelty shall bepunished with imprisonment for a term

which may extend to three years and shallalso be liable to fine.

CONCLUSION

Gender disparity manifests itself in vari-ous forms. It is very clear that even afterdecades of independence, we are unableto provide social security to women. It isan abject truth and a horror to feel that:

women are not safe even in the womb.The principle of gender equality is en-shrined in the Indian Constitution in itsPreamble, Fundamental Rights, Funda-mental Duties and Directive Principles.The Constitution not only grants equalityto women, but also empowers the Stateto adopt measures of positive discrimina-tion in favour of women. The womensmovement and a wide-spread network ofNon-Government Organisations whichhave strong grass-roots presence and

deep insight into womens concerns havecontributed in inspiring initiatives for theempowerment of women. However, therestill exists a wide gap between the goalsenunciated in the Constitution, legisla-tion, policies, plans, programmes, andrelated mechanisms, on the one hand andthe situational reality of the status of

women in India, on the other.

The underlying causes of gender ine-quality are related to social and eco-nomic structure, which is based on infor-mal and formal norms, and practices.Womens equality in power sharing andactive participation in decision making,including decision making in politicalprocess at all levels will have to be en-sured for the achievement of the goals ofempowerment. All measures will be takento guarantee women equal access to andfull participation in decision making bod-ies at every level, including the legislative,executive, judicial, corporate, statutorybodies, and also the advisory Commis-sions, Committees, Boards, Trusts etc.

Affirmative action such as reservations/quotas, including in higher legislativebodies, will have to be considered when-ever necessary on a time bound basis.

Womenfriendly personnel policies willalso to be drawn up to encourage womento participate effectively in the develop-mental process.

It is evident that there is a need for re-framing the policies for access to employ-ment and quality of employment. Benefitsof the growing global economy have beenunevenly distributed leading to wider

economic disparities, the feminization ofpoverty, increased gender inequalitythrough often deteriorating workingconditions and unsafe working environ-ment especially in the informal economyand rural areas. Strategies will have to bedesigned to enhance the capacity of

women and empower them to meet thenegative social and economic impacts,which may flow from the globalizationprocess. It is a stark and naked truth thatthe nation will have to set off in a newway to ferret something to save ourwomen in the womb.

(SUKHAMAY PAUL is the Chairman ofCoochbehar Jan Shikshan Sansthan(Institute of Peoples Education) under

Ministry of Human Resource Develop-

ment , Govt. of India. He has also workedas Director of Collaborative organizationof CHILDLINE India Foundation (CIF)under Ministry of Women and ChildDevelopment, Govt. of India.




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Because of lack of central

planning, the Indian masses aredenied the excellent facilitiesand expertise that are sought

out by medical tourists

ON THE TOURISTCASHING


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K R BOLTONFellow of the Academy of Social& Political Research, Athens

P O I S O N E D P O L I C I E S

Indias burgeoning population is gen-erally looked upon as a nightmarishproblem, particularly in the West

where the converse problem is thatof declining birth rates and aging popula-tions. The problem, however, is not thatof a large population, but with the lackof an orderly infrastructure and nationalplan to turn the problem into Indiasgreatest resource. The approach to In-dias problems, including those of health-care, need to be treated holistically.

THE NEED FOR AUTHORITY

India should not look to failed Westerneconomic and political paradigms. Itsbelligerent neighbour, China, has shown

what can be achieved when a largepopulation is mobilised under a nationaleconomic plan directed by a strong cen-tral political authority. India, of course,need not indeed, must not follow thecommunist nor even the social demo-cratic path. No nation can claim to be a

world power nor even a real nation whilea large proportion of its population isdiseased and malnourished and living inpoverty. Such a condition is a standingdisgrace and a conspicuous sign of a na-tions lack of resolve. Indias problemsare not unique in this; the problems arehowever a matter of proportion due tothe inability to resolve rapid population

expansion. The problems of poverty,slums and hygiene faced by India werealso faced by England during her analo-gous period of economic modernisationstarting from the era of the IndustrialRevolution. At that period, a formerrural population became proletarian-ised; uprooted rural workers becameurbanised, with the resulting problems

of slums, disease, overcrowding and lackof sanitation.

While England presented itself as agreat nation that ruled a large propor-tion of the world, a large element of itspopulation lived in degradation. Itshould be noted that the economicmodel that ruled England was the FreeMarket or Free Trade. Friedrich Engels

wrote for example of the slum dwellingsof 19th Century Manchester:

Of the irregular cramming togetherof dwellings in ways which defy all ra-tional plan, of the tangle in which theyare crowded literally one upon the other,it is impossible to convey an idea.

Below the bridge you look uponthe piles of debris, the refuse, filth, andoffal from the courts on the steep leftbank; here each house is packed closebehind its neighbour and a piece of eachis visible, all black, smoky, crumbling,ancient, with broken panes and windowframes. The background is furnished byold barrack-like factory buildings.(Slum Housing, Cotton Times).

Yet despite the failed 19th centurymodel of Liberal economics, over the pastseveral decades in the West it has beenrevived as a panacea. The socio-econom-ic problems are however caused by afailure of the financial mechanism: that ofdebt to the international banking system

that is based on usury. Hence govern-ments are selling their national assets andstate owned enterprises to pay off the in-terests on debt in the short-term but willin the long term be left with no assets andthere will be a new cycle of debt.

HEALTH SERVICES

International companies are looking to

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Indias health system as a potentialsource of profit. Indias people will betreated not as a resource that can bemobilised for great national purposesbut as an economic commodity fromwhich profit can be accrued for foreign

investors. Once a state opens itself up tofree trade it no longer has control overits own destiny, which is determined byoutside companies.

A 2007 report by Price WaterhouseCooper is tellingly entitled Healthcarein India: Emerging Market Report. Thatis the bottom line as far as private invest-ments in health are concerned: healthproblems are looked upon as an emerg-ing market. The figures collated for thisreport are informative:

In 2007, the total, value of the health-care sector was $34 billion; 6% of theGDP. This is projected as $40billion in2012. The private sector accounts for80% of the total healthcare spending.Unless, there is a considerable declinein federal and state deficits, the oppor-tunity for significantly higher publichealth spending will be limited. (Health-care in India: Emerging Market Report2007, Price Waterhouse Cooper, p. 1).

Yet, the report, citing Goldman Sachs,states that Indias economy is growing intandem with the population, projectedto expand by at least 5% over the next 45years, as the only emerging economy tomaintain such a robust pace of growth.However, according to 2004 figures,27.5% of Indian lived below the povertyline, 300,000,000 live on less than a dol-lar a day, and more than 50% of allchildren are malnourished. (Healthcarein India, ibid., p. 2).

These figures indicate somethingradically wrong with the financial andeconomic mechanisms, when a largeproportion of Indias population lives indestitution, despite the economy increas-ing in tandem with the population.

What the private overseas investorsare looking at is Indias expanding mid-dle class, with more disposal income tospend on healthcare. (Healthcare in

India, ibid., p. 3). According to the FreeMarket model, what seems to be indi-cated by the Reports projection for in-vestments into private healthcare for themiddle class is the accentuation of dis-

parity in healthcare among those ofvariable per capita incomes. Privateforeign investment is therefore directedtowards the expanding middle class as amatter of simple profitability.

The problem at issue is that of the

flawed financial system, which is a com-plex issue that must remain outside thescope of this article. What can be said,however, is that, as stated, an economythat is expanding at the same rate as thepopulation, should potentially be thesource of strength and not one of growingeconomic disparity. (K R Bolton, StateCredit and Reconstruction: The First NZ

Labour Government, International Jour-nal of Social Economics, Issue 1, Volume38. 2011; and The Global Debt FinanceSystem, Veritas, St Clements University,Vol. 2, No. 1, December 2010).

The State needs to resort to the Key-nesian method of vast public worksprojects that deal with the problems ofhygiene, housing, fouled waterways, sew-age, rodents, and lack of healthcarecentres and hospitals. It needs to injectstate credit into these schemes. India has

the people in abundance; what is re-quired is the organisation to mobilisethem. Slum clearance should not uprootcommunities that have developed overgenerations, nor create high-rise apart-ments. A State Labour Corps should be

created to undertake these vast publicworks, utilising Indias population as avaluable resource.

WESTERN DEBILITATION

There is another debilitating factor thatIndia is importing from the West, andagain the problem comes back to FreeTrade. The Price Waterhouse Cooperreport refers to the adoption of un-healthy Western diets that are high in fatand sugar, causing a rise in lifestylediseases such as hypertension, cancer,and diabetes, which is reaching epi-demic proportions. Over the next 5-10years, lifestyle diseases are expected togrow at a faster rate than infectiousdisease in India and to result in an in-crease in cost per treatment. Presentlyan estimated 41,000,000 Indians are dia-betic, and this is projected to rise to 73.5


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million by 2025. During the 1970s only2.1% of Indians in urban areas had dia-betes; now the figure is 12.1% for adultsover the age of 20. Indians have a ge-netic susceptibility toward diabetes,

which has been triggered by the change

in both diet and lifestyle. (Healthcare inIndia, op. cit., p. 4).

The Free Market model that is recom-mended by the Price WaterhouseCooper report refers optimistically to thegrowth of Indias pharmaceutical indus-try. One of the problems for investors isthat the Indian Government increasesthe number of medicines brought underprice control, which adversely impacts oninvestment opportunities. (Healthcare inIndia, ibid., pp. 4-5).

Here again the State must considerwhether it is to pursue a Free Marketeconomy that adversely impacts uponthe health of its people, or to look fornew directions that place the interests ofIndia first, which therefore places Indiaoutside the push for Free Trade. Indiashould also reconsider whether joiningFree Trade agreements is desirable, assuch FTAs undermine the States au-thority to intervene in the market and inthis instance in controlling the price andtype of pharmaceuticals, or in keepingout undesirable corporations, such asfast-food chains.

As the Price Waterhouse Cooper re-port indicates, global investors win intwo ways to the detriment of India: (1)The fast-food chains profit from accessto the Indian market, (2) The pharma-ceutical and private healthcare compa-nies profit by treating the symptoms ofunhealthy foreign diets. What is elimi-nated from the equation is prevention,by the State intervening in the nationalinterest and by not allowing fast foodchains to literally poison the population.The decline in health, and the rise incancers, diabetes, and obesity that in-

fects the West due to the decline in die-tary standards should serve as a warningto India.

Both traditional and technologicalmethods of work also contribute tophysical debilitation among both themenial and the managerial and clericalprofessions. Posture and osteopathicproblems in particular can be expected

to become widespread among classesother than the menial, as well as amongthe young. Computers and computergames are causing widespread healthproblems among the young and thosewith occupations that increasingly re-volve around the use of computers, in-cluding: overuse injuries of the hand,obesity, muscle and joint problems, eye-strain, and spinal curvature.

Again, there is a question of the short-term versus the long-term perspective.Employers should regard the long-termhealth of their workforce as more impor-tant that trying to eke out every last hourof labour, like some 19th Century Eng-lish merchant out of a Charles Dickensnovel. The State should design nationalprogramme, coordinated by a workplacefitness authority. Japan provides amodel in this as it does in the manner by

which State and private enterprises arecoordinated. The Japan IndustrialSafety and Health Association (JISHA)has wide-ranging influence over indus-try, including physical exercise, nutri-tion guidance, health guidance or coun-selling, and/or sends experts toenterprises upon request for practicalin-house training of the instructorsJISHA also provides a health-adviceservice that has been developed in theform of health guidance tools to pro-mote workers self-awareness.

JISHA implements regular healthexaminations. JISHA also implementsspecial health examinations for work-ers dealing with chemical hazards, en-

gaged in VDT work, or working amidvibration or noise, and gives overalladvice on health management thattakes into consideration each type ofworking environment.

CONCLUSION

While healthcare for the Indian massesis in disarray, India produces some of

the finest doctors, medical specialistsand researchers in the world. The 2007report alludes to Indias growing medi-cal tourism, where Westerners come totake advantage of Indias well-educatedEnglish-speaking medical staff, state-of-the-art private hospitals and diagnosticfacilities, and relatively low cost incomparison to the high costs of health-care in the West. (Healthcare in India,op. cit., p. 10). Medical tourism is pro-jected to reach $2billion in 2012. ManyWesterners are also seeking Indiantraditional medicine. (Ibid., p. 11). Be-cause of lack of central planning, theIndian masses are denied the excellentfacilities and expertise that are soughtout by medical tourists.

The state has a duty to enact long-term national planning, in conjunction

with private enterprise. Japans revivalfrom wartime devastation provides asuccessful example of this method.Large-scale public works are requiredfor slum clearance, the constructionhospitals and clinics, and projects forsewage and garbage disposal, waterquality and rodent control. India has thepopulation to undertake such public

works schemes.

(DR K R BOLTON is a contributingwriter for Foreign Policy Journal, and aFellow of the Academy of Social & Politi-cal Research, Athens. He is widely pub-lished on a range of subjects by scholarlyand other media, including: World Affairs;

India Quarterly; International Journal ofRussian Studies; Geopolitica (MoscowState University); Journal of Social, Po-litical & Economic Studies; InternationalJournal of Social Economics, etc.

The views expressed in the article are per-sonal and do not reflect the official policyor position of the organisation.)

A LONG-TERM NATIONAL PLANNING

NEEDS TO BE ENACTED IN JOINT

VENTURE WITH PRIVATE ENTERPRISES

TO BRING REFORMS IN HEALTH SECTOR

P O I S O N E D P O L I C I E S

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SIGNIFICANT IMPROVEMENTS

IN HEALTH CONDITION OF THE

PEOPLE WOULD PROBABLY LEAD TO

REDUCTION IN POVERTY

MAKING HEALTH INSURANCE A

REALITYWith a very low income at its disposal, will it beeasy for the poor section to enroll for this schemeor will it compromise again with the miseries?

AKASH ACHARYA

Assistant Professor, Centrefor Social Studies (CSS),VNSGU Campus, Surat

Health is a critical factor in thedevelopment of any country,for two reasons, first, healthstatus is a key indicator of

populations welfare (Sen 1985) andsecond, improving the health status of

the population leads to greater eco-nomic productivity (Strauss and Tho-mas 1995) and can also positively affecteducation outcomes (Glewwe et. al).Theoretical work as well as empiricalevidence clearly show the linkagesbetween good health, well being of in-dividuals and overall economic devel-opment. Today, the health status ofpopulation is considered an importantindicator of development and widelyrecognized as both an input and anoutcome of broader social and eco-nomic developments.

In India, states with better equity inpublic spending have better healthstatus outcomes and states with highermorbidity and mortality are under-developed. States with high access andutilization rates reveal lower mortalityrates (Dreze and Harris 1996). Ill healthand poor health services are increas-ingly recognized as major dimensionsof poverty. Commission on Macroeco-nomics and Health (CMH) says thathealth improvements lead to economicgrowth and that in turn leads to furtherhealth improvements. Thus, reductionin poverty is probably not possiblewithout significant improvements inhealth condition of people.

MEDICAL POVERTY TRAP

The evidence available from the Na-tional Sample Survey (NSS) indicatesthat healthcare expenditure is one ofthe fastest growing components ofhousehold consumption even amongthe poor. On an average, about 5.3percent (13.7 percent of nonfood expen-

ditures) of annual household expendi-

ture in India is spent on health care(World Bank 2001). Expenditure onhealth is often unexpected and can becatastrophic in nature. This is eventruer for the poor where even a tem-porary incapacity of the breadwinnerto earn due to illness can drive a fam-ily into destitution. It cuts poorshousehold budget in both ways, not

only do they have to spend a largeamount of money and resources onmedical care but also they are unableto earn during the period of illness.Moreover, rural people have signifi-cantly higher burden of almost allcomponents of indirect cost (such as

expense on transport, food/stay, tipsgiven to get access to any person or facil-ity, opportunity cost to the sick as well

as the accompanying person etc).Very often, the poor have to borrow

funds at a very high interest rate frommoney lenders to meet medical ex-penditure as well as other householdconsumption need, which in turn putsthem into indebtedness. This can leadto pauperization and indebtedness forgenerations. More than 40 per cent of

individuals, who are hospitalized,borrow money or sell assets to coverthe cost (World Bank 2001). Between1986 and 1996, those sick but notavailing treatment for financial rea-sons increased from 15 per cent to 24per cent in rural areas and doubledfrom 10 per cent from 21 per cent inurban areas (GoI 2000).

Evaluation reports of the departmentof rural development indicate that healthexpenditure, particularly for hospitaltreatment, is major cause of rural indebt-edness. Thus, ill health disproportion-ately affects the poor, leading to highermorbidity and mortality.

One possible consequence of thishigh medical expenditure could bethe pushing of these families into a

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zone of permanent poverty (UNDP2001). More than a quarter of all hos-pitalized Indians fall below povertyline as a direct consequence of themedical expenses they pay, out-of-pocket, after being hospitalized

(World Bank 2001). Professor PeterBerman of Harvard School of PublicHealth estimates that out-of-pockethealth expenditure contributes morethan two per cent to the Indias pov-erty ratio (Berman et al. 2002). Thisenormous financial burden arisesbecause poor are not insured. A largemajority of the rural and urban slumpopulation in India remains excludedfrom the health insurance system andhas low protection from risk.

MICRO HEALTH INSURANCE

(MHI) FOR THE POORGiven the rising expenditure onhealth care and the state as well as themarkets inability to protect the vul-nerable section of society, it becomesincreasingly important to look atvarious alternatives for including theexcluded. An important part of healthfinance in India is the service pro-vided by voluntary and charitable or-ganization commonly known as NonGovernment Organisations (NGOs).Learning from their experiences frommicro credit programmes (e.g. healthexpenditure a major cause of default),some NGOs have started micro insur-ance programmes.

Community-based health insur-ance (CBHI) or Micro Health Insur-ance (MHI) is a mechanism that al-lows for pooling of resources to coverthe costs of future, unpredictablehealth-related events. It offers indi-

viduals and households, protectionagainst the uncertain risk of cata-strophic medical expenses in ex-change for regular payment of premi-

ums. This mechanism, under whichthe healthy, can cross subsidise thepoor, may make a positive impact onequity. The World Health Report2000 noted that prepayment schemes(like is the case with micro health insur-

ance) represent the most effective wayto protect people from the costs ofhealth care, and called for investiga-

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tion into mechanisms to bring thepoor into such schemes (WHO

2000).The WHOs Commission on Mac-

roeconomics and Health (CMH), forexample, recommends, that out-of-

pocket expenditures by poor com-munities should increasingly be chan-neled into community financingschemes to help cover the costs ofcommunity-based health delivery.

SALIENT FEATURES OF

NGO RUN MHI SCHEMES

As per recent ILO estimates, thereare about 90 micro health insuranceschemes in India covering about85,00,000 people. However, theschemes are diverse in nature rangingfrom few hundred to more than1,00,000 members. One can see somekind of geographic clustering/concen-tration in South India perhaps be-cause of higher number of micro fi-nance institutions (MFIs) in thisregion. Existing micro health insur-ance schemes differ in terms of theirdesign and management, number ofmembers, target population, patternof enrolment, unit of membership,level of premium, as well as schemebenefit package. This makes it some-

what difficult to compare the schemes.Each scheme is unique in nature andhas its own strengths and weakness.This section presents some importantcharacteristics of Indian micro healthinsurance schemes for the poor.

SIZE AND AGE OF THE SCHEME:The smaller schemes covered onlyhundreds of people (AKHS in Gu-jarat), while larger schemes like SEWAcovered more than one lakh members.The schemes, also varies tremen-dously in terms of their age, the oldeststarting in 1955 (SHH, Calcutta) and

the youngest within the last few years(Dhan foundation, WWF and Yeshash-wini in Karnataka). Many more NGOsare in process of developing schemes.

SCHEME OWNERSHIP

AND MANAGEMENTThis aspect is very important as oftenthe success or failure depends onscheme design and management.Three main patterns of scheme own-ership and management haveemerged. Firstly, in many schemes theNGO running the insurance scheme

is also the health care provider. Sec-ondly, there are several NGO-ownedschemes where the NGO is the in-surer, but does not provide healthcare itself. Thirdly, several of theschemes involve an NGO acting as anintermediary between the targetpopulation and insurance company(public or private).

This seems a reasonable strategygiven that NGOs generally dont havethe actuarial skills required for settingpremium and benefit package. On theother hand, insurance company can

reduce its administrative cost by piggybacking on NGO structure. Anotherimportant feature is that all of theNGOs that own and manage schemesprovide services other than just insur-ance. For example, some of the NGOsare involved in various development-oriented activities, including educa-tion, micro-credit, micro-savings and

TO HELP THE POOR & DEPRIVED LOT,NGOS ARE AIMING AT EXPOSINGAND ENROLLING THEM FOR THEBASIC HEALTH INSURANCE SCHEMES


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work-generation.

UNIT OF MEMBERSHIPMost of the Indian schemes enrollhouseholds or families may be toavoid the problem of adverse selection

(a phenomenon where only the sick orhigh risk people join). There are only afew schemes where enrolment is ofgroups larger than the household,such as Sevagram hospital in Wardhawhere entire village in enrolled intothe scheme if this is agreed upon ingram sabha meetings.

PREMIUM AND BENEFITPremium amount ranges from zero toRs. 365 (one rupee a day) per personand is flat (one rate for all) in natureexcept in scheme of sevagram hospital

where the premium is based on abilityto pay. Almost all of the schemes col-lect the premium during an annualmembership drive. Very few schemesallow individuals/members to join thescheme around the year. Someschemes cover inpatient (hospitalisa-tion) services only, and some bothoutpatient and inpatient services.

Almost all of the schemes that restricttheir benefits to inpatient services areassociated with insurance companiesand they also exclude certain medicalconditions from coverage like pre-existing conditions, chronic condi-tions, treatment related to pregnancy/childbirth, and HIV/AIDS and itscomplications. Almost all of theschemes that cover the costs of hospi-talization provide coverage only to apredefined limit or ceiling. Moreover,in most schemes, the insured must payfor care out-of-pocket and then seekreimbursement from the insurer.

FINANCIAL SUSTAINABILITYMost of the schemes received some form

of external support or financial subsidyat some point of time, without which theycould not have survived on their own.This means making these schemes finan-cially viable is an uphill task especiallybecause in process of making theseschemes financially viable, premiumsusually go up which adversely affect theequity. Thus, there is a trade-off between

financial sustainability and equity.

COMMUNITY RESPONSEFaith and trust in the leadershipseem to be the two most importantfactors in acceptability of the scheme.In most cases the people are happywith the scheme but they feel frus-trated when their claim is rejected.This happens because the awarenessregarding exclusions and other guide-lines is quite low among the commu-nity (Acharya and Ranson 2005).

DISCUSSION

Micro health insurance is still a rela-tively new concept and it is difficultfor the poor to comprehend thatmoney has to be prepaid for a possi-ble sickness which may never comeand in that case the premium is notreturned. Since poor has many othercompeting priorities, the motivationfor joining a health insurance pro-gramm is low (Acharya 2006). Theoverall assessment of the NGO man-aged schemes is that they have so farreached only a very small part of thepoor in the unorganized sector interms of coverage. It seems unlikelythat such a scattered and piecemealmovement can lead to universal cov-erage. Even where the schemes havereached, there are not enough statis-tics on inclusion of the poorest of thepoor, increased access to health care,extent of protection to the poor frommedical indebtedness etc.

There is a need for health insur-ance services among the poor but itremains to be seen whether the poor-est in society will be able to affordthe insurance premium, even when itis low by market standards. Manyquestions remain pertaining to theability of such schemes in catering tothe health needs of the poor and they

cannot be termed as panacea forhealth problem of poor.

Overall NGOs seem to have beena relatively successful platform forproviding health insurance servicesto the poor as they can address manyof the felt needs of the populationand community trust them. However,even if these NGOs have been suc-cessful in increasing the access tohealth care, the whole issue of qual-ity of the care provided, remainsunanswered. It seems that the NGO-Corporate Partnership (NCP) is mostrational model for extending healthinsurance to the poor as NGO alonedoesnt have actuarial or financialexpertise to set premiums and in caseof sudden claims load. NGO wont beable to cope with it without backingof corporate insurer which will havea larger and diversified risk pool.NCP strategy also gels well with theCorporate Social Responsibility(CSR) debates as through NCP routecorporate can serve a large commu-nity by taking care of their healthcare needs.

(AK ASH ACHARYA is a faculty atCentre for Social Studies (CSS), Surat.He has an interdisciplinary academicbackground in Economics and Man-agement. He has worked on collabora-tive research projects with Universitiesin West and his papers have been pub-lished in international peer-reviewed

journals like Social Science and Medi-cine, Health Policy and Planning andHealth Policy. On invitation, Akashhas visited Universities in the USA, UKand Germany.


FAITH AND TRUST WOULD DEFINE

THE SCHEME ACCEPTABILITY BY THE

MASSES AND NEED TO BE TAKEN

CARE OF BY THE NGOS AND NCPS


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Reeling under ailing health and social protection schemes, Indiahas one of the lowest public spending on health care in the world

eeling under ailing health and social protection schemes, IndiaHEALTHAND SYSTEM CHALLENGES


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I N A D E Q U A T E I N F R A S T R U C T U R E

SARIT KUMAR ROUTEconomist with specialization

in health econo

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