India’s health care ‘crisis’?

Sen and Dreze highlight all that is bad with the state of health in India – as well as some promising success storiesindia-and-the-world-400x400-imadh9nfxmvmqsh4


I read all the reviews and articles accompanying the release of Sen & Dreze’s Uncertain Glory with interest – I was specifically curious to know if we would learn anything new from such a book. This curiosity did not just emerge from Sen’s tendency to repeat himself. Questioning India’s efforts to position itself as a new superpower by highlighting it’s poor social indicators (especially compared to Bangladesh) seems to be a line of enquiry that has already been well traversed ( for example, by Ramachand Guha).


When I got the book from Flipkart (imported from the US) I jumped straight to chapter six India’s Health Care Crisis.


Crisis? As a public health professional, it is a dynamic time to be working in India. The National Rural Health Mission has injected new money into a flagging system and opened the door to innovation. Gains include ending polio (a fragile victory, sure), increasing institutional deliveries through JSY, setting up the Public Health Foundation of India, and introducing a new cadre of community health workers who are remunerated on the basis of payments for services performed (ASHAs).


Criticism of the state of health in India is definitely historically appropriate. It was an area neglected for a long time in public spending, and a poorly qualified, unregulated and unscrupulous private sector took over. Even now, India has some of the highest proportion of private sector spending in the world at about 70%. And public sector spending on health is still low at only 1.2% of GDP, compared with 2.7% in China, 3.8% in Latin America and a global average of 6.5% (see page 149).


Sen and Dreze remind us that despite NRHM gains, the status of health in India remains dismal – especially compared to much poorer countries:

  • India’s vaccination rates are some of the lowest in the world. Vaccination rates for polio are only 70%, compared to 79% in sub-Saharan Africa (UNICEF 2012)
  • The nutritional status of children in India worse than sub-Saharan Africa, with 74% of school aged children with anemia compared to 68% in sub-Saharan Africa (UNICEF 2012)
  • Furthermore, health is generally absent from national dialogue in parliament or the media (I have already described my frustration at the poor level of reporting on the HPV vaccine here). They point out:


“Since the practice of democracy depends greatly on which issues are publicly discussed, the comparative silence of the media on health care makes it that much more difficult to remedy the problems from which health care suffers. There are, thus, two interrelated problems faced by health care in India: first, its massive inadequacy, and second, the near- absence of public discussion on this inadequacy.”


In the face of this, the NRHM is described as (to paraphrase) – too little too late (see page 152). In fact, I was surprised to learn that the NRHM has only seen funding increase from 1% to 1.2% of GDP.


One of the most scathing criticisms is saved for an NRHM initiative, the health insurance scheme – the Rasthtriya Swasthya Bhima Yojana (RSBY). Private health insurance has devastated public health in the US – leading to increased spending and poorer health outcomes. It neglects the cost effective work of prevention, and prioritizes expensive hospital based care. In the face of this massive and visible failure in the US, adopting this as a policy does seem a little odd.


So it does seem appropriate to call the status of health in India is a ‘crisis’.


However, one of the most important points in the chapter is that within India, there are successes. Specifically, they describe the active, creative and inclusive social and health policies in Tamil Nadu. First of all is a strong network of primary health centres, free medicines and a focus of preventing illness, rather than curing it. Sen and Dreze point out that Tamil Nadu’s successes are the result of democratic action and citizen engagement – often absent in other states.


  Tamil Nadu India
Infant mortality rate (per 1000 live births) 22 44
Proportion of children below age 5 who are undernourished. Weight for age. 2005-6 29.8 42.5
Proportion of children under three years who start breastfeeding within one hour of birth 76.1 40.5

(from page 170).


These experience help exemplify how health services can be delivered at low cost in an equitable manner – a great lesson for the whole world.

Sen (left) and Dreze.

Sen (left) and Dreze.

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One Comment

  1. Dr Aahok Agarwal
    Posted September 22, 2013 at 11:34 am | Permalink

    The governance of the country requires complete overhauling

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  • By Most inspiring public health books… on October 12, 2019 at 1:09 pm

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