Need huge efforts to meet SDG commitments on health

Given the ground reality of India’s health sector, India’s commitment to the UN Sustainable Development Goals (SDGs) on health is laudatory and ambitious. The SDG 3.1 aims at decreasing the maternal mortality rate drastically (at 70 per 1,00,000 live births) by 2030 and Goal 2.2 seeks to end all form of malnutrition by 2030. To be able to meet these goals, huge efforts will have to be made on the part of the Central and state governments to raise the level of health infrastructure and improve the delivery of healthcare services in India.

Even though we heard recently from Niti Ayog CEO that India’s growth path will take us to 10% growth in the future, and to a $10 trillion economy, various human development indicators on the health front will have to be addressed first. High growth may be a wonderful thing, but if it means that the health of the people remains in a precarious state, it will not have a big impact on their well being. Thus achieving 10% growth rate with little trickle down into other sectors will only increase the inequality of incomes and in the case of healthcare, may lead to problems of higher ‘out-of-pocket expenditure’ which includes private expenditure on health. According to the World Bank, India’s out-of-pocket expenditure was at 89% for 2011-15.

Around 70% of households in urban and 63% in rural areas depend on the private medical sector because of the inefficient public healthcare system. Take the case of an average public hospital. It is marked by crowds of people waiting outside to get an appointment with a doctor. People wait in queues at daybreak in New Delhi’s AIIMS to see a specialist. The ratio of doctor to 10,000 people is woefully low at 6.5, and there are only nine hospital beds per 10,000. Hence of prime importance is to increase the number of doctors, nurses and hospital beds in the country. In an emergency, most people go for private healthcare.

A posh private hospital is usually fully air-conditioned and has clean floors, toilets and waiting areas that are furnished with comfortable chairs. The price of such comfort is high compared to near-free service of a public hospital. The expensive hospitals can often create a big hole in the pocket because of unnecessary tests and surgical interventions which can jack up the bill. Usually, the poor are helped by relatives or they sell assets or borrow from informal sources. Only 24% of the population has health insurance. Even with health insurance, one is afraid of incurring the extra expenditure which is not covered by the insurance policy. Around 55 million Indians fall into a serious poverty trap annually because of their healthcare spending. Clearly, there is need for regulations on private healthcare and it should work in tandem with public healthcare, and not be a substitute for it. Also, a certain proportion of private health services should be made available to the poor free of cost.

The government has introduced many programmes to improve the healthcare system, especially for pregnant women. India has one of the highest maternal mortality rates in the world at 167 per 1,00,000 live births (2011-13) and we were unable to meet the Millennium Development Goal target (140), despite efforts. The reason is that there are problems with timely and effective medical assistance in the villages in times of emergency. The National Rural Health Mission was started in 2005 (now National Health Mission) to give cash incentives to pregnant women under the Janani Suraksha Yojana to have institutional delivery with proper medical staff in attendance. In many states, this scheme has been successful, but there are problems due to lack of trained staff and equipment. For example, if there are complications during delivery, the local medical centres often are not able to prevent maternal death through timely and professional intervention. Thus, though the number of institutional deliveries is increasing, the number of maternal deaths has not decreased steeply enough. Hence there are gaps in the scheme which need to be filled, otherwise maternal death numbers will not decrease fast enough to meet the SDGs.

The same is the case for children’s nutritional health. The poorer sections of the population in big cities and towns are provided with anganwadis under the Central scheme of Integrated Child Development Services to take care of their children. But, newspaper reports about the poorly run anganwadis and their inadequate infrastructure paint a dismal picture. Lack of toilets, space for children to play, good nutritional diet mar the usefulness of these anganwadis, and people with higher income refrain from sending their children to them. They opt for private pre-nursery schools instead. There is a booming private business in such schools. At the higher end of such pre-schools, children get good day care comparable to that of developed countries.

Without proper nutrition, children grow up stunted and various studies have shown that they also are not able to develop their mental faculties to the fullest. Stunted and underweight children are handicapped for life and it is the state’s responsibility to ensure that all children have access to a nutritious diet in their formative years. Even though the percentage of underweight children has come down to 30.1% (2013-14), more needs to be done to end malnutrition.

Hence even if India grows at 10%, the top 1% of Indians who have everything will earn more and enjoy even a higher lifestyle. The Central government will then have to make sure that enough revenue is collected to finance a better health infrastructure. By relegating the responsibility of healthcare to the states is not enough because in the past, often due to lack of infrastructure or sheer lethargy, many states did not spend the amount granted to them for healthcare. It has long been argued by eminent doctors/scientists that the public expenditure on health should be raised from the current 1.3% of the GDP to 3%. The government has to realise the importance of universal healthcare and adequate nutrition for children from low-income groups.

 This commentary originally appeared in The Tribune.

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Jayshree Sengupta