Thursday, April 04, 2002
How sick are we?
SHANKAR ACHARYA
NO, I am not referring to the tragedies in Gujarat, though heaven knows there is plenty of sickness there. I mean our health status as Indians. Over the past year there have been at least two major reports on India’s health system, one by the World Bank and another by ICRIER. It’s an opportune time to marshal some answers to the question above.
First, the good news. Since 1950 life expectancy at birth has climbed from 36 to 62 years in the late nineties. The infant mortality rate has dropped from 146 per thousand births to 70. Fewer children are dying before attaining their fifth birthday, with the child mortality rate having fallen from 57 per thousand to 23.
These are impressive gains in health status even if they have taken fifty years or so. Public heath initiatives, rising average incomes and better management of droughts and famines have all played a role.
But over the same period, many other developing countries, including populous Asian ones, have done much better. In China life expectancy at birth has risen to 70 years, infant mortality is down to 30 per thousand and child mortality is only about 11 per thousand.
In Indonesia life expectancy is 66 years, infant mortality is only 42 per thousand and child mortality is below 20 per thousand. Yes, neighbouring Pakistan boasts worse indicators than us but note that even Bangladesh has a significantly lower infant mortality rate than ours.
There is clearly no room for complacency, certainly not if we look at our share in the global burden of disease as measured by disability-adjusted life years (DALYs) lost to premature death and disability.
The DALY index, routinely used by the World Health Organisation, attempts to combine the years lost due to premature death and years lost due to disability and ill-heath. As the table shows, while India accounts for a sixth of the world’s population it bears about 20 per cent of the world’s burden of disease.
What’s more, some of the main sources of DALYs, such as lower respiratory infections (mainly pneumonia), diarrhoeal diseases, tuberculosis, measles and anaemia, are potentially amenable to public health initiatives (including more effective immunisation programmes).
While we are still struggling to reduce the heavy toll of “traditional” communicable diseases (especially among children), the threat from HIV/AIDS is on the rise and malaria is making a come back.
Furthermore, the “industrial country” ailments of heart disease and various cancers are growing fast, much faster than our public health system is adapting to the new challenges. By 1998 ischemic heart disease was the top killer ailment in India and the third highest cause of DALYs, accounting for over 22 per cent of global DALYs from this cause.
National averages mask the disproportionate burden of ill-health on the poor. Studies show that the poorest 20 per cent of Indians suffer infant mortality rates as high as 109 per thousand, which is two and a half times the rate amongst the richest 20 per cent (44 per thousand).
When child mortality is included, the below 5 years mortality rate among the poorest quintile rises to 155 per thousand , almost three times higher than the rate for the richest quintile. Poverty, malnutrition and absence of clean water are major causes of this disparity.
But it is troubling that the public health system is not playing a bigger role to counter this disadvantage. Indeed, when it comes to curative services, studies show that the poorest quintile receive only a tenth of the public subsidy while the richest quintile corner a full third.
Public health spending (about four-fifths by states) amounts to only one per cent of GDP, putting India in the bottom 20 per cent of countries ranked by share of GDP allocated to public spending on health.
With public spending so low (and that too increasingly on wages/salaries of public employees rather than on medicines and other necessary inputs) it is little wonder that India “boasts” one of the world’s highest shares of private spending on health, above 80 per cent.
Even among the poor, for 80 per cent of outpatient care they have to go to private practitioners, many of whom are ill-qualified. What’s more, they have to pay for such services out of pocket, since health insurance is notable by its absence.
Private hospitals are unaffordable by the poor; even for the non-poor hospitalisation often results in financial disaster. One study found that about a quarter of hospitalised people are driven below the poverty line by the burden of expenses.
In a nutshell, public heath services are thinly spread and very inadequate while private services are skewed in favour of the well to do but far from satisfactory. For the poor, India’s health system provides a very raw deal.
The situation is not hopeless. One very positive feature is the large variation in health indicators across India’s states. At the top end is Kerala, with under 5 mortality below 20 per thousand, comparable to much richer countries like Argentina and Uruguay.
At the bottom end are the BIMARU states with under 5 mortality (100 to 140) comparable to Sudan and Tanzania. Much of this variation is due to disparities in income, poverty and nutrition. But some of it arises from differences in the scale and quality of health services.
States such as Kerala and Tamil Nadu not only spend double the amount per capita on public health than Bihar and Madhya Pradesh but they also spend it more equitably and effectively.
The current answer to the title question has to be: pretty sick. For the situation to improve, the majority of Indian states have to adopt the best practices of the better-performing states, there has to be more effective partnership between public and private health services, the policy emphasis has to shift in favour of preventive over curative medicare and viable modes of heath insurance have to be evolved.
(The author is a professor at ICRIER on leave from his previous assignment as Chief Economic Adviser, ministry of finance. The views expressed are strictly personal)
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