Brave attempt at a health policy
Health minister C P Thakur has made a brave attempt to prepare a new draft health policy to face up to the health challenges of the early decades of the 21st century. The last one prepared in 1983 has lost its relevance, the draft document says, because "there have been very marked changes in the determinant factors to the health sector," and, of course, because "outcomes have not been as expected." But the document does not address several critical areas that any health policy must address itself to.
There are three key dimensions that any health policy in India must deal with. One, it must address itself to the extent and quality of the delivery of health services. Two, it must deal with the emerging 'double burden of disease', which former director-general of the Indian Council of Medical Research, V Ramalingaswami, had predicted nearly two decades ago. And, three, it has to go beyond the curative aspects of health and also talk about disease prevention programmes. The draft health policy leaves a lot to be desired on all the three counts.
As is true with any political document in India, 'health equity' is definitely brought in upfront but the document presents no new ideas on how health services will be improved in a way that they truly reach out to the rural and urban poor. Involvement of civil society and local self-governments as part of a larger strategy for 'decentralisation' is mentioned but there is no clarity on the whats and hows of this decentralisation. The importance given to the Indian systems of medicine in reaching out to the poor is indeed welcome but a separate document on this aspect has yet to be prepared.
The 'double burden of disease' has not even been seriously addressed in the document. On one hand, probably a million children below the age of five die every year, most of them because of a combination of diarrhoeas and dysenteries together with malnutrition. Acute respiratory infections are known as another chief killer of young children and 80 per cent of these respiratory infections is now attributed to indoor air pollution. On the other, diseases like aids , cancer, respiratory disorders, diabetes and heart problems are rapidly gaining ground. If we assume an incidence of just 100 cancer cases per 100,000 people, it means we now get some one million cases of cancer a year.
The best way to treat the first set of health problems is to ensure food security and supply of adequate and clean drinking water. The government's track record on both these counts, as of yet, is so shameful that there is no guarantee it will become better in the coming decades unless there is a sea change in its attitudes and approaches. As regards the latter, they are extremely expensive to treat which creates serious 'health equity' problems in a country like India, but easier to prevent as they are deeply related to lifestyles and environmental changes. The draft document almost tends to skirt this issue.
For instance, in its only passing mention of rising vehicle density in cities, the document says this leads to accidents. But there is no mention of growing air pollution and its impact on human health. There are growing number of studies, which speak of the deadly poisoning of our bodies and growing incidence of respiratory and heart diseases.
The document instead finds an easy way out. It states, "Improved health standards are closely dependent on major non-health determinants such as safe drinking water supply, basic sanitation, adequate nutrition, clean environment and primary education, especially of the girl child. The health policy will not explicitly address itself to the initiatives in these areas. However, the attainment of the various targets set in the health policy assume a reasonable performance in these allied sectors." In other words, most ministers from environment and rural development to urban development and food will play a key role in meeting the country's health targets. Given the total lack of concern that most ministers show for the country's health and environment and incompetence within the bureaucracy, this is too much to expect. Petroleum minister Ram Naik's effort to derail the Supreme Court's efforts to clean up the air of Delhi is one graphic example.
At the end of day, the biggest problem is the lack of public pressure. Indian people think very little about their health till they fall ill. Even industrial workers who work in noxious environments don't demand better working conditions. They only demand higher wages or 'toxic allowances'. And the trouble is that in no democracy do the 'dead and unhealthy' constitute vote banks. And, in India's democracy especially, where politicians unashamedly serve only vote banks, health is, therefore, of no concern to them. This is reflected in the decline in expenditure on public health from 1.3 per cent in 1990 to 0.9 per cent in 1999. One bump in salaries of government servants can take away more than what the health sector gets. So don't expect much even if the new health policy was a better document.
- Anil Agarwal