China
too essentially followed the same model. China's modernization
and economic surge since 1978 have been possible because
of the high level of literacy and health care achieved in
the first three decades of communist rule. Despite the disasters
of 'Great Leap Forward' and the excesses of the cultural
revolution, phenomenal success was achieved in human development.
South East Asia too achieved impressive levels of literacy
and health before the economic boom.
Quantum
jump in economic growth was always preceded by human development.
It does not necessarily follow that high level of human
development guarantees economic prosperity. Political stability
and peace are necessary conditions for growth. Sri Lanka,
which achieved impressive levels of human development even
by the 70's has not made an economic breakthrough because
of two decades of civil war. Similarly, relatively small
nations can sometimes witness economic boom without human
development. This is almost always because of abundant natural
resources which are in short supply globally. The boom in
the middle-East and countries like Morocco and Brunei is
based on a single commodity which commanded premium price.
But such a boom is necessarily short-lived unless those
nations invest heavily in human development and improve
the skills and productive capacities of the people. With
commodity prices showing a long-term decline and modern
technology finding cheaper substitutes in time, large scale
export of natural resources cannot be sustained.
The
lessons of the past six decades are clear. Human development
is the precondition for prosperity. And more importantly,
good health and higher quality of life are the very purpose
of economic growth. Einstein once famously said that the
twentieth century was characterised by perfection of means
and confusion of ends. In India, this confusion continues
in the twenty-first century too. Healthy life is obviously
a goal of all economic activity, and good health is a precondition
for productivity and growth. And yet, we have steadfastly
failed to create a viable, well-functioning health care
model. In Punjab in the forties, most villagers were chronically
ill with Malaria, and there were not enough healthy workers
on the farms. Control of Malaria itself significantly improved
agricultural productivity. But that lesson was never internalised.
True,
there have been significant gains on the health front over
the past 50 years. Average life span has been doubled, and
many communicable diseases are under check. But there is
far too much of avoidable suffering even today. And this
is unacceptable in modern era. Planning Commission's figures
show that only 42% of our children are fully vaccinated
against preventable communicable diseases. Human Development
Report 2002 shows that only 31% population has access to
adequate sanitation facilities. These two indicators are
a damning indictment of our health care system. Our health
expenditure is certainly lower than in many countries. The
US spends 12.8% of GDP on health, 5.7% in public sector,
and 7.1% in private sector. Most OECD countries spend 8
- 12% of GDP. Our public expenditure on health is around
1% of GDP, and private expenditure is 4.2% of GDP. But there
are countries whose expenditure is lower, but results are
better. Sri Lanka spends only 3.5% of GDP (1.7% public,
1.8% private), and China only 5.1% (2.1% public, 3% private).
But infant morality in Sri Lanka (27) and China (32) is
less than half of that in India (67). In many other verifiable
indicators like average life span, birth rate, death rate,
our performance is well below that of Sri Lanka and China.
We account for the largest number of tuberculoses cases
and preventable blindness. Thanks to uncontrolled proliferation
of mosquitoes, malaria is rampant, though there is obviously
gross under reporting: we report only 191 cases per 100,000
population, as opposed to neighbouring Sri Lanka's 1111
cases!
All
these statistics establish two things. We need to invest
more in health. But more happily, the current expenditure
levels also can bring better results if only resources are
properly deployed. Our public health institutions are in
shambles. There is misallocation of resources, coupled with
poor delivery of services. Hospitals, medical education
and dispensaries account for over 60% of the budget and
only 26% is spent on preventive care and family welfare.
Nearly 60% of all pubic health expenditure is in the form
of wages. These distortions result in two inequities. The
poor benefit more from preventive care and primary health,
and denial of these services hurts them disproportionately.
Preventable disease is a major cause of impoverishment and
indebtedness of the poor. And as the public health delivery
is appalling, the few services provided are cornered by
the more influential, depriving the poor. We need to make
primary health centres accountable to local governments,
and ensure better value for the money. Once they function
effectively, a little more investment in infrastructure,
vaccines and medicines will yield huge improvements.
We
are relatively good at military style campaigns. The success
of pulse polio programme is a good example. We need to design
special programmes for Malaria and Rheumatic heart disease
(RHD). Nearly 200,000 children a year fall prey to heart
disease on account of simple sore throat between the ages
of 5 and 15. Compare this with total heart surgeries, mostly
coronary bypasses, of under 100,000 in India every year,
at a whopping cost of about Rs 1000 crores. And yet, RHD
can be eliminated by simple use of antibiotics for sore
throat, at an annual cost of under Rs 10 crores!. Such are
the miracles of modern medicine.
All
is not lost in this war against preventable disease and
avoidable suffering. We have the technology, vaccine and
drug production capability, and highly skilled manpower
in India. The people understand the value of health. Improved
health care delivery is politically profitable. States like
Kerala and Tamil Nadu showed what can be achieved. Lower
birth rates in southern states show that poverty and even
illiteracy need not inhibit successes in health care. Low
costs yield high dividends. Many pioneers like Dr Arole
have shown how great improvements are possible with minimal
inputs, few resources and local talent. All it takes is
genuine commitment, and capacity to build institutions to
deliver services. Economists and politicians would do well
to focus on viable health care systems, reallocation of
resources and instruments of accountability.
***