Commentary

K.R.Nayar

That all plan perspectives begin with a sad story and end on a happy note make one wonder about the ‘continuity’ of different plans. The ninth plan perspective on health is no different. It starts on how our great traditions were lost by ‘inappropriate use of science’ and ‘colonial pattern of industrialization’ and how these resulted in the impoverishment of masses. After the usual statement on history, the perspective starts on the gloomy side of Indian health service system by stating or rather admitting that the health system is functioning sub-optimally . The health service system is plagued by lack of essential infrastructure, suitable equipment and appropriate manpower especially in some critical positions, and poor referral services (source: nicnet).

The stated intentions of the perspective on health could be found in any number of such earlier Government documents. They are:

(i) an absolute and total commitment to improve access to, and enhance the quality of, primary health care in urban and rural areas by providing an optimally functioning primary health care system as a part of the Basic Minimum Services;

(ii) to improve the efficiency of existing health care infrastructure at primary, secondary and tertiary care settings through appropriate institutional strengthening, improvement of referral linkages and operationalisation of Health Management Information System (HMIS);

(iii) to promote the development of human resources for health, adequate in quantity and appropriate in quality so that access to essential health care services is available to all and there is improvement in the health status of the community; periodically organise programmes for continuing education in health sciences, update knowledge and upgrade skills of all workers and promote cohesive team work;

(iv) to improve the effectiveness of existing programmes for control of communicable diseases; to achieve horizontal integration of ongoing vertical programmes at the district and below district level; to strengthen the disease surveillance with focus on rapid recognition, reporting and response at district level; to promote production and distribution of appropriate vaccines of assured quality at affordable cost; to improve water quality and environmental sanitation; to improve hospital infection control and waste management;

(v) to develop and implement integrated non-communicable disease prevention and control programme within the existing health care infrastructure ;

(vi) to undertake screening for common nutritional deficiencies especially in vulnerable groups and initiate appropriate remedial measures; to evolve and effectively implement programmes for improving nutritional status, including micronutrient status of the population;

(vii) to strengthen programmes for prevention, detection and management of health consequences of the continuing deterioration of the ecosystems;to improve linkage between data from ongoing environmental monitoring and that on health status of the population residing in the area;

(viii) to improve the safety of the work environment and worker's health in organised and unorganised industrial and agricultural sectors especially among vulnerable groups;

(ix) to develop capabilities at all levels for emergency and disaster prevention and management; to implement appropriate management systems for emergency, disaster, accident and trauma care at all levels of health care;

(x) to ensure effective implementation of the provisions for food and drug safety; strengthen the food and drug administration both at the Centre and in the States.

(xi) to increase the involvement of ISM&H practitioners in meeting the health care needs of the population.

(xii) to enhance research capability with a view to strengthening basic, clinical and health systems research aimed at improving the quality and outreach of services at various levels of health care.

(xiii) to increase the involvement of voluntary, private organisations and self-help groups in the provision of health care and ensure inter-sectoral coordination in implementation of health programmes and health-related activities; to enable the Panchayati Raj Institutions (PRI) in planning to and monitoring of health programmes at the local level so that there is greater responsiveness to health needs of the people and greater accountability to promote inter-sectoral coordination and utilise local and community resources for health care.

Two important areas which need closer scrutiny in a perspective on health are its approach to primary health care and to disease control programmes.

The existing primary health care institutions, according to the document are functioning sub-optimally because of inappropriate location, poor access, lack of maintenance; lack of professional and para-professional staff at the critical posts; mismatch between the requirement and availability of health professionals especially physicians at PHC; lack of funds for essential drugs; lack of First Referral Units (FRUs) as linkage for referral services. On realising that the goal of "Health for All (HFA) by 2000 AD" laid down in the National Health Policy (1983) was unlikely to be achieved within the time specified, the eighth plan restated the goal as `Health for Under-privileged (HFU) by 2000' . It appears that even this nominal ‘target’ would not be achieved within the plan period.

The Primary Health Care Units have been in shambles as revealed in the plan document. Even the referral units are not functioning effectively. The number of functioning CHCs which form the First Referral Unit (FRU) is far below the projected requirement. There are also marked disparities at the State and district level while the Basic Minimum Services are not been given priority by some states. It is a matter of concern that many of the districts with poor Health Indices do not have adequate health infrastructure. Taking cognizance of the widening disparities among the States in the availability of Basic Minimum Services (BMS), the Conference of the Chief Ministers in July 1996, recommended that Additional Central Assistance (ACA) may be provided to the States for correcting the existing gaps in the provision of seven Basic Minimum Services (BMS). But it is doubtful whether the pattern of utilization of such additional assistance could have led to any reduction in the disparities. This could be largely attributed to diversion of such funds by some ‘critical’ states. Construction of buildings rather improving the quality of services was given priority. Even the funds received from the department of family welfare and the externally assisted projects were used for construction of buildings. Thus, the reasons for the ‘sub-optimal’ functioning of primary health care institutions identified in the plan perspective are only partially addressed. An initiative which could be vigorously pursued and probably more concretely stated than in two lines in the ninth plan is the role of people’s planning under Panchayati Raj. This is of course is easier said than done as a number of states even now have not initiated revitalization of Panchayati Raj Institutions. It appears that P.R is largely used to transfer responsibilities and impose programmes on the lower levels than evolving a democratic set-up for decision-making. Therefore, a clear statement on the policy of decentralization in health and identification of problems in achieving this objective needs to be included in the document.

The secondary and tertiary care on the other hand are handled differently with a dose of World Bank medicine. The added thrust on privatization is quite evident in the policy prescriptions regarding secondary and tertiary care. A whole lot of concessions such as land, water and electricity and exemption from import duty for diagnostic equipment for the private sector is suggested for setting up tertiary care/super speciality institutions.

One of the problems in the post-liberalization period with regard to health care is the gradual neglect of an integrated health care delivery system including control of communicable diseases and the entry of vertical, technocentric and selective packages. These included tuberculosis, blindness control, reproductive health, AIDS etc. largely because of the external assistance to these programmes. Some of the new initiatives in the 9^th plan include horizontal integration of vertical programmes, hospital infection control and waste management, and disease surveillance and response. An integrated approach to disease control programmes have been tried earlier with the multi-purpose workers. However, what we witnessed is further verticalization and added thrust on specific diseases influenced by the external assistance. Unless the linkages between financing and programming are clearly understood, the alien ideas which accompany the packages would wreck the disease control programmes.

Among the communicable diseases, malaria and tuberculosis are certainly given importance. The National Malaria Eradication Programme intends to implement an intensive implementation of the Modified Plan of Operation (MPO) in the malariogenic areas of the country in the 9^th plan. The areas identified are the seven north eastern states and 100 districts spread over the states of Andhra Pradesh, Bihar, Gujarat, Madhya Pradesh, Maharashtra, Orissa and Rajastan based on the criteria of , a) annual parasite index of more than 2 for the last three years b) death due malaria c) P.Falciparum rate of more than 30% d) tribals constituting more than 25 % of the population. The main components to be strengthened in the ninth plan are 1. Early diagnosis and prompt treatment through active and passive surveillance and laboratory diagnosis 2. Selective vector control by integrating various vector control approaches and promotion of personal protection methods 3. Prediction, early detection and effective response to malaria outbreaks 4. Intensified information, education and communication campaigns.

The programme still strongly depends on clinical and technical solutions than on addressing epidemiological, ecological and social dimensions of the disease. The methods which are being advocated such as personal protection through impregnated bed nets shows that the social dimension of the disease has not been well conceptualized. It appears that the perspective has not learned from the past mistakes of the programme. What is needed for the intensive phase is a better managerial approach with emphasis on ecological and social dimensions.

The National Tuberculosis Control Programme (NTCP)also receives considerable attention in the perspective. The revised programme for tuberculosis (RNTCP) would be implemented in 103 districts apart from strengthening 203 Short course chemotherapy (SCC) districts. This extension is based on the experience of pilot studies in 17 project sites in which it is claimed that 60 to 80 per cent cure rate was achieved. It is not known how this can be replicated given the intensive efforts done during the pilot phase and the fact that most of these were carried out by agencies in the private/NGO sector in urban areas. Nevertheless, efforts should be made to reveal and address the problems identified during the pilot phase instead of blindly carrying the programme forward just because assistance is available from the World Bank.

The AIDS control programme is the classic example of the external control over India’s communicable disease control programmes. While diseases of the poor such as cholera and diarrhoeal diseases do not find a place in the perspective, AIDS occupy a central place as a cent per cent centrally aided programme through external assistance. Similarly, non-communicable diseases also receive considerable attention. These include cancer control, micro-nutrient malnutrition, diabetes, cardio-vascular diseases, mental health etc. Some states had also initiated pilot schemes in the eighth plan for integrated non-communicable disease control with diabetes as a model in some districts. In the ninth plan as well these will be continued with added emphasis on diagnosis and management through the primary and secondary care level assuming that diseases like diabetes, cardio and cerebro-vascular diseases and malignancies are going to be the major disease burden in the rural areas. In reality, this apart from adding to the programme burden of the PHCs and CHCs would also serve as a conduit for private diagnostic institutions sprouting up in the rural areas.

The perspective on environment and health starts with a broader approach with focus on detection, prevention and management of existing deficiencies or excesses of certain elements in the natural environment, macro environmental contamination of air, land, water and food, natural disasters etc. However, the communicable diseases due to environmental conditions in the urban and rural areas need to be clearly spelt out in terms of specific programmes and strategies than a garbage clearing approach which mainly evolved in the post-plague period. One of the positive features of the perspective is the stated intention to evolve programmes for the agricultural and unorganized sectors. Any structured health programmes evolved for these sections including vulnerable groups such as women and children, however needs to be carefully conceptualized in the perspective so that it may not result in yet another vertical programme.

That external assistance has considerably influenced the outlook of the 9^th plan perspective on health is quite evident. The strength of India’s health care system is its elaborate network of health care infrastructure which is systematically undone in recent years despite the claim that external assistance has been used to improve primary health care infrastructure. However, apart from buildings there have been no improvements in the quality of services. In fact, the focus during the eighth plan was on strengthening health care infrastructure aimed at improving the quality and outreach of services. However, health care infrastructure was largely visualized as construction of buildings. Along with this, the clear policy shift towards privatization during this period has resulted in the utter neglect of public health services. The outlay for health sector has also steadily declined from 3.3 per cent of the total plan outlay in the first plan to around 1.7 per cent in the eighth plan. More than one-third of this investment is by external assistance linked to specific diseases such AIDS, blindness control etc. On the other hand, investment for family planning has been growing over the years. The annual report of the Ministry of Health states that the public expenditure in the health sector has been a little over 1.5 per cent of the GDP while WHO recommends that it should be at least 5 per cent of the GDP. The collapse of the public health system in the country and the loss of faith of the people on government health services could be largely attributed to the declining investments especially after the structural adjustment programmes. At the same time, these trends are also used as a rationale for usher in privatization of health sector. The collapse of the public health system has also influenced the epidemiological profile of the country. Acute respiratory infections and malaria are showing a rising trend from 1988 onwards. Pneumonia, tuberculosis, viral hepatitis, cholera, and enteric fever have also been showing a rising trend in recent years. The dramatic decline in the infant mortality rate, a sensitive indicator of health status occurred only during the pre-reform period. The rates have been rising, stagnating or the decline has slowed down in most of the vulnerable states of India. Even in Kerala the IMR has been showing a rising trend. In Karnataka, the rate has not declined much over the last ten years. The situation warrants effective intervention. As a beginning, the comprehensive review of public health system in the country undertaken by the planning commission could now be discussed in an open forum to enlist the views of public health scholars from different parts of the country before any major reformulation in the national policy and revision in the public health strategies as proposed in the perspective are initiated.