Health deteriorates

By Gita Sen

THE IMPACT of the structural economic reforms of the 1990s on human development in India has been a subject of controversy from the start. But while there has been a fair amount of public debate on whether we need to improve our general health and education levels if the economic reforms are to be successful, there has been less discussion on the actual impact of the reforms themselves. In a country with so much poverty and economic insecurity, riven by severe inequalities between rich and poor, upper and lower castes, women and men, the extent to which health services are affordable and equitable is crucial to the well-being and indeed survival of the disadvantaged.

At Independence, the Health Survey and Development Committee (Bhore Committee, GoI 1946) was emphatic that comprehensive health care should be universally accessed by all regardless of their ability to pay. Despite this, progress in health over the intervening decades has been very uneven. Worse still, the pace of improvement in key health status indicators appears to have slowed down and even stalled in some cases in the past decade. The pace of decline in infant mortality has been very slow in the 1990s, and perinatal and neonatal mortality have not fallen. In its review of the working of the 9th Plan, the Planning Commission has expressed concern at the drop in routine immunisation of children. The recent second round of the National Family Health Survey (1997-98) showed that maternal mortality is still extremely high. Health inequalities across States, between urban and rural areas, and across the economic and gender divides have become worse.

Three aspects of the economic reforms of the 1990s may have played a role in this: stagnating Government health expenditures, the skyrocketing prices of drugs and rising cost of health services, and increasing unregulated privatisation of the health care sector. Between 1990-91 and 1994-95, the real value of Government (Centre and States) health expenditures remained stagnant at around Rs. 33 per capita. Thereafter, there was a modest increase, but no significant infusion of funds until 1998. As a result, public expenditures on health stagnated at under three per cent of total Government expenditure, and were only 0.86 per cent of GDP at the end of the decade.

A second set of policy changes that had a crucial bearing on the quality and costs of health care in the 1990s was the systematic deregulation of drug prices. The effects of industrial deregulation on drug prices began to be felt in the 1980s, and these continued and accelerated in the 1990s. The result was spiralling costs of drugs, and the continued absence of a regulatory list of essential drugs meant that the market continued to be flooded with irrational drugs. National Sample Surveys from the mid 1980s and 1990s point to significant increases in the cost of both in-patient and out-patient health care in rural and urban areas. Drug costs and rising fees for different health services undoubtedly played a major role in this. These cost increases affected both private and public health services, and in fact the cost of public in-patient care came closer to the cost of private care. Rising cost of care is a critical concern for poor people. A review done in the mid-1990s showed that the proportion of household spending on treatment by the poorest income groups in five major States was higher than the average for all income groups. The rising cost of health care can have a range of possible impacts on the poor. These include cutbacks on other consumption such as food which directly impacts on health status; increased indebtedness; growing untreated illness; and growing gender biases in health seeking behaviour.

A third aspect of the reforms of the 1990s was the growing support for private health care providers. This included a variety of subsidies for corporate hospitals, such as urban land in prime locations in exchange for their providing a proportion of their services free to the poor. There is increasing evidence of non-compliance with this condition by major private hospitals in metropolitan areas. Furthermore, as corporate hospitals have come to set the standard for medical technology and interventions, there is reason to believe that they have contributed to the increases in health costs overall. Given the poor quality of care and the low labour productivity in the public sector, not all attempts to increase the role of the private sector are necessarily inequitable. However, the overall impression is one of rapid privatisation with little accountability to patients, while public health services have continued to deteriorate.

Until the mid-1980s, public hospitals were still the dominant providers of in-patient care especially for the poor, even though patients increasingly resorted to the private sector for out- patient services. Although this varied considerably across States, public hospitals provided an important alternative to the private sector and at significantly lower cost.

By the mid-1990s, there is clear evidence that the private sector had become dominant in terms of both out-patient and in-patient services, and that the average cost of all care (and particularly of in- patient care) has gone up significantly. Untreated illness among the poor has clearly increased. Inequity by economic class appears to have worsened, and the divide between rich and poor in terms of untreated illness and expenditures on health services, as well in the use of both public and private health care institutions, has grown. The rich are now the major users of not only private but also public hospitals!

A comparison based on the National Sample Surveys provides sobering evidence of the worsening situation. NSS data from the mid-1980s already showed striking differences across the economic class spectrum and by gender in the extent of untreated illness, as well as in expenditures on in-patient and out-patient care. Already in 1986-87, untreated illness was 15-21 per cent higher among women and girls. This figure does not include the reservoir of untreated sexual and reproductive illness that these surveys do not capture. Inequality by household expenditure groups for untreated illness was highly significant in both rural and urban areas. The poor were less likely to get treated for their illnesses than the rich, and this was worse among women than men. When the poor did get treatment, they tended to spend less on both outpatient and in-patient care.

In the 1990s, we found even greater inequality across economic classes in the extent of untreated illness, and in health expenditures for both women and men in urban areas and for men in rural areas. The conclusion that health care is becoming increasingly difficult for poor people to access is borne out by the reasons that people gave for untreated illness. Compared to 1986-87, the proportion of those who said they were unable to access health care because of `financial reasons' went up significantly in both rural and urban areas. So did the proportion who said that there was no medical facility available.

Gender inequity, particularly in untreated illness, remains severe. However, the worsening of inequality in the extent of untreated illness, and hospital utilisation has been somewhat sharper for men. This relative worsening of access for poor men, even though they continue to be better off in absolute terms than poor women, may imply that poor households are now really stretched to the breaking point in terms of access and affordability of health services. There may be so little left to cut by way of women's access to health services that poor households are now forced to cut on the men. This may reflect the worst kind of `catching up' in terms of gender equality.

The overall impression is that, unless significant steps are taken to make health care affordable and accessible, India's already abysmal performance on human development is likely to get worse.

(The writer is Professor at the IIM, Bangalore, and research on which this analysis is based was done jointly by her, Aditi Iyer, and Asha George.)

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