By Dr. Kavita Kalkoti:
India’s health scenario has been significantly unhealthy despite implementing plethora of Government programs, huge spending, establishing number of health delivery centers and providing tens of thousands of staff. The HUNGaMA Survey [2011] on Hunger and Malnutrition in 100 focused districts in six States of Bihar, Jharkhand, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh reveals [i] 42% children under five are underweight and 59% are stunted, of which half are severely stunted [ii] malnutrition is significantly higher among children from low-income families. Children from Muslim, SCs and STs generally have worse nutrition indicators [iii] 51% mothers did not give colostrum to the new born soon after birth and 58% mothers fed water to their infants before six months [iv] 11% mothers reported using soap to wash hands before a meal and 19% after a visit to the toilet [v] while 86% mothers accessed Anganwadi centers for immunization only 19% mothers reported Anganwadi centers counseling to parents despite 96% villages having Anganwadi centers and 61% having pucca building. Every year nearly 60,000 women die in pregnancy and childbirth while around 1.7 million children less than five years also die. Maternal mortality per 100,000 lives is 212 and infant and child [0-4 years] mortality per 1000 live births is 47 and 14 respectively. Millions of adolescent girls and women experience severe health problems during their menstrual cycles.
The Lancet Medical Journal revealed that in 2010, India with four other countries accounted for 50% of the estimated number of global deaths due to eight main preventable infectious diseases in children younger than five years. Pneumonia and diarrhea caused about 4,00,000and 2,10,000 deaths respectively. Pneumonia and diarrhea were responsible for about 1,43,000 and 19,000 deaths respectively in neonates [less than 28 days old] and nearly 2,54,000 and 1,93,000 deaths of children aged 1-59 months respectively. The Lancet study of November 2010 revealed no significant improvements during 2005-10. According to the Lancet, India figures at the top of five countries that account for 50% of still births. India is followed by Pakistan, Nigeria, China, Bangladesh, Ethiopia, Indonesia, Afghanistan and Tanzania. In India, the stillbirth rates varied significantly from 20 to 66 per 1000 births among States. Major reasons are complications during the child birth, maternal infections in pregnancy, maternal disorders, especially hypertension and diabetes, foetal growth restriction and congenital abnormalities.
The National Family Health Survey [NFHS] on four major diseases viz. asthma, tuberculosis, jaundice and malaria reveals that 3697, 2468, 1361 and 544 persons per 100,000 populations were suffering from malaria, asthma jaundice and tuberculosis respectively. Their prevalence was high in rural areas. Incidence of Tuberculosis was 16% higher than that reported by NFHS-I [467/100,000]. According to the third NFHS, 55.3% of women in the age group of 15-49 years are anaemic.
In 2010-11 a total of 1,26,800 cases of leprosy were detected of which 48.58% were Multi Bacili, 36.20% [female], 9.83% [children] and grade-II disability [3.10%]. In India, one new case is detected every five minutes, including 10,000 new leprosy affected children every year. Children accounted for more than 10% of new cases in nine States/UTs viz. D& N Haveli [18.54%] followed by Puduchery [16.90%], Bihar [15.75%], Tamil Nadu [15.72%], Sikkim [12.50%], Maharashtra [12.34%], Andhra Pradesh [11.96%], Kerala [11.92%] and Karnataka [11.03%]. Around 7.58 million people suffer from kidney failure. Every year one million babies, out of about 25 million born, die and most who survive do not grow and develop well. Under-nutrition contributes to 35% of deaths.
A majority of rural people have most unsatisfactory hygiene and have no access to safe drinking water and sanitation. A recent UNICEF report says in India 638 million people [54%] defecate in the open as against just 7% each in Brazil and Bangladesh. In India only 6% rural children below five years used toilets and about 50% of all Indians did not regularly wash their hands with soap after contact with excreta. Washing hands can reduce impact of diarrhea by over 40% and of respiratory infections including pneumonia by 30%. According to the Mumbai Hospital Infection Society, 25%to 35% of patients admitted to city hospitals become casualties of hospital infection.
Programs: Government has been implementing number of programs that, inter alia, include [i] Pradhan Mantri Swasthya Suraksha Yojana [ii] National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Strokes [iii] National Aids/HIV Control Program [iv] Reproduction and Child Health [v] Janani Suraksha Yojana [vi] Janani Shishu Suraksha Karyakram [vii] National Vector Borne Disease Control Program [viii] Revised National Tuberculosis Control Program [ix] National Leprosy Eradication Program [x] National Program for Control of Blindness [xi] National Program for Health care of the Elderly [xii] NPCDCS [xiii] Ayruveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy [xiv] ICDS [xv] RG Scheme for Empowerment of Adolescent Girls [xvi] RG National Creche Scheme for Children of working mothers [xvii] Integrated Child Protection Scheme.
Funding: Funding under NRHM significantly increased from Rs.27,700crore to 39,000 crore [from 0.95% of GDP to 1.05%] between 2004-05 and 2005-06 and progressively increased from Rs.14,702.76 crore in 2009-10 to Rs.14,988.02 crore in 2010-11, to Rs.18,115 crore in 2011-12 and further significantly to Rs.20,822 crore in 2012-13. Under the ICDS, the Union Government spent Rs.43,829.53crore as against budgetary allocations of Rs.43,186.70 crore during the Eleventh Plan. Under the Janani Shishu Suraksha Karyakram, a sum of Rs.1437 crore was allocated to the States during 2011-12. Budget for 2012-13 allocated Rs.1096.70 crore for the Rashtriya Swasthya Bima Yojana.
Manpower: Under the NRHM alone as on September 2011, the Government added over 1,40,000 staff which include 11,712 doctors and specialists, 10,851 AYUSH doctors, 66,784 auxiliary nurse midwives, 32,860 staff nurses and 14,434 paramedics and AYUSH paramedics. Besides, Government selected 8,55,000 ASHAs out of which 8,07,000 received orientation training and are already engaged and provided 7,41,000 ASHAs with drug kits. Each village or large habitation has one ASHA per 1000 population.
Centers: Under the NRHM as on March 2010, India had functioning 1,47,069 Sub-centers, 30,431 PHCs and 4,535 Community Health Centers. During 2005-12, 14,676 [48.23%] PHCs are converted into viable 24/7 facilities at least for Reproductive and Child Care against target of all existing PHCs. Further, 442 districts are equipped with mobile medical units
Health Committees: At village level, 4,96,338 Village Health, Sanitation and Nutrition Committees [VHSNCs] are constituted to create awareness about disease prevention and popularize preventive measures. Each VHSNC is annually provided Rs.10,000. States are also provided funds for capacity building and training VHSNC members..
Inefficiencies: Lack of serious concern, commitment and accountability at all levels has contributed to significant inefficiencies in the public health delivery system and injudicious use of human and financial resources. These, inter alia, include [i] poor upkeep and maintenance [ii] dilapidated infrastructure and inadequate supply of drugs and equipment [iii] unacceptable level of employee absenteeism, 40% nation-wide average [iv] some States are not deploying additional funds and resources, often due to inefficient PRIs [v] fund utilization in many States is around 70% [vi] despite elaborate institutional network of facilities, only 20% of those seeking outpatient services and 45% of those seeking indoor treatment avail public services [vii] many medical officers visit PHCs infrequently and practice privately in nearby towns [viii] ANMs are frequently unavailable to attend child births despite mother’s willingness to come to PHC. [viii] mostPHCs also charge a fee to poor though PHCs have to provide free services,
Universal Health Coverage: Now the Government is considering providing an assured “essential health package” to all citizens under its Universal Health Coverage initiative. Under this scheme all Indian citizens, regardless of their economic, social or cultural backgrounds will have the right to affordable, accountable and appropriate health services of assured quality defined in a published package of services and benefits. Will the operating and administrative staff and policy makers demonstrate their concern and commit to guarantee the delivery of health services and be accountable to consumers?