Saturday, July 21, 2012

Politics of Health Care in India

 Dr. S. Albones Raj

Inclusionist Policies and Exclusionist Outcomes: Some Reflections on Politics of Health Care in India

     This article argues that inclusion and exclusion could occur at multiple levels. It further contends that dysfunctional exclusion is often a structurally produced and systemically sustained. Social identities – as men and women, ruaralite and urbanite, dalit and non-dalit – provide differential access to social space to different social actors. T.K.Oomen, in the maiden issue of International Journal of Sociology (1985), introduced the ‘insider-outsider’ framework, which was staunchly rooted in Interactionist traditions of sociology. Though the Inclusion-Exclusion framework is couched largely in structuralist diction, the epistemic resemblance to Oomen’s dualist approach is unmistakable. Dwelling upon the state of the nation, Ommen traces the evolution of social identities through the socio-political history of Indian society.  Interestingly enough, the ‘insider’ is not necessarily ‘included’, as the ‘outsider’ is not necessarily ‘excluded’ in the social space!
   This article attempts to draw attention to two instances of exclusion in the domain of health care in India noted by scholars consistently over years, despite the well-intentioned Inclusionist policy of the State. This paper, while seeking to describe the nature of exclusions under reference and explore the causes for the same, also makes a plea for an effective realization and utilization of community resources, inter alia, as a mitigative and as an inclusive measure.  This article and its contents should not be misconstrued as an attempt to contest or belittle the efficacy of other instruments of mitigation. However, this article does debunk the cacophony of decentralization being touted as a panacea for the ills plaguing the system of health care in India.
The Two Scenarios
     The scholarship on health information system (HIS) is polarized on their interpretation of the shape of world’s health in general and in India in particular. Scholars with the demographic leaning are inclined to point to the inexorable deterioration and the catastrophic course the world has chosen, partly by default and partly by design. The teeming millions of the world’s major cities and the mounting problems they face - with very little hope of alleviation and relief – are taken as ominous signs of the suicidal course we opted to take. The doomsday cultists, as they are called, blame the generations of men and women for having witlessly ravaged the world’s resources without any passing thought for the posterity.
The source of inspiration for this article is a highly readable book authored by Lomborg (2005). Lomborg, a Statistician by profession, represents the all-is-well school of thinkers, à la utopians. He presents a powerful argument that we, as earth’s inhabitants, are indeed doing well, albeit belatedly. On health, Lomborg was quick to point out that the life expectancy has increased in the industrialized nations of the West and also in developing nations of the world. The increase in life expectancy from 31 years in 1909 to 41 in 1950 and 65 in 1998. As for AIDS claiming heavy toll among humans, he is hopeful that
                             “In the long run, massive AIDS prevention programs such as   
                              Uganda’s show the way, having dramatically lowered prevalence 
                               rates” (2005: 52)
In the same vein, he claims that

                              “…Victory over infectious diseases is clearly demonstrated…. The
                              important killers, pneumonia and tuberculosis have decreased
                              dramatically over the past century …“ (2005:54)

For Lomborg, the conditions of living have considerably improved for the humanity and this has had a telling impact on the survival probabilities of all populations including those of India. The middle-ground approach suggested by the present author is laced with objective criticism of the health reality in India – wherein an attempt is made to pinpoint the desiderata in health policy and its actualization – and a down-to-earth methodology for tackling the same at the community level.
 The two contrasting ‘realities’- cataclysm and utopia - captured in the preceding paragraphs, command wider support, though not to the same degree, in the academia.
The Indian Context:
                  “Chennai City has mosquito density of 117/10 man hours and larval density of
                  42/positive dip against the norm of 50-80/10 man hours and 5/positive dip,
                  respectively. Pulianthope, which is zone 3 of the Chennai Corporation has the
                  highest mosquito density of 275/10 man hours and a larval density of 85/
                  positive dip, followed by Tondiarpet with the mosquito density of 159/10 man
                  hours and Triplicane with 128/10 man hours”
                                                                                  - The Hindu, dated 1st February 2007

                        “The wide gap between policy statements, technical prescriptions and
                         actual implementation of the same still persists"
                                                           -    India Health Report, 2003

                       “Health budget was gradually reduced during the period 1988-2001 from
                        56 to 48 per cent”
                                        -  Report of the Independent Commission on Health in India, 1997

                        “New strain of malaria constitutes an old problem with a new challenge”
                                                                                                             -K. Park, 2002
The assorted excerpts of assertions featured above paint a grim picture of the Indian, hopelessly trapped in a tragic present and an apocalyptic future. It would appear as though the India, like the ‘cursed world, of the Time and the New Scientists, is fighting a loosing battle against forces of morbidity and mortality – the defeat guaranteed by our own ‘dysfunctional civilization’ and misplaced priorities.  The dooms day is, however, not just round the corner – so it would appear. Metaphorically, the India’s self-defeating course is punctuated with occasional success, bolstering its confidence to knock the challenger – communicable and non-communicable diseases - out of the ring, only to find the challenger springing back into action with a renewed vigor and stratagem. It would also appear that ‘rules of engagement’ would also include ‘know thy enemy’ i.e. awareness about the precipitative and necessary conditions causing illness.  Awareness is a powerful weapon in the armory of the mankind in its relentless battle against forces of morbidity, at all stages. However, if Misra, Chattarjee and Sujatha Rao are to be believed, in our battling strategy we have slighted and under-estimated the power of health education
                      “Health education has always occupied a lower priority in Indian public                     
                       policy. Its allocation under different budget, taken together is not more 
                       than 1- 2 per cent of annual health budget. Lack of information is one of
                       the major barriers to the effective access to services. The pulse polio
                       campaign is an example of how people change behavior in response to

(Mishra et al 2003:64).  Crediting health education as an effective way of enlisting people in the crusade against forces of morbidity, they state
                    “An activity associated with health education is the securing of social support to enable the effective implementation of disease control measures”

(Ibid, P-65). Thus, notwithstanding the proven efficacy of health education, continued lack of adequate emphasis on health education amounts to self-disarming ourselves in the face of a formidable and vengeful foe. The table below presents a picture of dismal apathy towards health education and training over different plan periods. The decreasing investment in the form of percentages spanning over eight Five Year Plans tell their own tale.
Plan Allocation for Health Education and Training in Five Year Plans (in Percentage)

1951-6   1956-61  1961-6   1966-9   1969-74  1974-9   1980-5   1986-91
15.4        16.0        14.1        9.6          8.5          4.8          --             1.3
Source: Health Statistics of India, 1988

That health itself occupies a place nadir in the national agenda becomes apparent from the table below:
Investment in Health (in percentage)

I Plan     II Plan    III Plan  IV Plan  V Plan   VI Plan  VII Plan VIII Plan
3.3          3.0          2.6          2.1          1.9          1.8          1.8          1.7
Source: Economic Survey 1991-02
 One begins to surmise that our health policy framers, after all, have their well-thought-out strategy in place and that they do not mind losing a skirmish, having set their eyes on winning their own battle of Plasy! It would even look that our precious little resources are being judiciously marshaled and strategically invested keeping in view the big picture and the ultimate victory! Perhaps reducing the pain of the suffering masses has taken precedence over health education - so one would reason. But then, the following observations of Mishra et al (2003) on the need to intensify rigor in program monitoring would make one suspect whether the systemic failure still plagues various programmes of health.

             “Untimely and inadequate procurement of insecticides.
             Low limits for the payment of wages and non-availability of recurring budgets to engage labor for   spraying operations.
             Lack of systems for the evaluation of insecticides application equipment.  Inadequate monitoring of insecticide resistance against malaria.
             Lack of evidence-based data on vectors responsible for malaria transmission and transmission period
             Lack of evidence for the introduction of new insecticides and      Lack of control on free availability and use of anti-malarials, delayed slide examinations and lack of information on the status of drug resistance”.
             “Untimely and inadequate procurement of insecticides.
             Low limits for the payment of wages and non-availability of recurring budgets to engage labor for spraying operations.
             Lack of systems for the evaluation of insecticides application equipment.  Inadequate monitoring of insecticide resistance against malaria.
             Lack of evidence-based data on vectors responsible for malaria transmission and transmission period
             Lack of evidence for the introduction of new insecticides and
             Lack of control on free availability and use of anti-malarials, delayed slide examinations and lack of information on the status of drug resistance”.

Any discerning reader of statistics could see as to why the alarmists are deeply concerned and sound the same in their typical shrill voice.  The correlation, if not causal connection, between the programmatic failure and the data on mosquito infestation in Chennai quoted from a survey published in ‘The Hindu’ is unmistakable.  Tamilnadu, in general, has been commended as one of the consistently well-performing states in the health front with ‘low endemicity’ (Mishra et al 2003). But Tamilnadu, too, conforms to the all India pattern of not taking recourse to health education, the two exceptions being pulse polio and HIV/AIDS campaigns. Lack of clarity apart, community action is yet another notable lacunae in the whole schema of well-ness programs promoted by the state and private players – a theme I shall return to in the ensuing pages

Epidemiogical Polarization:
Critics of our health and disease prevention policies have sounded yet another note of caution on the oft-bandied ‘Decentralization’. The zeal with which many programs are sought to be decentralized in some states, notably, Uttar Pradesh, Madhya Pradesh, Rajasthan, Bihar and Assam have not brought in significant improvement in health administration and health program implementation (Central Bureau of Health Information, Government of India 1991 & 2001). The BIMARU states, as they are called, have registered low progress on poverty-reduction, in particular and in the economic front, in general. There appears to be a convergence between the low economic index these states have registered and the abysmally poor performance in the area of disease containment. One cannot dismiss this as serendipitous coincidence. The states under reference have not been able to augment their financial resources and are unable to bear the recurring cost on account of program implementation. The central assistance, though sizeable, has to be combined with the state’s resources to ensure the achievement of targets. Thus, there appears to be a polarization among Indian states in disease prevalence and their ability to arrest the same.
       Problems related to health are rooted in political economy and sociology of these states. Understandably, these economically backward states are unequal to the challenge posed by the vectors and unhygienic conditions found in these states. Needless to point out that for these states, health education constitutes the last and the least important item in the states’ agenda. Such states are fit cases for centralized administration of health infrastructure and of health program implementation. However, the central administration with its vast resources – human, expert and financial – would be willing to redistribute its resources so as to reinvigorate health education programs itself is a moot point.  Thus, the far-from satisfactory strides we made in the arena of health in some states could be our Waterloos, but then we have our Plassys as well! One of the useful lines of investigation is – albeit qualitative – the probable relation the body politics may have with the poor performance of these states in the arena of health. Scholarship on politics – from Aristotle through Tocquiville to Lipset - has virtually deified centralization as the hallmark of democracies, paying rich dividends in all fronts of development in the long run!
Community as Social Capital –The Forgotten Cinderella of Health and Vector Management:
Wisdom dictates that in any battle no efforts should be spared in vanquishing a formidable foe. A battle-wise general, in mounting a war strategy, would enlist allies so as to make a short work of his enemies. The war on diseases is currently being fought single-handedly by the state agencies, by alienating the community.  Community’s power and potential in combating vectors remains vastly untapped and, wherever used, under-utilized.  Commenting on the role of local community and its involvement in health programs, Mishra et al (2003) observe that
 “The inclusion of health concerns with water and sanitation programs, adult literacy, poverty alleviation and developmental projects is limited. So is the cooption of local bodies and NGO’s to share responsibility, except in the cases of the leprosy, HIV/AIDS control programs. For example, in a highly community-based and localized programs such as malaria, the involvement of local bodies is almost non-existent – whether in introducing bio-environmental control methods or ensuring compliance to sanitary laws, or providing the required administrative and political leadership.  Such involvement of the community and local bodies, at both village and town levels is emerging as an imperative for effective control of communicable diseases”
It is true that no single blueprint for community action is available for replication elsewhere. It is a sociological truism that no two communities are alike. Nor is the magnitude and type of health problem facing communities is the same! A centralized approach, under the circumstances, would not pay dividends. A decentralized strategy aimed at community mobilization leading to collective and concerted action in vector control and disease management has greater probability of achieving the goals and best suited for the epidemiologically polarized regions of the Indian subcontinent.

A Note on Community Resources and Action:
   Sociologists and political scientists have generated vast array of data on the power of the local communities. Professional social workers and social entrepreneurs have carried out path-breaking studies and experiments on community organization and group work (Vasantha Kumaran et al 2004, Kramer and Specht 1971, Henderson et al 1980). But the phrase ‘community involvement’ is often paraphrased to mean ‘community cooption, at best and ‘community cooperation’, at worst. Not infrequently, reports and literature on the role of community in health speak of ‘non-cooperation’ and ‘community apathy’. Lack of awareness, which is often litanously associated with illiteracy, is blamed for the ‘poor response’ of the masses. Praxiologically, the ‘outside’ cooperation is wanting! The community is a passive recipient of the ‘gift of awareness’ from the all-knowledgeable bureaucrat-cum-expert.  The act of receiving and translating and effecting a behavioral modification is understood to mean ‘cooperation’. The follow-up often meant monitoring whether the recipient of the ‘precious knowledge’ takes initiative to actualize the same in day-today routine of his.
     To sum up, the article seeks to inform the advocacy research on health care to take note of the lacunae in implementation of health programmes in the much-acclaimed ‘progressive’ states in India and to critiquing of the oft-touted decentralized programme implementation. Even while advocating caution against claims of panaceal decentralization, this article highlights the need to reinforce the health initiatives at the community level in all earnestness.