With better governance, northern States can bring their health systems on a par with southern States
In the wake of the COVID-19 pandemic, there have been vociferous demands to strengthen the country’s public health system. Many erudite articles have stressed the need to revamp the system quickly so that we are better prepared to handle such emergencies in the future. Once the present crisis is over, however, public health will go into oblivion, as usual. Governments are already behaving as if things are fine and enough has been done on the health front.
Not surprisingly, the efficacy of the public health system varies widely across the country since it is a State subject. How good a public health system is can easily be judged just by looking at certain health parameters such as Infant Mortality Rate, Maternal Mortality Ratio and Total Fertility Rate for which annual surveys are conducted through the Sample Registration System.
Poor health indicators
With the numbers given in the chart, it is doubtful whether India will be able to achieve Goal 3 (good health and well-being) of the Sustainable Development Goals (SDGs) set by the United Nations General Assembly in 2015. India failed to achieve the earlier Millennium Development Goals because of the poor performance of the northern States. It is surprising that the Government of India does not hold them responsible and accountable for poor performance but is satisfied with the average. Equally surprising and disappointing is that these State governments themselves are indifferent to their poor performance.
Since health is a State subject, the primary onus lies with the State governments. Each State government must focus on public health and aim to improve the health indicators mentioned above. It is disappointing that some of the States have skewed priorities such as cow protection and ‘love jihad’. More mothers are perhaps dying for want of care than cows. Are these governments not concerned? Unless they give health the highest priority, rapid improvement is not possible. Instead of talking in generalities, they must start looking at numbers. To start with, the above parameters are good enough. Their close monitoring at the highest level may improve things.
These data are revealing. The northern States are performing very poorly in these vital health parameters. In Madhya Pradesh, the number of infant deaths for every 1,000 live births is as high as 48 compared to seven in Kerala. In U.P. the Maternal Mortality Ratio is 197 compared to Kerala’s 42 and Tamil Nadu’s 63. The percentage of deliveries by untrained personnel is very high in Bihar, 190 times that of Kerala.
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Another vital parameter that has an impact on poverty, Total Fertility Rate, is very high in Bihar (3.2) against the stabilisation rate of 2.1. Tamil Nadu and Kerala have done so well that their population will decline over the years. This has been made possible thanks to the effective Maternal and Child Health and Family Welfare services provided by these States.
Some of these States are performing so poorly that they are comparable to the poorest countries in the world, pulling down the average for India. The Government of India is just looking at the averages which are somewhat reasonable thanks to the excellent performance of well-governed States. Unless all the States perform well, there will be no dramatic improvement in the health system . It is sad this is the outcome despite Finance Commissions pouring non-Plan funds into these States in addition to substantial Plan allocation from the Ministry of Health and Family Welfare for the Empowered Action Group States. More money does not and cannot produce results. Only clear focus and better governance can.
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Tamil Nadu’s example
How did the southern States achieve this? It is because of enlightened political leadership which was interested in the health and well-being of the people. I vividly remember the family planning drives and innumerable camps organised to eradicate cataract in the 1970s. The district administration was spearheading these health initiatives because of the government’s focus and drive. The government encouraged a healthy competition among the districts by giving prizes to the well-performing ones. By the 1990s, family planning drives were no more necessary, and all that was needed was some fine-tuning of the Maternal and Child Health programme. The result is that the Total Fertility Rate of Tamil Nadu is among the lowest in the country (1.6) comparable to that of Germany (1.57) and Japan (1.43). In addition to a clear focus by the political executive, Tamil Nadu has the advantage of a public and preventive health structure. A good administrative structure could therefore deliver to the demands of the political executive, benefiting the people of the State.
The governments — both at the Centre and the Empowered Action Group States — should realise that public health and preventive care is a priority and take steps to bring these States on a par with the southern States. The Government of India has a vital role to play. With his huge mandate and popularity, the Prime Minister should get involved in this fundamental task of improving the health of the people. Public and preventive health should be his focus by holding the Empowered Action Group States accountable to the SDGs. They must be asked to reach the levels of the southern States within three to five years.
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Volumes have been written and hundreds of studies have been conducted on what needs to be done in each of these States. One wonders whether they are even read. Instead of slogans and promises, hard work is needed. Perhaps what was started in Tamil Nadu as early as the 1970s needs to be done in these States now. When Chief Ministers are focused on health and the district health administrations are held accountable, performance is bound to improve.
An important measure that can make a difference is a public health set-up in these States that addresses primary and preventive health. Many studies have stressed its importance to deliver better with the given resources. Tamil Nadu manages its public health set-up with just about 150 public health professionals. Therefore, it cannot be difficult for other States to build a public health cadre quickly.
Giving health importance
Unless we invest in human capital, FDI will not help. It will only increase the wealth of the already wealthy and accentuate income disparity. Investing in health and education is the primary responsibility of any government. It is time the governments — both at the Centre and States — gave health its due importance.
Announcing piecemeal schemes may help to get publicity but will not make a lasting improvement. Improving health of such a large population requires concerted efforts over years. The southern States started early and are enjoying the benefits, but they can still do more to reach the level of developed countries. The Empowered Action Group States must start in earnest at least now. There are no short cuts; only persistent and focused efforts at the highest level of government will improve preventive care and primary healthcare.
R. Poornalingam is former Health Secretary, Tamil Nadu