HEALTH CARE IN INDIA - VISION 2020 ISSUES AND PROSPECTS

R. Srinivisan

INTRODUCTION Key linkages in health Health and health care need to be disting ished !ro" each other !or no better reason than that the !or"er is o!ten incorrectly seen as a direct ! nction o! the latter# Heath is clearly not the "ere absence o! disease# $ood Health con!ers on a %erson or gro %s !reedo" !ro" illness & and the ability to reali'e one(s %otential# Health is there!ore best nderstood as the indis%ensable basis !or de!ining a %erson(s sense o! )ell being# The health o! %o% lations is a distinct key iss e in % blic %olicy disco rse in e*ery "at re society o!ten deter"ining the de%loy"ent o! h ge society# They incl de its c lt ral nderstanding o! ill health and )ell&being+ e,tent o! socio&econo"ic dis%arities+ reach o! health ser*ices and - ality and costs o! care# and c rrent bio&"cdical nderstanding abo t health and illness# Health care co*ers not "erely "edical care b t also all as%ects %ro %re*enti*e care too# Nor can it be li"ited to care rendered by or !inanced o t o! % blic e,%endit re& )ithin the go*ern"ent sector alone b t " st incl de incenti*es and disincenti*es !or sel! care and care %aid !or by %ri*ate citi'ens to get o*er ill health# .here+ as in India+ %ri*ate o t&o!&%ocket e,%endit re do"inates the cost !inancing health care+ the e!!ects are bo nd t be regressi*e# Heath care at its essential core is )idely recogni'ed to be a % blic good# Its de"and and s %%ly cannot there!ore+ be le!t to be reg lated solely by the in*isible had o! the "arket# Nor can it be established on considerations o! tility "a,i"i'ing cond ct alone# .hat "akes !or a / st health care syste" e*en as an ideal0 1o r criteria co ld be s ggested& 1irst ni*ersal access+ and access to an ade- ate le*el+ and access )itho t e,cessi*e b rden# Second !air distrib tion o! !inancial costs !or access and !air distrib tion o! b rden in rationing care and ca%acity and a constant search !or i"%ro*e"ent to a "ore / st syste"# Third training %ro*iders !or co"%etence e"%athy and acco ntability+ % rs it o! - ality care ad cost e!!ecti*e se o! the res lts o! rele*ant research# 2ast s%ecial attention to * lnerable gro %s s ch a children+ )o"en+ disabled and the aged# 1orecasting in Health Sector In general %redictions abo t ! t re health & o! indi*id als and %o% lations & can be notorio sly ncertain# Ho)e*er all %ro/ections o! health care in India " st in the end rest on the o*erall changes in its %olitical econo"y & on %rogress "ade in %o*erty "itigation 3health care to the %oor4 in red ction o! ine- alities 3health ine- alities a!!ecting

access5- ality(4+ in generation o! e"%loy"ent 5inco"e strea"s 3to !acilitate ca%acity to %ay and to acce%t indi*id al res%onsibility !or one(s health 4# in % blic in!or"ation and de*elo%"ent co"" nication 3to %ro"ote %re*enti*e sel! care and risk red ction by cond ci*e li!e styles 4 and in %ersonal li!e style changes 3o!ten directly res lting !ro" social changes and global in!l ences4# O! co rse it )ill also de%end on %rogress in red cing "ortality and the likely disease load+ e!!icient and !air deli*ery and !inancing syste"s in %ri*ate and % blic sectors and attention to * lnerable sections& !a"ily %lanning and n tritional ser*ices and )o"en(s e"%o)er"ent and the con!ir"ed interest o! "e siat&e 67 ens re / st health care to the 2argest e,tent %ossible# To list the" is to recall that Indian %lanning had at its best atte"%ted to ca%t re this synergistic a%%roach )ithin a de"ocratic str ct re# It is another "atter that it is no) re"e"bered only !or its "i,ed s ccess# A*ailable health !orecasts There is a !orecast on the ne) health challenges likely to e"erge in India o*er tne ne,t !e) decades# 8 rry and 2o%e' 9.orId :ank : ;777< ha*e %ro*ided a %ossible scenario o! the b rden o! disease 3:OD4 !or India in the year ;7;7+ based on a statistical "odel calc lating the change in DA2=S are a%%lied to the %o% lation %ro/ections !or ;7;7 and con*ersely# The key concl sions " st be nderstood kee%ing in the "ind the tact that the conce%t o! DA2=s incor%orates not only "ortality b t disability *ie)ed in ter"s o! healthy years o! li!e lost# In this !orecast+ DA2=s are e,%ected to dra"atically decrease in res%ect o! diarrhoeal diseases and res%iratory in!ections and less dra"atically !or "aternal conditions# T: is e,%ected to %latea by ;777+ and HI> in!ections are e,%ected to rise signi!icantly % to ;767# In/ ries "ay increase less signi!icantly+ the %ro%ortion o! %eo%le abo*e ?@ )ill increase and as a res lt the b rden o! non& co"" nicable disease )ill rise# 1inally cardio*asc lar diseases res lting any !ro" the risk associated )ith s"oking rban stress and i"%ro%er diet are e,%ected to increase dra"atically# Under the sa"e :OD "ethodology another *ie) is a*ailable !ro" a !o r & state analysis done in 6AA? 9.orld :ank : ;777< these !o r states & AP+ Ka"ataka+ .# :engal and P n/ab & re%resent di!!erent stages in the Indian health transition# The analysis re*eals that the %oorer and "ore %o% lated states# .est :engal+ )ill still !ace a large incidence o! co"" nicable diseases# 8ore %ros%ero s states+ s ch as P n/ab ! rther along the health transiting )ill )itness shar%ly increasing incidence o! non& co"" nicable diseases es%ecially+ in rban areas# The %ro/ections highlight that )e still o%erating on nreliable or inco"%lete base data on "ortality and ca ses o! death in the absence o! *ital registration statistics and kno) as yet little abo t ho) they di!!er bet)een social classes and regions or abo t the dyna"ic %atterns o! change at )ork# It also highlights the %olicy dile""a o! ho) to balance bet)een the artic late "iddle %%er class de"and !or "ore access to technologically ad*anced and s bsidi'ed clinical ser*ices and the "ore %ressing needs o! the %oor !or co*erage o! basic disease control inter*entions# This con!lict o*er de%loy"ent o! % blic reso rces )ill only get e,acerbated in ! t re# .hat "atters "ost in s ch esti"ates are not societal a*erages )ith res%ect to health b t so nd data ill "ining s%eci!ically the health conditions o! the disad*antaged in local areas 9$)atkin A ;777< that long tradition o! health sector analysis looking at ne- al access+ inco"e %o*erty and n/ stly distrib ted reso rces as the trigger to "eet health needs o! the %oor# That tradition has been totally re%laced by the c rrently do"inant school o! international tho ght abo t health )hich is concerned

%ri"arily )ith e!!iciency o! syste"s "eas red by cost e!!ecti*eness criteria# 1 t re o! State Pro*ided Health Care Historically the Indian co""it"ent to health de*elo%"ent has been g ided by t)o %rinci%les&)ith three conse- ences# The !irst %rinci%le )as State res%onsibility !or health care and the second 3a!ter inde%endence4 )as !ree "edical care !or all 3and not "erely to those nable to %ay4+ The !irst set o! conse- ences )as inade- ate %riority to % blic health+ %oor in*est"ent in sa!e )ater and sa"tati on and to the neglect o! the key role o! %ersonal hygiene in good health+ c l"inating in the %ersistence o! diseases like Cholera# The second set o! conse- ences %ertains to s bstantially nreali'ed goals o! NHP 6ABC d e to ! nding di!!ic lties !ro" co"%ression o! % blic e,%endit res and !ro" organi'ational inade- acies# The a"bitio s and !ar reaching NPP & ;777 goals and strategies ha*e ho)e*er been !or" lated on that edi!ice in the ho%e that the ga%s and the inade- ate )o ld be re"o*ed by % r%ose! l action# .itho t being too de!ensi*e or critical abo t its %ast !ail res+ the r ral health str ct re sho ld be strengthened and ! nded and "anaged e!!iciently in all States by ;77@# This can trigger "any dra"atically changes o*er the ne,t t)enty years in neglected as%ects or r ral health and o! * lnerable seg"ents# The third set o! conse- ences a%%ears to be the inability to de*elo% and integrate %l ral syste"s o! "edicine and the !ail re to assign %ractical roles to the %ri*ate sector and to assign % blic d ties !or %ri*ate %ro!essionals# To set right these ga%s de"anded %atient rede!inition o! the state(s role kee%ing the !oc s on e- ity# : t d ring the last decade there has been an abr %t s)itch to "arket based go*ernance styles and " ch in!l ential ad*ocacy to red ce the state role in health in order to en!orce o*erall co"%ression o! % blic e,%endit re an red ce !iscal de!icits# Peo%le ha*e there!ore been !orced to s)itch bet)een )eak and e!!icient % blic ser*ices and e,%ensi*e %ri*ate %ro*ision or at the li"it !orego care entirely e,ce%t in li!e threatening sit ations+ in s ch cases sliding into indebtedness# Health stat s o! any %o% lation is not only the record o! "ortality and its "orbidity %ro!ile b t also a record o! its resilience based on " t al solidarity and indigeno s traditions o! sel!&care & assets nor"ally in*isible to he %lanner and the %ro!essional# S ch resilience can be enriched )ith the State retaining a strategic directional role !or the good health o! all its citi'ens in accordance )ith the constit tional "andate# .ithin s ch a !ra"e)ork alone can the %ri*ate sector be engaged as an additional instr "ent or a %artner !or achie*ing shared % blic health o tco"es# Si"ilarly+ in indigeno s health syste"s " st be %ro"oted to the e,tent %ossible to beco"e another credible deli*ery "echanis" in )hich %eo%le ha*e !aith and a)ay !ond !or the *at n "ber o! less than !olly - ali!ied doctore in r ral areas to get skills %graded# P blic %rogra"s in r ral and %oor rban areas engaging indigeno s %ractitioners and co"" nity *ol nteers can %re*ent " ch seasonal and co"" nicable disease sing lo) cost traditional kno)ledge and based on the balance bet)een !ood+ e,ercise "edicine and "oderate li*ing# S ch an o*erall *ision o! the % blic role o! the heterogeno s %ri*ate sector " st in!or" the co rse o! ! t re o! state led health care in the co ntry#

KEY ACHIEVEMENTS IN HEALTH O r o*erall achie*e"ent in regard to longe*ity and other key health indicators are i"%ressi*e b t in "any res%ects ne*en across States+ The t)o Data Anne, re at the end indicate selected health de"ogra%hic and econo"ic indicators and highlight the changes bet)een 6A@6and ;776# In the %ast !i*e decades li!e e,%ectancy has increased !ro" @7 years to o*er ?D in ;777# I8R has co"e do)n !ro" 6DE? to E# Cr de birth rates ha*e dro%%ed to ;?#6 and death rates to B#E# At this stage+ a %rocess nderstanding o! longe*ity and child health "ay be se! l !or nderstanding %rogress in ! t re# 2onge*ity+ al)ays a key national goal+ is not "erely the red ction o! deaths as a res lt o! better "edical and rehabilitati*e care at old age# In !act )itho t reasonable - ality o! li!e in the e,tended years "arked by sel!&con!idence and absence o! nd e de%endency longe*ity "ay "en only a dis%lay o! technical skills# So - ality o! li!e re- ires as " ch e,ternal bio&"edical inter*entions as c lt re based acce%tance o! ine*itable decline in !ac lties )itho t o!!icio s start at si,ty b t r n across li!e li*ed at alt ages in red ction o! "ortality a"ong in!ants thro gh i"" ni'ation and n trition inter*entions and red ction o! "ortality a"ong young and "iddle aged ad lts+ incl ding adolescents getting in!or" abo t se, ality re%rod ction and sa!e "otherhood# At the sa"e ti"e+ so"e seg"ents )ill re"ain al)ays "ore * lnerable & s ch as )o"en d e to %atriarchy and traditions o! in!ra&!a"ily denial4+ aged 3)hose s r*i*al b t not al)ays de*elo%"ent )ill increase )ith i"" ni'ation4 and the disabled 3constit ting a tenth o! the %o% lation4# Red ction in child "ortality in*ol*es as " ch attention to %rotecting children !ro" in!ection as in ens ring n trition and calls !or a holistic *ie) o! "other and child health ser*ices# The cl ster o! ser*ices consisting o! antenatal ser*ices+ deli*ery care and %ost "orte" attention and lo) birth )eight+ childhood diarrhoea and ARI "anage"ent are linked %riorities# Progra""e o! i"" ni'ation and childhood n trition seen in better %er!or"ing stats indicate s stained attention to ro tine and co"%le, in*est"ents into gro)ing children as a gro % to "ake the" gro) into %ersons ca%able o! li*ing long and )ell O!ten interest !ades in % rs ing the ngla"oro s ro tine o! s %er*ised i"" ni'ation and is s bstit ted by % lse ca"%aigns etc# .hich in the long r n t rn o t co nter&%rod cti*e# Indeed %ersistence )ith i"%ro*ed ro tines and care !or - ality in i"" ni'ation )o ld also be a %ath )ay to red ce the )orld(s highest rate o! "aternal "ortality# In this conte,t )e "ay re!er to the large ratio&based r ral health in!rastr ct re consisting o! o*er @ lakh trained doctors )orking nder %l ral syste"s o! "edicine and a *ast !rontline !orce o! o*er E lakh AN8s+ 8P.S and Angan)adi )orkers besides co"" nity *ol nteers# The creation o! s ch % blic )ork !orce sho ld be seen as a "a/or achie*e"ent in a co ntry short o! reso rces and str ggling )ith great dis%arities in health stat s# As %art o! r ral Pri"ary health care net)ork lone+ a total o! 6#? lakh s bcenters+ 3)ith 6#;E lakh#( AN8a in %osition4 and ;;AE@ PHCs and ;AC@ CHCs 3)ith o*er ;D777 doctors and o*er C@77 s%ecialists to ser*e in the"4 ha*e been set %# To %ro"ote Indian syste"s o! "edicine and ho"eo%athy there are o*er ;;777 dis%ensaries ;B77 hos%itals :esides ? lakh anga)adis ser*e n trition needs o! nearly ;7 "illion children and D "illion "others# The total e!!ort has cost the b lk o! the health de*elo%"ent o tlay+ )hich stood at o*er Rs ?;#@775& crores or C&?D F o! total %lan s%ending d ring the last !i!ty years#

On any co nt these are e,traordinary in!rastr ct ral ca%acities created )ith reso rces co""itted against odds to strengthen grass roots# There ha*e been !acility ga%s+ s %%ly ga%s and sta!!ing ga%s+ )hich can be !illed % only by allocating abo t ;7F "ore ! nds and deter"ined ill to ens re good ad"inistration and synergy !ro" greater congr ence o! ser*ices+ b t gi*en the sheer si'e o! the endea*or thee )ilt al)ays be so"e !ail re o! co""it"ent and in ro tine ! nctioning# These get e,acerbated by %eriodic ca"%aign "ode and *ertical %rogra""e+ )hich ha*e only increased co"%art"entali'ed *ision and o*er&"edicali'ation o! health %roble"s# The initial key "istake arose !ro" the needless bi! rcation o! health and !a"ily )el!are and n trition ! nctions at all le*els instead o! %ro"oting "ore holis"# As a res lt o! all this the str ct re has been %recl ded !ro" reaching its o%ti"al %otential# It has got "ore !ir"ly established at the %eri%hery5s b& center le*el and dedicated to RCH ser*ices only# At PHC and CHC le*els this has ! rther been co"%o nded by a )eak re!erral syste"# There has not been eno gh con*ergence in GescortingG children thro gh i"" ni'ation co*erage and n trition ed cation o! "others and ens ring better !ood to children+ incl ding cooked "idday "eals and health checks al schools# There has also been no constr cti*e engage"ent bet)een allo%athic and indigeno s syste"s to b ild synergies+ )hich co ld ha*e i"%ro*ed %eo%le(s %erce%tions o! bene!its !ro" the in!rastr ct re in )ays that "ade sense to the"# One key task in the co"ing decades is there!ore to tili'e ! lly that created %otential by attending to )ell kno)n organi'ational "oti*ational and !inancial ga%s# The ga%s ha*e arisen %artly !ro" the so rce and scale o! ! nds and %artly d e to lack o! %ersistence+ both o! )hich can be set right# PHCs and CHCs are ! nded by States se*eral o! )ho" are nable to "atch Central assistance o!!ered and hence these centers re"ain inade- ate and o%erate on "ini" " e!!iciency# On the other hand o*er t)o thirds cost o! three !o rths o! s b&centers are ! lly "et by the Center d e to their key role " !a"ily )el!are ser*ices# : t in e- al %art these ga%s are d e to "any other non&"onetary !actors s ch as nd e centrali'ation and ni!or"ity+ !l ct ating co""it"ent to key ro tines at gro nd le*el+ ins !!icient e,%eri"entation )ith alternati*es s ch as getting % blic d ties discharged thro gh %ri*ate %ro!essionals and ens ring greater local acco ntability to sers# Health Stat s iss es The di!!erence bet)een r ral and rban indiactors o! health stat s and the )ide interstate dis%arity in health stat s are )ell kno)n# Clearly the rban r ral di!!erentials are s bstantial and range !ro" childhood and go on increasing the ga% as one gro)s % to @ years# Sheer s r*i*al a%art there is also the )e kno)n nder %ro*ision in r ral areas in %ractically all social sector ser*ices# 1or the children gro)ing % in r ral areas the dis%arities nat rally tend to get e*en )orse )hen co"%o nded by the )idely %racticed discri"ination against )o"en+ starting )ith !oeticide o! da ghters# In s%ite o! o*erall achie*e"ent it is a "i,ed record o! social de*elo%"ent s%ecially !ailing in in*ol*ing %eo%le in i"aginati*e )ays# E*en the a*eraged o t good %er!or"ance ides )ide *ariations by social class or gender or region or State# The classes in "ay States ha*e had to s !!er the "ost d e to lack o! access or denial o! access or social e,cl sion or all o! the"# This is clear !ro" the !act that co"%ared to the riches - intile+ the %oorest had ;#@ ti"es "ore I8R and child "ortality+ T1R at do ble the rates and nearly E@F "aln trition & %artic larly d ring the nineties#

Not only are the ga%s bet)een the better %er!or"ing and other States )ide b t in sa"e cases ha*e been increasing d ring the nineties# 2arge di!!erences also e,ist bet)een districts )ithin the sa"e better %er!or"ing State rban areas a%%ear to ha*e better health o tco"es than r ral areas altho gh the !ig res "ay not ! lly re!lect the sit ation in rban and %eri& rban sl "s )ith large in "igration )ith conditions co"%arable to r ral %ockets# It is esti"ated that rban sl " %o% lation )ilt gro) at do ble the rate o! rban %o% lation gro)th in the ne,t !e) decades# India "ay ha*e by ;7; a total rban %o% lation o! close to ?77 "illion li*ing in rban areas )ith an esti"ated 6D@ "illion li*ing in sl "s in ;776# .hat sho ld be a !air "eas re !or assessing s ccess in enhancing health stat s o! %o% lation I any !orecast on health care0 Disease 2oad in India and ChinaH .e need a basis !or co"%arati*e scenario b ilding# A"ong the nations o! the )orld China alone rank in si'e and scale and in co"%le,ity co"%arable to India di!!erences bet)een an o%en and !ree society and a se"i&controlled %olity do "atter# The re"arkable s ccess in China in co"bating disease is d e to s stained attention on the health o! the yo ng in China+ and o! % blic %olicy backed by reso rces and social "obili'ation& .hile co"%aring China and India in selected as%ects o! disease load+ de"ogra%hy and % blic e,%endit res on health+ the record on India "ay see" "i,ed co"%ared to the "ore all ro nd %rogress "ade by china# : t this sho ld also be seen in the %ers%ecti*e o! the larger b rden o! disease in India co"%ared to china and o! the transactional costs o! an o%en and !ree de"ocracy+ Tho gh India and China recorded the sa"e rate o! gro)th till E7s+ China initiated re!or"s a ! ll decade earlier# This ga*e it a head stat !or a higher gro)th rate and has res lted in an econo"ic ga% )ith India )hich has beco"e )ider o*er ti"e# This is beca se do"estic sa*ings in China are C?F o! $DP )hereas in India it ho*ers at ;CF+ "ostly in ho se&hold sa*ings# Again# China attracted ID7 billion in !oreign direct in*est"ent against I; billion in India# S%ecial econo"ic 'ones and rela,ed labo r la)s ha*e hel%ed# P blic e,%endit re on health in China has been consistently higher nderlining the regressi*e nat re o! !inancing o! health are in India# Ne*ertheless& it is not too nrealistic to e,%ect that India sho ld be able to reach by ;767 at least three !o rth the c rrent le*el o! %er!or"ance o! China in all key health indices# India(s c rrent %o% lation is not a bit "ore than E@F that o! China and India )ill o! co rse be catching % e*en "ore )ith China into the ;6 cent ry# This )o ld be o!!set by the handica% that Indian %rogress )ill be "oderated by the !act that it is an o%en !ree and de"ocratic society# A %ractical r le&o!&th "b "eas re !or an o%ti"istic !orecast o! ! t re %rogress in India co ld be & that bet)een ;777 and ;767 India sho ld do three !o rths as )ell as China did in 6AA7&;777 and+ a!ter ;767+ India sho ld try to catch % )ith the rate o! %er!or"ance o! China and do / st as )ell therea!ter# This )ill translate into+ !or+ instance+ a gro)th rate o! abo t BF !or India till ;767 and as close to 67F as %ossible therea!ter th s enabling do bling !irst in ten yeas and do bling !irst in ten year and do bling t)ice o*er e*ery se*en years therea!ter %rior to ;7;@# kee%ing this %ers%ecti*e in "ind+ )e "ay no) e,a"ine the %ro!ile o! "a/or disease control e!!ortJ the e!!ecti*eness o! a*ailable instr "ents !or deli*ery and !inancing % blic health action and assess !actors rele*ant to the re"aining e*ent o! * lnerability )ithin KOUT e"erging social %yra"id o*er ne,t t)o or three decades+

MAJOR DISEASE CONTROL EFFORTS A care! l analysis o! the $lobal : rden o! Disease 3$:D4 st dy !oc sing on age& s%eci!ic "orbidity d ring ;777in ten "ost co""on diseases 3e,cl ding in/ ries4 sho)s that si,ty %ercent o! "orbidity is d e to in!ectio s diseases and co""on tro%ical diseases+ a - arter d e to li!e&style disorders and 6CF d e to %otentially %re*entable %er& natal conditions# 1 rther do"estic RLD has been so !ar " ted in its e!!orts against an esti"ated ann al aggregate health e,%endit re in India o!Rs& B7+7775&crores RLD e,%endit re in India !or % blic and %ri*ate sector co"bined )as Rs 66@7 crores only# India " st %lay a larger %art in its o)n e!!orts at indigeno s RLD as *ery little )orld& )ide e,%endit re on RLD is likely to be de*oted to in!ectio s diseases# 1or instance o t o! the 6;CC ne) dr gs that ca"e into the "arket bet)een 6AE@ and 6AAE only 66 )ere indicated s%eci!ically !or tro%ical co ntry diseases+ .e ha*e already the distinction o! eli"ination or control acce%table to % blic health standards o! s"all %o, and g inea )or" diseases# In the dra!t National Health Policy &;6 It has no) been %ro%osed to eli"inate or control the !ollo)ing diseases )ithin li"its acce%table to % blic health %ractice& A good deal o! the e!!ort )o ld be !easible# M Polio =a)s and le%rosy by ;77@ )hich see"s distinctly !easible tho gh the re"o*al o! social stig"a and reconstr cti*e s rgery and other rehabilitation arrange"ents in regard to le%rosy )o ld re"ain inade- ate !or a decade or "ore#

M Kalaa'ar by ;7I7 and 1ilalriasis by ;767 )hich also see"s !easible d e to its locali'ed %re*alence and the %ossibility o! greater co"" nity based )ork in*ol*ing PR instit tions in the si"%le b t ti"e&li"ited tasks or % blic health %rogra"s& M :lindness %re*alence to 7#@F by ;767 sees less !easible d e to a graying %o% lation# At %resent the %rogra""e is "assi*ely s %%orted by !oreign aid as there are "any other legiti"ate de"ands on do"estic health b dgets&

M AIDS reaching 'ero gro)th by ;77E a%%ears to be %roble"atic as there are dis% tes e*en abo t base data on in!ected %o% lation# On "ost reckonings+ a!!ordable *accines re not likely to be a*ailable soon nor anti&retro *iral dr gs a%%ear likely at a!!ordable %rices in the near ! t re# 1 rther the %re*alence c r*e o! Aids in India is yet to sho) its sha%e# There is also larger nresol*ed - estion o! )here HI>5ATDS sho ld be !itted in o r %riorities o! % blic health+ es%ecially in this "assi*ely !oreign aided %rogra""e )hat ha%%en i! aid does not beco"e a*ailable at so"e %oint# Un!inished b rden o! co"" nicable diseases A%art !ro" the abo*e+ there re"ains a *ast n!inished b rden in %re*enting controlling or eli"inating other "a/or co"" nicable diseases and in bringing do)n the risk o! deaths in "aternal and %eri&natal conditions# Ende"ic diseases arising !ro" in!ection or lack o! n trition contin e to acco nt !or al"ost t)o thirds o! "orality ad "orbidity India# Indeed ele*en o t o! thirteen diseases reco""ended by the :hore Co""ittee )ere in!ectio s diseases and at least three o! the" "ay )ell contin e to be )ith s !or the ne,t t)o decades :aring 2e%rosy )hich is al"ost on the %ath to total control by ;77@+ the other key co"" nicable diseases )ill be T: 8alaria and Aids& to

)hich diarrhoea in children and co"%licated and high risk "aternity sho ld be added in *ie) o! their %er*asi*e incidence and a*oidable "ortality a"ong the %oorer and nder ser*ed sectors+ T berc losisH T berc losis has had a )orld )ide res rgence incl ding in India# It is esti"ated lhai abo t 6D "illion %ersons are in!ected+ i#e# 6#@@ o! total %o% lation s !!er !ro" radio logically acti*e T berc losis# Abo t 6#@ "illion cases are identi!ied and "ore than C77 777 deaths occ r e*ery year :et)een N1HS 6 and N1HS ; the %re*alence has increased !ro" D?EB %er lakh %o% lation to @DD# Un!ort nately+ %re*alence a"ong )orking age ad lts 36@&@A4 is e*en higher as ?E@# All these "ay )ell be nderesti"ates in so !ar as %atients are traced only thro gh hos%ital *isit# Only abo t hal! reach the hos%ital# O!ten )rong diagnosis by ins !!iciently trained doctors or "is nderstood %rotocols is another key %roble" both % blic and %ri*ate sectors# T: is a )ide s%read disease o! %o*erty a"ong )o"en li*ing and )orking in ill *entilated %laces and other nderno rished %ersons in rban sl "s it is increasingly a!!ecting the yo nger ad lts also in the econo"ically %rod cti*e seg"ents# No ni*ersal screening is %ossible# S% t " %ositi*e test does not %recede diagnosis b t dr gs are %rescribed on the basis o! !e*er and shado)s as a res lt inco"%lete c re beco"es co""on and delayed tests only %ro*e the )rong diagnosis too late# I"%ro*ed diagnosis thro gh better training and clear %rotocols and eli"ination o! dr g resistance thro gh inco"%lete c re sho ld be %riority# Treat"ent costs in case o! dr g resistance can soar close to ten ti"es the nor"al le*el o! Rs# C777 to D7775&%er %erson treated# Si"ilarly e*en tho gh the resistant strain "ay co*er only BF at %resent+ it co ld s ddenly rise and as it a%%roaches ;775o or so+ there is a danger that T: "ay get o t o! control# The DOTS %rogra""e trying !or ! ll co"%liance a!ter %ro%er diagnosis is settling do)n b t already has so"e clai"s o! s ccess# 8ore tan C777 laboratories ha*e been set % !or diagnosis and abo t 6#@ lakh )orkers trained and )ith total %o% lation co*erage by ;77E c re rates 3already clai"ed to ha*e do bled4 "ay rise s bstantially# There is reason to ho%e that DOTS %rogra"s )o ld %ro*e a greater s ccess o*er ti"e )ith increased co"" nity a)areness aeneration# The key iss e is ho) soon and ho) )ell can it be integrated into the PHC syste" and "ade s b/ect to ro tines o! local acco ntability+ )itho t )hich no lo) cost regi"e o! total co"%liance is !easible in a co ntry as large as India# An o%ti"istic assess"ent co ld be that )ith co""it"ent and ! ll se o! in!rastr ct re it )ill be %ossible to arrest ! rther gro)th in absol te n "bers o! T: cases kee%ing it at belo) 6#@ "illion till ;767 e*en tho gh the %o% lation )ill e gro)ing# Once that is done T: can be bro ght do)n to less than a "illion lie )ithin internationally acce%ted li"its and disa%%ears as a "a/or co"" nicable disease in India by ;7;7# 8alariaH As regards "alaria+ )e ha*e had a long record o! s ccess and !ail re and each inter*ention has been th)arted by ne) %roble"s and %lag ed by recr descence# At %resent India has a large "an%o)er ! lly a)are o! all as%ects o! "alaria abo t o!ten lo) in "oti*ation# It can be trans!or"ed into a large&scale )ork !orce !or a)areness generation+ tests and distrib tion o! "edicine# In s%ite o! %ast s ccesses+ there is e*idence o! ree"ergence )ith !ocal attacks o! "alaria )ith the *ir lent !alci%ar " *ariety es%ecially " tribal areas# Priority tnbal area "alaria stands ! lly ! nded by the center#

Abo t ; "illioncases o! "alaria are recorded allo*er India e*ery year )ith seasonal high incidence local !ail res o! control# Dr g resistance in h "ans and insecticide resistant strains o! "os- itoes %resent a signi!icant %roble"# : t there is a )indo) o! o%%ort nity I res%ect o!DDT sensiti*e areas in eastern India )here e*en no) "alaria incidence can be bro ght do)n by abo t @7F )ithin a decade and be bene!icial !or control o! kala'aar and KE# There is gro)ing interest and co"" nity a)areness o! biological "ethods o! control o! "os- ito gro)th# Un!ort nately diligent gro nd le*el % blic health )ork is in gra*e disarray n these areas b t can be i"%ro*ed by better s %er*ision greater se o! %anchayatra/ instit tions and b ildings on "odest de"onstrated s ccesses# As regards a *accine+ there see"s t be no s !!icient incenti*e !or international RLD to !oc s on a relati*ely lo)er %riority or research# Roll back "alaria %rogra""es o! the .HO are "ore likely to concentrate on A!rica )hose %ro!ile o! "alaria is not si"ilar to o rs# The search !or a *accine contin es b t has little likelihood o! i""ediate s ccess# In s%ite o! *ario s di!!ic lties+ i! the restr ct ring o! the "alaria )ork !orce and the strengthening o! health in!rastr ct re takes %lace+ one can e,%ect that the incidence can be i ed ce by a third or e*en %to hal! in the ne,t decade or so# 1or this it is necessary that ro tine tasks like ti"ely s%raying and logistics !or taking blood slides testing and their analysis and organic "ethods o! red cing "os- ito s%read etc# Are do)n staged to co"" nity le*el and %enor"ed nder s %er*ision thro2igh %anchayais )iih co"ai2ini2y %artici%ation % blic ed cation and local "onitoring# 8alaria can certainly be red ced by a third e*en %to a hal! in ten years+ and there is a %ros%ect o! near !reedo" !ro" "alaria !or "ost o! the co ntry by ;7;7#

The case o! AIDSH There is !inally the case o! HI> AID# The "agnit de in the n "bers o! HI> in!ected and o! AIDS %atients by ;7;@ can be kno)n only as trends e"erge o*er a decade !ro" no)# )hen better e%ide"iological esti"ates are a*ailable b t at %resent these !ig res are hotly contested# (.e cant start )ith the n "ber in!ected )ith HI> as %er NACO sentinel s r*eillance in ;777 a c " lati*e total C#B? "illion+ a !ig re dis% ted in recent % blic health debate# .e can then ass "e that abo t 67F )ill t rn into ! ll&blo) cases o! se*ere and intractable stage o! Aids# There is as yet no basis to kno) ho) "any o! those in!ected )ill beco"e AIDS %atients+ %re*enti*e e!!orts !oc sed on beha*ior change )ill sho) % !ir"ly only a!ter a decade or so# D ring this %eriod one can ass "e an additional 67F gro)th to acco nt !or ne) cases e*ery year# The Dra!t NHP ;776 seeks to sto% ! rther in!ection by ed cating and co nseling and condo" s %%lies to le*el it o!! aro nd ;77E+ )hich see"s so"e)hat a"bitio s# .e ha*e yet to "ake a decisi*e dent into the %roble" o! a)areness )ith the broader %o% lation and so !ar )e ha*e been at )ork only on high risk gro %s# N1HS; sho)s only a third o! )o"an re%orting that they e*en kne) abo t the HI>5AIDS# 1 rther s ch a)areness e!!orts " st be !ollo)ed by " lti&%ronged and c lt rally co"%atible techni- es o! % blic ed cation that go beyond seg"ents easier to be con*inced or beha*io r changed# There are *oices already raised abo t the a%%ro%r lateness o! IEC "ass "edia content and o! the nder e"%hasis o! !ace to !ace co nseling+ calling !or inno*ati*e "obili'ation strategies rooted in indigeno s belie! syste"s# .hat it i"%lies is that )e "ay be carrying by ;76@closeto @ "illion in!ected and %to a

tenth o! the" co ld t rn into ! ll blo)n cases# .e "ay not be able to le*el o!! in!ection by ;77E 1 rther these "agnit des "ay t rn o t " act al !act to be )ildly o!! the "ark# On any acco nt it is clear that AIDS can lead to high "ortality a"ong the %rod cti*e gro %s in society a!!ecting econo"ic ! nctioning as also % blic health# E*en i! 67F o! the" say @7 to ?7777 cases beco"es ! ll blo)n cases the state has the onero s and gri" choice to look at co"%eting e- ities and decide on a %olicy !or !ree treat"ent o! AIDS %atients )ith e,%ensi*e anti&retro *iral dr gs# And i! it decides not to+ the iss e re"ains as to ho) to e*ol*e h "ane balanced and a!!ordable %olicies that do not lead to a social breakdo)n# In abo t a decade *accine de*elo%"ent "ay %ossibly be s ccess! l and dr gs "ay by "ore e!!ecti*e b t they "ay not al)ays be a!!ordable nor can be gi*en !ree# There )o ld ho%e! lly be )ider cons ltation )ith %ersons )ith caring sensibilities incl ding AIDS %atients on ho) to co nsel in di!!erent e*ent alities and to get the balance right bet)een hos%ital and ho"e care and ho) to de*elo% a h "ane a!!ordable %olicy !or anti retro*iral dr gs !or AIDS %atients# Is there a case !or %ro*iding the" )ith dr g !ree o! cost "erely to e,tend their li*es !or !e) years0 The "atter in*ol*es a tr e dile""a+ !or % blic health %riorities the"sel*es certainly arg e !or "ore ! nds sho ld address diseases constit ting bigger %o% lation based ha'ards# In*est"ents "ade " s ch e,%ensi*e inter*entions can instead be "ade in s %%orting hos%ice e!!orts in the *ol ntary and %ri*ate sectors# .hate*er %osition "ay e"erge in research or s%read o! in!ection o! case !atalities+ a " lti %ronged atte"%t !or a)areness+ " st contin e and to gh choices " st get disc ssed o%enly )itho t artic late s%ecial+ o!ten rban "iddle class interests denying other *ie)s and es%ecially % blic health %riorities o! the %oor# The %ro"otion o! barrier %rotection " st increase b t has to related to a syste" o! *al es+ )hich )o ld be acce%table to the %eo%leNs belie!s# .e need to strengthen sentinel s r*eillance syste"s and a)areness e!!ort# .e also need sensiti*e !eed back on the e!!ects they lea*e on yo nger "inds !or a balanced c lt rally acce%table strategy# All this is !easible and can be acco"%lished i! )e are not s)e%t a)ay by the %o)er o! ! nding and ad*ocacy and !ear o! being acc sed to be o t o! line )ith do"inant )orld o%inion# In any case "any o! the ill cannot a!!ord the high %rices or ha*e access to it !ro" % blic agencies# The strict %atent regi"en nder TRIPS is bo nd to %re*ail+ not)ithstanding the a"bi*alently )orded Doha decision o! .TO that % blic health e"ergencies %ro*ide s !!icient ca se o! co ntries to se the !le,ibility a*ailable !ro" *ario s %ro*isions o! TRIPS# A recent analysis re*eals that the three dr g regi"en reco""ended )ill cost I67777 %er %erson %er year !ro" .estern co"%anies and the treat"ent )ill be li!elong# Three Indian co"%anies are o!!ering to Central $o*ern"ent anti retroJ *iral dr gs at I?775 Rs# C7+7775%er %erson %er year and to an international charity at an e*en lo)er %rice I C@75 Rs# 6C+7775%er year %ro*ided it )as distrib ted !or h "anitarian relie! !ree in S# A!rica# It has been % blic %olicy in :ra'il that the dr g is s %%lied !ree to all AIDS sho ld be no e,ce%tion# I! dr gs are s %%lied acting on a % blic health e"ergency basis and %rices can stabili'e at Rs# 67775& or so %er year the % blic health b dget sho ld be able to acco""odate the cost )eighed against tr e % blic criteria# : t the ai" o! le*eling o!! in!ection o! ;77E still see"s nlikely#

8aternal and Parental Deaths 8aternal and %arental deaths are si'eable b t the ad*antage here is that they can be %re*ented "erely by "ore intensi*e tili'ation o! e,isting r ral health in!rastr ct re# Policy and i"%le"entation " st kee% steady !oc s on key ite"s s ch as i"%ro*ed instit tional deli*eries better trained birth attendants and ti"ely antenatal screening to eli"inate anae"ia and at the sa"e ti"e isolate cases needing re!erral or other targeted attention# A!ter all Ta"il Nad has by s ch "ethods ens red closed to A7F instit tional deli*eries backed by a ! nctional re!erral# 1ir" ad"inistrati*e )ill and conc rrent s %er*ision o! s%eci!ied screening tasks incl ded in 8CH ser*ices can gi*e s a )indo) o! o%%ort nity to dra"atically bring do)n )ithin a !e) years alar"ing "aternal "ortality c rrently one o! the highest in the )orld# 1ro" N1HS I data+ it )as esti"ated at D;D %er lac births it has risen to @D7 %er lac births in N1HS II+ b t the .HO esti"ate % ts it higher at @E7# There can be a syste"atic ca"%aign o*er !i*e years to increase instit tional deli*eries as near as %ossible to the Ta"il Nad le*el+ also taking into acco nt assisted+ ho"e deli*eries by trained sta!! )ith doctors at call# 1or the interi" T:As sho ld be relied on thro gh a "ass a)areness ca"%aign in*ol*ing $ra" Panchayats too# O*er a %eriod o! ti"e there is no reason )hy AN8s entitled bene!its o! children to hel% in their gro)th and not re"ain as )el!are "eas re# Using the in!rastr ct res ! lly and )ith co"" nity %artici%ation and e,tensi*e social "obili'ation "any tasks in n trition are !easible and can be in %osition to "ake i"%act by ;767#

Child Health and N trition Associated )ith this is the iss e o! in!ant and child "ortality+ 3E7 o t o! 6777 dying in the !irst year and AB be!ore *ide years4 and lo) birth )eight 3;;F U. at birth ands DEF EK. at belo) C years4 "ost "ortality occ rs !ro" diarrhoea and the stagnation in I8R in the last !e) year is bo nd to ha*e a negati*e e!!ect on %o% lation stabili'ation goals# A recent re*ie) o! the Ninth %lan indicated that e*en )ith accelerated e!!orts )e "ay reach at best I8R5@7 by C77;+ b t "ore like I8R5@?# since the easier %art o! the %roble" is taking child "ortality is o*er e*ery %o"t gain herea!ter )ill deal )ith districts at greater risk and needing better organi'ational e!!iciencies in i"" ni'ation# At the sa"e ti"e+ "ore strea"lined RCH ser*ices are getting established as %art o! % blic syste"s and thro gh %ri*ate %artnershi%s There!ore there is e*ery reason to ho%e that the NPP ;777 target o! C7 %er tho sand li*e births by ;767 )ill be "et barring a !e) %ockets o! inaccessible and reso rce lean areas )ith st bborn %ersistence o! %o*erty and do"inantly co"%osed o! )eaker sections 3e g in %art o! Orissa as seen !ro" N1HS II4# As regards childhood diarrhoea+ deaths are totally %re*entable si"%le co"" nity action and % blic ed cation by targeting children o! lo) birth )eights and detecting early those children at risk !ro" "aln trition thro gh %ro%er lo) cost screening %roced re+ the %resent arrange"ent has got too b rdened )ith atte"%ting total %o% lation co*erage getting all children )eighed e*en once in three "onths and "aking AN8s de%ots !or ORS and !or si"%le dr gs !or !e*er and "oti*ating the co"" nity to take %ride in healthy children are the lessons o! the s ccess o! the Ta"il Nad N trition Pro/ect+ I! this is done there is a reasonable chance o! t)o thirds decline in "oderate "aln trition and abolition o! serio s grades co"%letely by ;76@# The s ccess can be b ilt %on till ;7;@

!or reaching le*els co"%arable to China# Concentration on %re*enti*e "eas res o! "aternal and child health and in %artic lar i"%ro*ed n trition ser*ices )ill be %artic larly se! l beca se it )ill hel% that generation to ha*e a head start in good health )ho are going to be a %art o! the de"ogra%hic bon s# The bon s is a yo ng ad lt b lge o! abo t CD7 "illion 3)ith not less than ;@7 "illion !ro" r ral %o% lation and abo t 677 "illion born in this cent ry4# The bon s )ill a%%ear in a se- ence )ith So th Indian States co"%leting the transition be!ore North Indian States s%read it o*er the ne,t three decades& To ens re best res lts a2 this stage the %resent n tritional ser*ices " st be con*erted into targeted 3and entitled4 bene!its o! children to hel% in their gro)th and not re"ain as )el!are "eas re# Using the in!rastr ct res ! lly and )ith co"" nity %artici%ation and e,tensi*e social "obili'ation "any tasks in n trition are !easible and can be in %osition to "ake i"%act by ;767# 8ild and "oderate "aln trition still %re*alent in o*er hal! o! o r yo ng %o% laaon can be hal*ed i! !ood as the s %%le"ental %ath)ay to better n trition beco"es a %riority both !or sel! reliance and lo)er costs# There has been a tendency !or "icro n trient s %%le"entation to o*er)hel" !ood deri*ed no rish"ent# This trend is assisted by !oreign aid b t o*er a long r n "ay %ro*e ns stainable& :y engaging the adolescents into %ro%er n trition ed cation and re%rod cti*e health a)areness )e can sea"lessly )ea*e into the n tritional sec rity syste" o! o r co ntry a cor%s o! in!or"ed interconnected and i"aginati*e ideas can be tried o t# S ch social "obili'ation at lo) cost can be the best %re*enti*e strategy as has been ad*ocated !or long by the N trition 1o ndation o! India 39 $o%alan ;7764 and can be a %riority in this decade o*er the ne,t t)o %lan %eriods# Un!inished agenda & non co"" nicable diseases and in/ ries Three "a/or s ch diseases *i'++ cancer cardio*asc lar diseases and renal conditions & and neglect in regard to "ental health conditions & ha*e o! late sho)n )orriso"e trends# C res !or cancer are still el si*e in s%ite o! %alliati*es and e,%ensi*e and long dra)n che"o & or radio &thera%y )hich o!ten in!lict catastro%hic costs+ In the case ot(C>D and renal conditions kno)n and tried %roced res are a*ailable !or relie!# There is e*idence o! greater %re*alence o! cancer e*en a"ong yo ng ad lts d e to the stress o! "ode" li*"g# In India cancer is a leading ca se o! death )ith abo t 6#@ to ; "illion cases at anyti"e to )hich E lac ne) cases are added e*ery year )ith C lakh deaths# O*er 6@ lakh %atients re- ire !acilities !or diagnosis and treat"ent# St dies by .HO sho) that by ;7;? )ith the e,%ected increase in !i!e e,%ectancy+ cancer b rden in India )ill increase to abo t 6D lac cases# C>D cases and Diabetes cases are also increasing )ith an B to 66 % %re*alence o! the latter d e to !ast li!e styles and lack o! e,ercise# Tra "as and accidents leading to in/ ries& are o!!shoots o! the sa"e co"%etiti*e li*ing conditions and rban tra!!ic conditions Data sho) one death e*ery "in te d e to accidents or "ore than 6B77 deaths e*ery day& in Delhi alone abo t 6@7 cases are re%orted e*ery day !ro" accidents on the road and !or e*ery death B li*ing %atients are added to hos%itals d e to in/ ries# There is !inally the e"erging a!ter"ath o! ins rgencies and "ilitant *iolence leading to "ental illnesses o! *ario s ty%es# It is esti"ated that 67 to ;7 %ersons o t o! 6777 %o% lation s !!er !ro" se*ere "ental illness and C to @ ti"es "ore ha*e e"otional disorder# .hile there are so"e !acilities !or diagnosis and treat"ent e,ist in "a/or cities there is no access )hate*er in r ral areas# It is ackno)ledged that the only )ay o! handling "ental health %roble"s is thro gh incl ding it into the %ri"ary health care

arrange"ents i"%lying trained screening and co nseling at %ri"ary le*els !or early detection# All these are e"inently !easible %re*enti*e ste%s and can be % t into %ractice b* ;77@ and )e sho ld be doing as )ell or better than China by ;7;7 considering the greater load o! non co"" nicable diseases they bear no)# The b rden o! non&co"" nicable diseases )ill be "et "ore and "ore by %ri*ate sector s%eciali'ed hos%itals )hich s%ring % in rban centers# 1acilities in %restigio s % blic centers )ill also be nder strain and they sho ld be redesigned to take ad*antage o! co"" nity based a%%roach o! a)areness+ early detection and re!erral syste" as in the "ode4 de*elo%ed s ccess! lly in the Regional Cancer Center Keraia# P blic sector instit tions are also needed to %ro*ide a co"%arator basis !or costs and e*al ating technology bene!its#( 1or the less a!!l ent sections %rolonged high tech c re )ill be na!!ordable# There!ore % blic ! nds sho ld go to %ro"ote a ro tine o! %ro%er screening health ed cation and sel! care and ti"ely in*estigations to see that inter*entions are started in stages I and II#

HEALTH INFRASTRUCTURE IN THE PUBLIC SECTOR Iss es in regard to % blic and %ri*ate health in!rastr ct re are di!!erent and both o! the" need attention b t in di!!erent )ays# R ral % blic in!rastr ct re " st re"ain in "ainstay !or )ider access to health care !or all )itho t i"%osing nd e b rden on the"# Side by side the e,isting set o! % blic hos%itals at district and s b&district le*els " st be s %%orted by good "anage"ent and )ith ade- ate ! nding and ser !ees and o t contracting ser*ices+ all as %art o! a ! nctioning re!erral net )ork# This de"ands better ro tines "ore acco ntable sta!! and attention to %ro"ote - ality# 8any re% ted % blic hos%itals ha*e s !!ered !ro" lack o! a tono"y inade- ate b dgets !or non&)age OL8 leading to !altering and %oorly "oti*ated care# All these are being tackled in se*eral states are %art health sector re!or"+ and )ill red ce the )aste in*ol*ed in si"%ler cases needlessly reaching tertiary hos%itals direct These+ atte"%ts " st %ersist )itho t any )a*ering or %olicy changes or %eriodic denigration o! their %ast )orking# 8ore a tono"y to large hos%itals and district % blic health a thorities )ill enable the" to %lan and i"%le"ent decentrali'ed and !le,ible and locally controlled ser*ices and re"o*e the dichoto"y bet)een hos%ital and %ri"ary care ser*ices# 1 rther# "ost %re*enti*e ser*ices can be deli*ered by do)n staging to a % blic health n rse " ch o! )hat a doctor alone does no)# S ch long ter" co""it"ent !or de"ysti!ication o! "edic"e and do)n staging o! %ro!essional hel% has been lost a"ong the %oliticians b rea cracy and technocracy a!ter the decline o! the PHC "o*e"ent# One conse- ence is the h ge regional dis%arities bet)een states )hich are getting stagnated in the transition at di!!erent stages and so"eti"es+ %olari'ed in the transition# So"e !easible ste%s in re*itali'ing e,isting in!rastr ct re are e,a"ined belo) dra)n !ro" s ccess! l e,%eriences and there!ore !easible else)here+ 1easible Ste%s !or better %er!or"anceH The ado%tion o! a ratio based a%%roach tor creating !acilities and other "% ls has led 2O short!alls esti"ated %to t)enty %ercent# It ! nctions )ell )here e*er there is diligent attention to s %er*ised ad"inistrati*e ro tines s ch as orderly dr gs %roc re"ent ade- ate OL8 b dgets and s %%lies and credible %roced res !or redressal o! co"%laints#

C rrent PHC CHC b dgets "ay ha*e to be increased by 67F %er year !or !i*e years to dra) le*el# The %ro%osal in the Dra!t NHP ;776 is ti"ely that State health e,%endit res be raised to 7% by ;76@ and to BF o! State b dgets therea!ter# Indeed the target co ld be ste%%ed % %rogressi*ely to 67F by ;7;@# it also s ggests that Central ! nding sho ld constit te ;@F o! total % blic e,%endit re in health against the %resent 6@F# The %eri%heral le*el at the s b center has not been 3and "ay not no) e*er be4 integrated )ith the rest o! the health syste" ha*ing beco"e dedicated solely to re%rod ction goals# The i""ediate task )o ld be to look dee%ening the range o! )ork done at all le*els o! e,isting centers and in %artic lar strengthen the re!erral links and ! ller and !le,ible tili'ation o!PHC5CHCs# Ta"il Nad is an instance )here a re*ie) sho)ed that o t o! 6D77 PHCs ADF ! nctioned in their o)n b ildings and had electricity+ ABF o! AN8s and A@F o! %har"acists )ere in %osition# On an a*erage e*ery PHC treated abo t 677 %atients ;;D o t o! the ;@7 o%en ;D ho r PHCs had a"b lances# .hat this ill strates is that e*ery State " st look !or i"aginati*e ses to )hich e,isting str ct res can be % t to ! ller se s ch as "aking ;D ho rs ser*ices o%en or tra "a !acilities in PHCs on high)ay locations etc# The %ersistent nder ! nding o! rec rring costs had led to the colla%se o! %ri"ary care in "any states+ so"e s%ectac lar !ail res occ rring in "alaria and kala'ar control# This has to do )ith ade- acy o! de*ol tion o! reso rces and )ith lack o! ad"inistrati*e )ill %robity and co"%etence in ens ring that deter"ined %riorities in % blic health tasks and ro tines are carried o t ti"ely and in ! ll# Only gen ine de*ol tion or si"%ler tasks and reso rces to %anchayats+ )here there )ill be a third )o"en "e"bers& can be the ans)er as seen in Kerala or 8#P# )here %anchayats are "ade into ! lly co"%etent local go*ern"ents )ith assigned reso rces and control o*er instit tions in health care# 8any inno*ati*e cost contain"ent initiati*es are also %ossible thro gh !oc sed "anage"ent & as !or instance in the strea"lining o! dr g % rchase stocking distrib tion arrange"ents in Ta"il Nad leading to C7F "ore *al e )ith sa"e b dgets# The PHC a%%roach as i"%le"ented see"s to ha*e strayed a)ay !ro" its key thr st in %re*enti*e and % blic health action# No syste" e,ists !or % r%ose! l co"" nity !oc sed % blic in!or"ation or seasonal alerts or ad*isories or co"" nity health in!or"ation to be circ lated a"ong doctors in both %ri*ate %ractice and in % blic sector# PHCs )ere "eant to be local e%ide"iological in!or"ation centers )hich co ld de*elo% si"%le co"" nity# Tertiary hos%itals had been gi*en concessional land+ c sto"s e,e"%tion and liberal ta, breaks against a co""it"ent to reser*e beds !or %oor %atients !or !ree treat"ents# No %roced res e,ist to "onitor this and the disclos re syste"s are !ar !ro" trans%arent+ redressal o! %atient grie*ances is %oor and allegations o! c ts and co""issions to %ro"ote needless %roced re are co""on# The b lk o! noncor%orate %ri*ate entities s ch as n rsing ho"es are r n by doctors and doctors& entre%rene rs and re"ain nreg lated cither in ter"s o! !acility o! co"%etence standards or - ality and acco ntability o! %ractice and so"eti"es o%erate )itho t syste"atic "edical records and a dits# 8edical ed cation has beco"e "ore e,%ensi*e and )ith ra%id technological ad*ances in "edicine+ s%eciali'ation has "ore attracti*e re)ards# Indeed the re)ard e,%ectations o! %ri*ate %ractice !or"erly s%read o t o*er career long earnings are s- ee'ed into a !e) years+ )hich beco"es %ossible only by )orking in hi tech hos%ital so"e ti"es r n as b sinesses# The res%onsibilities or %ri*ate

sector in clinical and %re*enti*e % blic health ser*ices )ere not s%eci!ied tho gh nder the NHP 6ABC nor d ring the last decade o! re!or"s !ollo)ed % either by go*ern"ent o! %ro!ession by any strategy to engage allocate+ "onitor and reg late s ch %ri*ate %ro*ision nor assess the costs and bene!its or s bsidi'ation o! %ri*ate hos%itals# There has been talk o! % blic %ri*ate %artnershi%s+ b t this has yet to take concrete sha%e by i"%osing % bic d ties on %ri*ate %ro!essionals+ )here*er there is agree"ent on e,%licitly % blic health o tco"es# In !act it has re- ired the S %re"e Co rt to lay do)n the %ro!essional obligations o! %ri*ate doctors in accidents and in/ ries )ho sed to be re! sed treat"ent in case o! %otential beco"ing %art o! a cri"inal o!!ence# The res%ecti*e roles o! the % blic and %ri*ate sectors in health care has been a key iss e in debate o*er a long ti"e# .ith the o*erall s)ing to the Right a!ter the 6AB7s+ it is broadly acce%ted that %ri*ate %ro*ision o! care sho ld take care o! the needs o! all b t the %oor# hi doing so+ risk %ooling arrange"ents sho ld be "ade to lighten the !inancial b rden on theirs )ho %ay !or health care# As regards the %oor )ith %riced ser*ices# Taking into acco nt the si'e o! the b rden+ the clinical and % blic health ser*ices cannot be sho ldered !or all by go*ern"ent alone# To a large e,tent this health sector re!or" " India at the state le*el con!ir"s this trend# The distrib tion o! the b rden+ bet)een the t)o sectors )o ld de%end on the sha%e and si'e o! the social %yra"id in each society# There is no ob/ection to introd ce ser !ees+ contract al arrange"ents+ risk %ooling+ etc# !or "obili'ation o! reso rces !or health care# : t+ the line sho ld be dra)n not so " ch bet)een % blic and %ri*ate roles+ b t bet)een instit tions and health care r n as b sinesses or r n in a )ider % blic interest as a social enter%rise )ith an econo"ic di"ensions# In a "arket econo"y+ health care is s b/ect to three links+ none o! )hich sho ld beco"e o t o! balance )ith the other & the link bet)een state and citi'ens( entitle"ent !or health+ the link bet)een the cons "er and %ro*ider o! health ser*ices and the link bet)een the %hysician and %atient# HEALTH FINANCING ISSUES P blic e,%endit re le*els 1air !inancing o! the costs o! health care is an iss e in e- ity and it has t)o as%ects ho) " ch is s%ent by $o*ern"ent on % blicly ! nded health care and on )hat as%ects0 And secondly ho) h ge does the b rden o! treat"ent !all on the %oor seeking health care0 Health s%ending in India at ?F o! $DP is a"ong the highest le*els esti"ated !or de*elo%ing co ntries# In %er ca%ita ter"s it is higher than in China Indonesia and "ost A!rican co ntries b t lo)er than in Thailand# E*en on PPP I ter"s India has been a relati*ely high s%ender in!or"ation sheets based on re%orting !ro" a net)ork associating %ri*ate doctors also as has been done s ccess! lly at C8C >ellore in their r ral health %ro/ects or by the Kho/ %ro/ects o! the >ol ntary Health Association o! India# It is only thro gh s ch co"" nity based a%%roach that re*itali'ation o! indigeno s "edicines can be done and %eo%le trained in sel! care and acce%t res%onsibility !or their o)n health# PHC a%%roach )as also intended to test the e,tent to )hich non&doctor based healthcare )as !easible thro gh e!!ecti*e do)n staging o! the deli*ery o! si"%ler as%ects o! a care as is done in se*eral co ntries thro gh n rse %ractitioners and %hysician assistants+ AN8sJ %hysician assistants etc can each get trained and recogni'ed to )ork in allotted areas nder re!erral5s %er*ision o! doctors# This "ay indeed be "ore acce%table to the "edical %ro!ession than the dra!t NHP %ro%osal to restart licentiates in "edicine as in the

thirties and gi*e the" shorter %eriods o! training to ser*e r ral areas# S ch a licentiate syste" cannot no) be recalled against the %ro!ession(s o%%osition nor )o ld %eo%le acce%t t)o le*el ser*ices# 1inally it is i"%ortant 67 noie so"e dangers inhere" " arrange"enis itiai %ro"ote deli*ery syste"s s bstantially o tside go*ern"ent channel either thro gh N$Os or thro gh registered societies at State and district le*els# Clearly this "ay by a better a%%roach than lea*ing it to the "arket and )elco"e as %ath breaking o! inno*ati*e e!!orts as a %rec rsor to la nching a % blic %rogra"# : t as a long r n deli*ery "echanis" it is neither %ractical nor s stainable as s ch arrange"ents tend to by%ass go*ern"ent nder o r constit tional sche"e o! %arlia"entary res%onsibility and )o ld also c t into the %otential o! %anchayatra/ instit tions# Each "a/or disease control %rogra" has no) got a se%arate society at state and district le*els o!ten as %art o! access to !oreign aid# .hat is lost is the %rinci%le o! %arlia"entary acco ntability o*er the !lo) o! ! nds that arise o t o! *oted b dgets and international agree"ents to )hich $o*ern"ent is a %arty and ans)erable to %arlia"ent# 2ike ca"%aign "odes and *ertical inter*entions+ the registered society a%%roach )o ld )eaken the long&ter" co""it"ent and integrity o! % blic health care syste"s# SHAPE OF THE PRIVATE SECTOR IN MEDICINE The key !eat res o! the %ri*ate sector in "edical %ractice and health care are )ell kno)n# T)o - estions are rele*ant# .hat role sho ld be assigned to it0 Ho) !ar and ho) closely sho ld it be reg lated0 O*er the last se*eral decades+ inde%endent %ri*ate "edical %ractice has beco"e )ides%read b t has re"ained st bbornly rban )ith %olyclinics+ n rsing ho"es and hos%itals %roli!erating o!ten thro gh doctor entre%rene rs# At o r le*el tertiary hos%itals in "a/or cities are in "ay cases r n by b siness ho ses and se cor%orate b siness strategies and hi&tech s%eciali'ation to create de"and and attract those )ith e!!ecti*e de"and or the critically * lnerable at increasing costs# Standards in so"e o! the" are tr ly )orld class and so"e )ho )ork there are o tstanding leaders in their areas# : t gi*en the co""odi!ication o! "edical care as %art o! a b siness %lan it has not been %ossible to reg late the - ality+ acco ntability and !airness in care thro gh criteria !or accreditation+ trans%arency in !ees+ "edical a dit+ acco ntable record kee%ing+ credible grie*ance %roced res etc# s ch accreditation+ standard setting and licens re syste"s are best done nder sel! reg lation+ b t sel! reg lation syste"s in India "edical %ractice ha*e been de!icient in "any res%ects creating %roble" in credibility# Ac te care has beco"e the key %riority and contin es to attract "an%o)er and in*est"ent into related s%ecialty ed cation and !acilities !or technological i"%ro*e"ent# Co""on treat"ents+ ine,%ensi*e diagnostic %roced res and !a"ily "edicine are re%laced and %riced o t o! the reach o! "ost citi'ens in urban areas# P blic health s%ending acco nts !or ;@F o! aggregate e,%endit re the balance being o t o! %ocket e,%endit re inc rred by %atients to %ri*ate %ractitioners o! *ario s h es# P blic s%ending on health in India has itsel! declined a!ter liberali'ation !ro" 6#CF o! $DP in 6AA7 to 7#AF in 6AAA# Central b dget allocations !or health ha*e stagnated at 6#CF to total Central b dget# In the States it has declined !ro" 7.0% to @#@#F o! State health b dget# Consider the contrast )ith the :hore Co""ittee reco""endation o! 6@F co""itted to health !ro" the re*en e e,%endit re b dget+ Indeed .HO had reco""ended @@ o! $DP !or health# The c rrent ann al %er ca%ita % blic health e,%endit re is no "ore than Rs. 6?7 and a recent .orld :ank re*ie) sho)ed that o*er

all %ri"ary health ser*ices acco nt !or @BF o! % blic e,%endit re "ostly b t on salaries+ and the secondary5tertiary sector !or abo t CBF+ %erha%s the greater %art going to tertiary sector+ incl ding go*ern"ent ! nded "edical ed cation# O t o! the total %ri"ary care s%ending+ as " ch as B@F )as s%ent on or c rati*e ser*ices and only 6@F !or %re*enti*e ser*ice# 9.orld :ank 6AA@< abo t DEF o! total Central and State b dget is s%ent on c rati*e care and health !acilities# This "ay see" e,cessi*e at !irst sight b t in !ace the !ig re is o*er ?7F in co"%arable co ntries+ )ith the b lk o! the e,%endit re de*oted % blicly ! nded care or on "andated or *ol ntary risk %ooling "ethods+ in India close to 75% o! all ho sehold e,%endit re on health is s%end !ro" %ri*ate ! nds and the conse- ent regressi*e e!!ects on the %oor is not s r%rising# In this connection# Ehe %ro%osals in the dra!t NHP ;777 are )elco"e seeking to restore the key balance to)ards %ri"ary care+ and bring it to internationally acce%ted %ro%ortions in the co rse o! this decade# Pri*ate e,%endit re trends 8any s r*eys con!ir" that )hen ser*ices are %ro*ided by %ri*ate sector it is largely !or a"b latory care and less !or in%atient carte# There are *ariations in le*els o! cost+ %ricing+ transactional con*eniences and - ality o! ser*ices# There is e*idence to s ggest that dis%arities in inco"e as s ch do not "ake a di!!erence in "eeting health care costs+ e,ce%t !or catastro%hic or li!e threatening sit ations 1inally it has been established that bet)een ;5Crds to C5Dths o! all "edical e,%endit re is s%end on %ri*ately %ro*ided care e*ery ho sehold on the a*erage s%ends % to 67F o! ann al ho sehold cons "%tion in "eeting health care needs# This regressi*e b rden sho)s % *i*idly in the cycle o! inco"%lete c re !ollo)ed by rec rrence o! illness and dr g resistance that the %oor !ace in diseases like T: or Kala'ar or 8alaria es%ecially !or daily )age earners )ho cannot a!!ord to be o t o! )ork# Pri*ati'ation has to be disting ished !ro" %ri*ate "edical %ractice )hich has al)ays been s bstantial )ithin o r "i,ed econo"y# .hat is critical ho)e*er is the ra%id co""erciali'ation o! %ri*ate "edical %ractice in %artic lar ne*en - ality o! care# There are co"%le, reasons !or this trend# 1irst is the high scarcity cost o! good "edical ed cation+ and second the re)ard di!!erential bet)een % blic and cor%orate tertiary hos%itals leading to the rel ctance o! the yo ng %ro!essional to be l red a)ay !ro" the "arket to % blic ser*ice in r ral areas and !inally there is the co"% lsion o! ret rns on in*est"ent )hene*er e,%ensi*e e- i%"ent in installed as %art o! %ractice# Increasingly+ this has shi!ted the balance !ro" indi*id al %ractice to instit tionali'es %ractice+ in hos%itals+ %olyclinics+& Etc# this con/ nction e,%lodes into nbearable cost escalation )hen backed by a third %arty %ayer syste"5& This in t rn ind ces increases in ins rance %re"i "s "aking s ch co*er beyond the ca%acity to %ay# There is a distinct %ossibility o! s ch cycles o! cost escalation %eriodically occ rring in the ! t re+ %ro"oted ! rther by global trans!er o! kno)ledge and so!t)are+ tele&"edicine etc# es%ecially a!ter the ad*ent o! %redicti*e "edicine and gene "ani% lation# Doctors %racticing in the %ri*ate sector are so"eti"es acc sed o! %rescribing e,cessi*e+ e,%ensi*e and nsky "edicines and )ith sing ra"%ant and less than / sti!ied se o! technology !or diagnosis and treat"ent# So"e "ethod o! accreditation o! hos%itals and !acilities and better licens re syste"s o! doctors is likely )ithin a decade# This )ill enables so"e "oderation in le*els o! charges in sing ne) technology# High cost o! care is so"eti"es so ght to be / sti!ied as necessary d e to de!ensi*e "edicine %racticed in

order to "eet risks nder the Cons "er Protection Act# There is little e*idence !ro" decisions o! Cons "er Co rts to / sti!y s ch !ears# .hile the line bet)een "istaken diagnosis and negligent beha*io r )ill al)ays re"ain thin+ case la) has already beg n to settle aro nd the doctor(s ability to a%%ly reasonable skills and not the highest degree o! skill# .hat has lieen established is the right o! the %atient to - estion the treat"ent and %roced res i! there is !ail re to treat according to standard "edical %ractice or i! less than ade- ate care )as taken# As health ins rance gets established it "ay i"%ost "ore stringent criteria and restrictions on %hysician %er!or"ance )hich "ay te"%t the" into de!ensi*e "edicine# There "ay also be atte"%t to coll si*e ca%t re and 3indirect o)nershi%4 o! ins rance co"%anies by cor%orate hos%itals as in other co ntries# Ad*ances in "edical technology are ra%id and do"inant and easily tra*el )orld )ide and o!ten seen as good in*est"ent and brand e- ity in the %ri*ate sector# Pri*ate inde%endent %ractices & and to s"aller e,tent hos%itals+ dis%ensaries+ n rsing ho"es tele& are seen as "arkets !or "edical ser*ices )ith each seg"ent seeking to "a,i"i'e gains and b ild " t ally s %%orting links )ith other seg"ents# 8ore than one st dy on the - ality o! care indicates that so"eti"es "ore ser*ices are %er!or"ed to "a,i"i'e re*en e+ and ser*ices5 "edicines are %rescribed )hich !!l&e not al)ays necessary# Allegations are also )idely "ade o! coll si*e deals bet)een doctors and hos%itals )ith co""issions and c ts e,changed to %ro"ote needless re!erral+ dr gs or %roced res 9.orld :ank A 6AA@< A%%ro%riate reg lation is likely in the ne,t decade !or "ini" " standards and acco ntability and that sho ld consist o! a balanced "i, o! sel! reg lation e,ternal reg lation by standard setting and accreditation agencies incl ding %ri*ate *ol ntary health ins rance# Ho) !ar can health ins rance hel%0 .hat constit tes a !air distrib tion o! the costs o! care a"ong di!!erent social gro %s )ill al)ays be a nor"ati*e decision e"erging o t o! %olitical debate# It incl des risk %ooling initiati*es !or sharing costs a"ong the healthy and the sick leading to ins rance sche"es as a s bstit te !or or as s %%le"entary to State %ro*ision !or "ini" " ni!or" ser*ices# It also co*ers risk sharing initiati*es across )ealth and inco"e in*ol*ing % blic %olicy decisions on %rogressi*e ta,ation+ "erit s bsidy and cross s bsidi'ation by d al %ricing# :oth )ill contin e to be necessary in o r conditions )ith "ore e"%hasis on risk sharing as gro)th %icks %# Risk %ooling )ithin %ri*ate *ol ntary and "andated ins rance sche"es has beco"e ine*itable in all co ntries beca se o! the do ble b rden o! sickness and to ens re that !inancial costs o! treat"ent do not beco"e an e,cessi*e b rden relati*e to inco"es# It is di!!ic lt b t necessary to e"bed these notions o! !air !inancing into legislation+ reg lations and sche"es and %rogra"s e- ity is ai"ed at in health care# .ith the recent o%ening % o! the general Ins rance sector to !oreign co"%anies+ there is the %ros%ect o! t)o trends# Ne) ins rance %rod ct )ill be % to t so e,%and b siness "ore be dee%ening than )idening risk co*ered# The second trend )o ld be to concentrate on rban "iddle and %%er classes and settled iobholders )ith ca%acity to %ay and )ith a %ercei*ed interest in good health o! the !a"ily# :oth trends "ake so nd b siness sense in a *ast gro)th "arket and )o ld increase e,tensi*e hos%ital se and %rotection against h ge hos%itali'ation e,%enses+ and %ro"oted by rban %ri*ate hos%itals since their clientele )ill increase# Ins rance is a )elco"e necessary ste% and " st do btless e,%and to hel% in !acilitating

e- itable health care to shi!t to sections !or )hich go*ern"ent is res%onsible# Indeed !or those not able to access ins rance it is go*ern"ent that )ill ha*e to contin e to %ro*ide the "ini" " ser*ices+ and inter*ene against "arket !ail res incl ding denial thro gh ad*erse selection or "oral ha'ard# Indeed in the long r n the degree o! ine- ity in health care a!ter ins rance syste"s are set % )ill de%end ironically on the strength and deli*ery o! the % blic syste" as a co nter%oise in holding costs and rele*ance in technology# The ins rable %o% lation in India has been assessed at ;@7 "illion and at an a*erage o! Rs 67775& %er %erson the %re"i " a"o nt %er year )o ld be Rs ;@+7775& crores and is e,%ected to treble in ten years& .hile the ins rance %rod ct )ill d ti! lly re!lect the de"ands o! this colossal "arket and related technological de*elo%"ents in "edicine+ it sho ld be re- ired to e,tend beyond hos%itali'ation and co*er do"iciliary treat"ent too in a big )ayJ !or instance+ e,tending co*er to a"b latory "aternal and selected chronic conditions like Asth"a "ore %re*alent a"ong the %oor# The ins rance reg latory a thority has anno nced %riority in licensing to co"%anies set % )ith health ins rance as key b siness and has e"%hasi'ed the need !or de*elo%ing ne) %rod cts on !air ter"s to those at risk a"ong the %oor and in r ral areas# 8 ch )ill t rn on )hat %rogress takes %lace thro gh so nd reg lation co*ering as%ects indicated belo)# In order to be socially rele*ant and co"inercially *iable the sche"e " st ai" at a %ro%er "i, o! health ha'ards and co*er "any broad social classes and inco"e gro %s# This is %ossible in %oor locations or co"" nities only i! a gro % *ie) is taken and on chat basis a %o% lation& based nsk is assessed and co"" nity rated %re"i "s deter"ined co*ering !a"ilies !or all co""on illnesses and based on e%ide"iological deter"ined risk# In order that e,cl sions co&%ay"ents ded ctibles etc# re"ain "ini" " and rele*ant to o r social sit ation+ so"e )ell / dged go*ern"ent "erit s bsidy can be incor%orated into anti %o*erty !a"ily )el!are or %ri"ary ed cation or )el!are %ension sche"es "eant !or old age# Inno*ati*e co"" nity based ne) %rod cts can be de*elo%ed by sing the scattered e,%erience o! s ch %rod cts !or instance in SE.A+ so that a "ini" " core co*er can be de*elo%ed as a "odel !or inno*ati*e ins rance by %anchayats )ith reins rance back % by co"%anies and go*ern"ent bearing %art o! %ro"otional costs# The b lk o! the !or"al sector "aybe co*ered by an e,%anded "andatory ins rance )ith a!!ordable co*er and con*enient "odes o! %re"i " %ay"ent# O tside the !or"al "an !act ring sector inno*ate sche"es can be designed aro nd s%eci!ic occ %ation gro %s in the in!or"al sector )hich are steadily beco"ing a base !or old age %ension entitle"ents+ as in Kerala and Ta"il Nad & and bro ght nder co""on risk rating# 1inally+ as in the .est health ins rance sho ld de*elo% in!l ence and ca%acity as b lk % rchaser or "edical and hos%ital ser*ices to i"%act on - ality and cost and %ro*ide greater nderstanding abo t Indian health and illness beha*io rs+ %atterns o! tili'ation o! care and intra !a"ily %riorities !or accessing "edical care# Health ins rance sho ld be )elco"ed as a !orce !or a !airer healthcare syste"# : t its s ccess sho ld be / dged on ho) )ell ne) %rod cts are de*elo%ed )ith a co*er beyond hos%itali'ation+ ho) !airly and incl si*ely the co*er is o!!ered and ho) !ar co"" nity rated %re"i "s are established# The IRDA has an i""ense res%onsibility and )ith its leadershi% one can o%ti"istically e,%ect abo t C7F co*erage by ;76@ relie*ing the b rden on the % blic syste"s#

HEALTH PERCEPTIONS AND PLURAL SYSTEMS: Health %erce%tions %lay an i"%ortant %art in ens ring so nd health o tco"es# To a large

e,tent they are c lt rally deter"ined b t also s b/ect to change )ith econo"ic gro)th and social de*elo%"ent# Peo%le int iti*ely de*elo% ca%acity to "ake choices tor being treated nder the )estern o! indigeno s syste"s o! "edicines+ kee% a balance bet)een good habits traditionally de*elo%ed !or healthy li*ing and "ode" li!estyles+ decide on )here to go !or chro"e and ac te care and ho) to a%%ortion intra&!a"ily tili'ation o!healthcare reso rces# The %ro!essional is generally bo nd by his disci%line and its inherent logic o! ca sation and e!!ect and tends to disco nt e*en )hat )ork as s ccess! l %ractice+ I !it does not !all )ithin the acce%ted nderstanding o! his %ro!ession# So"e "o*e"ent is occ rring a"ong e"inent allo%athic doctors trying+ !or instance+ to re)ork Ay r*eda theory in a "ode" idio" starting !ro" res%ect! l re*erse analysis !or act al s ccess! l conte"%orary %ractice o! Ay r*eda and %ro*ide a theoretical !ra"e linking it to conte"%orary needs# There is e*idence !ro" % blic health ca"%aigns in Ta"il Nad )here e*ery se*enth %erson s%ontaneo sly e,%ressed a %re!erence !or Sidda 8edicine# Ho"eo%athy !or chronic ail"ent is )idely acce%ted# The herbal base !or Ay r*da "edicine )idely %racticed in the Hi"alayan belt has do)n )orld attention a h ge e,%ort "arket re"ains to be ta%%ed according to the kno)ledgeable trade so rces b t the danger o! bio&%ri*acy re"ains and legal enable"ents sho ld be % t in %lace soon that )o ld ! lly e,%and on o r rights nder the .TO agree"ents# The dra!t national %olicy on ISI*IH has atte"%ted to %lace these %l ral syste"s in a "ode" ser*ice deli*ery and research and ed cation conte,t+ it has co*ered its nat ral reso rce base+ traditional kno)ledge base and de*elo%"ent o! instit tions to carry a national heritage !or)ard# There is ho%e !or the s r*i*al and gro)th o! the sector only i! it beco"es an e,a"%le o! con*ergence bet)een %eo%le(s and %lanner(s %erce%tions and ens re its rele*ance+ acco ntability and a!!ordability to conte"%orary illnesses and conditions# At the sa"e ti"e it is ndeniable that there is " ch cross %ractice by IS8 %ractitioners )hich s ally incl de %rescri%tions )e )estern "edicine as %art o! indigeno s treat"ent A%%ro%riate reg lation is needed to %rotect %eo%le !ro" !ra d and other dangers b t the larger - estion is ho) to "ake the %erce%tions o! the %ro!essionals and %lanners regarding indigeno s syste" o! "edicine less a"bi*alent# The se%arate de%art"ent !or IS8LH sho ld be able to bring abo t ! nctional integration o! IS8 and )estern "edicine in ser*ice deli*ery at PHC le*els by ;77@ )hereby it )ill sher in an ni- ely Indian syste" o! care# EMERGING SCENARIO .hat then can )e concl de abo t the %ros%ects o! health care in India in ;7;70 An o%ti"istic scenario )ill be %re"ised on an a*erage BF rate o! econo"ic gro)th d ring this decade and 67F %er ann " therea!ter& I! so+ )hat )o ld be the "a/or !all o t in ter"s o! res lts on the health scene0 In the !irst %lace+ longe*ity esti"ates can be considered along the !ollo)ing lines# China in ;777 had a li!e& e,%ectancy at birth o! ?A years 384 and EC314 )hereas India had res%ecti*ely ?7 384 and ?C 314# 8ore i"%ortantly+ healthy li!e e,%ectancy at birth in China )as esti"ated in the .orld Health Re%ort ;776 at ?6 384 and ?C#C 314 )hereas in Indian !ig res )ere @C 384 and @6#E 314# I! )e look at the %ercentage o! li!e e,%ectancy years lost as a res lt o! the disease b rden and e!!ecti*eness o! health care syste"s+ Chinese "en )o ld ha*e lost 66#? years against Indian "en losing 6;#E years# The corres%onding !ig res are 6C#; !or Chinese )o"en and 6E#@ !or Indian )o"en# Clearly+ an integrated a%%roach is necessary to deal )ith a*oidable "ortality and "orbidity and %re*enti*e ste%s in % blic health are needed to bridge the ga%s+ es%ecially in regard to the Indian )o"en# Taking all the !actors into

consideration+ longe*ity esti"ates aro nd ;7&;@ co ld be aro nd E7 years+ %erha%s+ )itho t any distinction bet)een "en and )o"en# This leads s to the second - estion o! the re"aining disease b rden in co"" nicable and non&co"" nicable diseases+ the e!!ecti*e o! inter*entions+ s ch as+ i"" ni'ation and "aternal care and the e,tent o! * lnerability a"ong so"e gro %s# These iss es ha*e been death )ith in detail earlier# Clearly an o%ti"istic !orecast )o ld en*isage s ccess in %olio+ ya)s+ le%rosy+ kala'ar t(ilaria and blindness# As regards T: it is %ossible to arrest ! rther gro)th in absol te n "bers by ;767 and therea!ter to bring it to less than an "illion )ith" internationally acce%ted li"its by ;7;7# .ith regard to 8alaria+ the incidence can be red ced by a third or e*en %to hal! )ithin a decade# In that case+ one can e,%ect near !reedo" !ro" 8alaria !ro" "ost o! the co ntries by ;7;7# As regards AIDS+ it looks nlikely that in!ection can be le*eled o! by ;77E# The %rognosis in regard to the ! t re sha%e o! HI> 5 AIDS is ncertain# Ho)e*er+ it can be a !easible ai" to red ce "aternal "ortality !ro" the %resent D77 to 677 %er lakh %o% lation by ;767 and achie*e )orld standards by ;7;7# As regards child health and n trition+ it is %ossible to reach I8R>C7 %er tho sand li*e births by ;767 in "ost %arts o! the co ntry tho gh in so"e areas+ it "ay take a !e) years "ore# .hat is i"%ortant is the chance o! t)o thirds decline in "oderate "aln trition+ and abolition o! serio s "aln trition co"%letely by ;76@ in the case o! Cancer+ it is !easible to set % an integrated syste" !or %ro%er screening+ early detection+ sel! care and ti"ely in*estigation and re!erral# In the "atter o! disease b rden as a )hole+ it is !easible to atte"%t to reach standards co"%arable to china !ro" ;767 on)ards# Taking the third as%ect *i' !airness in !inancing o! health care and re!or"ed str ct re o! health ser*ices+ an o%ti"istic !orecast )o ld be based on the !act that the ! ll %otential o! the *ast % blic health in!rastr ct re )o ld be ! lly reali'ed by ;767# its e,tension to rban areas )o ld be "oderated to the e,tent s bstantial %ri*ate %ro*ision o! health care is a*ailable in rban areas+ concentrating on its sensible and e!!ecti*e reg lation# A reasonably )ide net)ork o! %ri*ate *ol ntary health ins rance co*er )o ld be a*ailable !or the b lk o! the e"%loyed %o% lation and there )o ld be "odels o! re%licable co"" nity based health ins rance a*ailable !or the norgani'ed sector# As regards the %ri*ate sector in "edicine+ it sho ld be %ossible in the co rse o! this decade to settle the % blic role o! %ri*ate "edical %ractice & inde%endent or instit tional# 1or this % r%ose+ "ore e,%eri"ents are to be done !or %ro"oting % blic %ri*ate %artnershi%s+ !oc sing on the iss e o! ho) to erect on the basis o! shared % blic health o tco"e as the key basis !or the %artnershi%# A sensible "i,t re o! e,ternal reg lation and %ro!essional sel!&reg lation can be de*ice in the cons ltation )ith the %ro!ession to ens re co"%etence+ - ality and acco ntability# The ! t re o! %l ral syste"s in "edical nderstanding and e*al ation o! co"%arati*e le*els o! co"%etence and reliability in di!!erent syste"s & a task in )hich+ the se%arate de%art"ent !or Indian syste"s o! "edicine and ho"eo%athy )ill %lay a leading role in ind cting - ality into the indigeno s "edical %ractices# The ne,t iss e relates to the desirable le*el o! % blic e,%endit re to)ards health ser*ices# China de*otes D#@F to its $&DP as against India de*oting @#6F# b t this hides the !act that in China+ % blic e,%endit re constit tes CBF )hereas in India+ it is only 6SF o! total health e,%endit re# An o%ti"istic !orecast )o ld be that the le*el o! % blic e,%endit re )ill be raised %rogressi*ely s ch that abo t C7F o! total health e,%endit re )o ld be "et o t o! % blic ! nds by %rogressi*ely increasing the health b dget in states

and the central and charging ser !ees in a%%ro%riate cases# The !ig re "entioned )o ld %erha%s corres%ond to the %ro%ortion o! the %o% lation )hich "ay still need assistance is social de*elo%"ent# 1inally it is %ro%er to re"e"ber that health is at botto" an iss e in / stice# It is in this conte,t that )e sho ld ask the - estion as to ho) !ar and in )hat )ay has %olitics been engaged " health care0 The record is disa%%ointing# 8ost health sector iss es !ig ring in %olitical debate are those that a!!ect interest gro %s and seldo" central to choices in health care %olicy# 1or instance conditions o! ser*ice and re)ard syste"s !or $o*ern"ent doctors ha*e dra)n " ch attention o!ten based on inter ser*ice co"%arison o! no )ider interest# Inter&syste" %roble"s o! o r %l ral "edical care ha*e dra)n "ore attention !ro" co rts than !ro" %olitics# Hos%ital "anage"ent and strikes+ %oor )orking o! the 8CI and corr %tion in recognition o! colleges+ dra"atic cases o! s% rio s dr g s %%ly etc ha*e been debated b t there has been no s stained attention on s ch iss es as )hy "alaria recr descence is so co""on in so"e %arts o! India or )hy co"%laints abo t absence o! in!or"ed consent or !re- ent in testing on )o"en+ or on the *ariations in %rices and a*ailability o! essential dr gs or !or co"bating e%ide"ic attacks in de%ri*ed areas seldo" dra) attention# The !ar reaching reco""endations "ade by the Hathi Co""ittee re%ort and or the 2entin Co""ission re%ort+ ha*e been i"%le"ented %atchily# The role to be assigned to %ri*ate sector in "edicine+ the need !or a good re!erral syste" or the irrationality in dr g %rescri%tions and s e ha*e seldo" been the %oint o! %olitical debate# Indeed the lack l ster %rogress o! 8NP o*er the Plans sho)s %olitical disinterest and the only )ay !or %olitics to beco"e "ore salient to the health o! the %oor and the red ction o! health ine- alities is !or a " ch greater trans!er o! % blic reso rces !or %ro*ision and !inancing & as has ha%%ened in the .est+ not only in UK or Canada b t in the US itsel! )ith a si'able o tlay on 8edicaid and 8edicare#