Is there hope for South Asia?
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7443.777 (Published 01 April 2004) Cite this as: BMJ 2004;328:777
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The catastrophic failure of public health in rural India
There is hope to improve health of South Asian if medical
professionals, politicians and administrators think so(1). India is an
agriculture country. More than 60% population stays in villages.
Illiteracy is rampant in villagers. Even illiteracy runs from generation
to generation in adivasis shepherds , pardhi and sugarcane laborers(2)
In India three tier system exist for the management of public health
i.e. primary heath center(PHC), rural or cottage hospital (RH)and civil
hospital. Out of these PHCs and cottage hospitals form the backbone of
public health. Each PHC covers ten to twelve thousand population. PHC and
RH is suppose to provide preventive and curative intervention for various
health problems affecting villagers. The condition of these so called
health institutes are unhygienic and no more better than a cattle shade.
At PHC at times even a simple sterile dressing material is not available .
patients at times have to buy such basic medical equipment as saline
bottles and intravenous set. Thus only thing that is free is a bed on the
floor and a stained sheet ( 3 ). Due to lack of trained staff and
facilities to manage emergency like pesticide poisoning , injuries ,
severe dehydration, acute bronchopneumonia, chest pain , snake and
scorpion envenoming cases reported to PHCs are referred soon after
examination to RH. Many of them dies on way to big hospital.
Medical officers are fresh graduate had rarely seen and treated such
emergency before. He rarely stays at head quarter and not available
during night hours for to treat acute medical emergency. Deliveries are
conducted by poorly trained mid-wives or at times female attendants( 4 ).
At PHC life saving drugs like anti-snake venom are always short supply.
Many poisonous bite victims with acute bleeding and respiratory paralysis
are transferred to civil hospital. Though there is repeated news of huge
fund available for HIV epidemic but it is surprise to note even HIV
testing kits are not available to cottage hospital.
Majority of medical officers are busy in their private practice and
utilized the PHC or RH as stepping stone to settle their own practice near
the vicinity of their appointment. They are busy in family planning,
attending meeting at district place and killed time , money to please
the politicians, higher officers so as to turn blind eye to their
irregularities or illegal private practice.
Corruption flourished all over the health department in purchasing drugs,
gadgets and appointment of staff. Many health officers are caught red
handed for accepting bribe for issuing illegal certificate for treatment
or even to manipulate postmortem report and even huge unaccounted money
searched out during income tax red. Medical officers left the hospital due
to threat by relatives of death of their patient because of negligence
or delay in attending. At times honest ,dedicated and sincere medical
officers are neglected in the health department, many times they have to
face departmental inquiry or get repeated transfer.
Private doctors and hospital are busy in treating acute illness and are
not interested in intervention to improve the public health. Furthermore,
health professionals think it is duty of government agencies to promote
public interventions.
Recently many health trusts are flourished all over India for to improve
public health, maternal and child health. Many of trustee of health
trusts and non-government health organizations are fully aware of the fact
that registration of their organization can help to avail of the enormous
funds and conveniently arranged their tours abroad to secure monitory help
from non-residential Indian and charitable institutes, only almighty knows
where it reaches.
There is no point in throwing masses of funds at diseases such as
HIV/AIDS, tuberculosis and malaria without paying close attention to
health system that will deliver the interventions that will impact these
diseases (5). Improving nutrition, immunization, sanitation and
eradication of illiteracy remains a deserved priority.
Yours sincerely
H.S.Bawaskar
Bawaskar hospital and research center Mahad Dist- Raigad Maharashtra India
402301
E-mail-himmatbawaskar@rediffmail.com
References
1-Bhutta Z , Nundy K, and Abbasi K . Is there hope for south Asia?
(Editorial) BMJ;328:777-78.
2- Bawaskar HS. The world’s forgotten children. ( Letter) Lancet
2003;361;1224.
3- Bawaskar HS. Whos interests does the world trade organization serve? (
Letter). Lancet 2003;361:1298-99.
4-Bawaskar HS and Bawaskar PH. Securing reproductive rights. (Letter)
Lancet 2004;362:991
5-Walt G. WHO,s World Health report 2003. BMJ 2004;328:6
Competing interests:
None declared
Competing interests: No competing interests
The analysis of the editorial team cites two countries that have been
repeatedly mentioned for years by UN agencies (e.g. UNICEF), the World
Bank and sundry other international intergovernmental expert "knowledge
based" bodies. This is a typical example of how impressions and
stereotypical landscapes are created and perpetuated among experts. The
situation in Sri Lanka warrants a closer and more honest, also informed,
examination. While the fact of the civil war is mentioned, nothing more is
said. Since the armed conflict between the government and the Tamil Tigers
began, a large geographical portion of the country has undergone a sea
change in terms of many indicators. The impact of the conflict on health
and health services canot be ignored in a superficial sweep.
The health of the youth and children in the island's populous north-
east are dramatically and adversely affected for the two decades. In this
scenario, how can we continue to spin a picture that somehow manages to
gloat over burgeoning health statistics for this country. To quote from a
recent study, "Children from the Northeast have been particularly at risk
from malnutrition, poor health care and education, displacement, shelling
and aerial bombing, disappearance, torture, rape, mass arrest and
prolonged detention. Efforts by the security forces to eliminate the
rebels in the areas the military controls, attempts to weaken the
indigenous population in areas the LTTE controls, and general indifference
by the government to a politically and economically marginalized community
have all contributed to the miserable condition of these, primarily Tamil,
children." (Avis Sri-Jayantha: Impact of War on Childrennin Sri Lanka,
2002, revised 2003) The study estimated, based on a figures derived from a
controversial UNICEF intervention project, that roughly about 1 million
children (Tamil and Sinhalese) are severely affected.
Indicators of general well-being of children in the war zones has
declined dramatically during the 19 years of war. Infant mortality has at
least quadrupled in the Jaffna peninsula since the start of the war and is
at least twice the rest of Sri Lanka.(Medical Institute of Tamils, London,
Oct. 1997) In a 1993 survey in Jaffna, the infant mortality rate was
41/1000 live births, compared to 23 for the island as a whole.(N.
Sivarajah, MD, Proceedings of the International Conference on Health,
London, Sept., 1994). This is but only the tip of the "ice-bomb" in Sri
Lanka. Mental health, maternal health, nutritional health are other
aspects of Sri Lanka's decline.
The editorial analysis of the BMJ is expected to be more balanced and
sensitive to the real scenario in South Asia.
Competing interests:
None declared
Competing interests: No competing interests
"Srilanka does not have MRI facilities inthe public sector" is
entirely wrong. We do have MRI facilities in the largest tertiory care
hospital- National Hospital in Colombo since 2001. Its free and available
to everybody who needs it most.
Also i should add that we have a good community midwifery system well
intergrated into our society as well as availability of consultant led
care to all district hospitals with theatre and blood bank facilities for
pregnant women.
Competing interests:
None declared
Competing interests: No competing interests
The editorial was interesting and thought-provoking. Authors have
intentionally focussed on the better aspects of Kerala and forgotten the
negative aspects. Kerala has the highest literacy rate in India as pointed
out, but it also has the dubious distinction of having the highest SUICIDE
rates in the country. One main reason is that people are not getting
satisfactory jobs according to their educational attainment. Also, there
is a lack of jobs in Kerala, so, people have to migrate to various parts
of the country and abroad (Gulf, etc) in search of a job. This leads to
disintegration of the family in certain cases.
If smoking is low in Kerala, the consumption of alcohol is among the
highest. If non-communicable diseases are low, the incidence of non-
communicable diseases are not. Therefore, a lot still remains to be done.
However, the rest of India must imbibe all the good things from Kerala as
pointed out in the editorial, leaving behind the negatives.
Competing interests:
None declared
Competing interests: No competing interests
Editor, It is heart warming to learn Sri Lanka as a role model for
rest of South Asia in healthcare.However things could have been even
better if not for twenty year long ethnic conflict which cost a collosal
sum annualy. This vast sum of money could have been spent on poverty
alleviation, education and healthcare.
As a by product of ethnic conflict came provinicial conucils which is
unnecessary for a small country such as Sri Lanka. Effect of provincial
administration on Healthcare system only produced disastrous results. As
central government released large number of district and provincial
hospitals from its control provincial administrations had to fund their
healthcare which resulted in chroinc shortage essential drugs and other
facilities due to lack of funds. In addition political interference at all
levels made matters worse.Frequent strikes were the order of the day. All
these lead to one certain thing which is non delivery of healthcare.
We live in a highly commercialised society and medical community in
Sri Lanka is not immune it. Majority of Consultants and Specialists do
work in private sector because of the poor salaries. However there is no
regulation of fees and certain percentage of (albeit minority) Consultants
/Specialists do neglect their primary duty and taken more interest in
private work. In a counrty where a large percentage of population living
below the poverty line this can result in inequality in provision of
healthcare.
Authors Abbasi et al sees lack corruption as a contributory factor
for gains in healthcare. However I strongly disagree. Corruption in Sri
Lankan society is as bad as any South Asian country.Rampant corruption and
political patronage resulted in polarisation society.Gap between rich and
poor is ever widening. This will only result in two tier health system
which already is the case.
Still due to dedication of medical community and farsighted planners
Sri Lanka managed to achieve the role model status in South Asia. I
sincerely hope it will be maintained.
Competing interests:
None declared
Competing interests: No competing interests
In a recent book by Charles Lindholm, The Middle East---An Historical
Anthropology, Afghanistan has been mentioned as part of The Middle East.
However a German trained philosopher and poet, but living in the Sub
Continent of India mentioned in the '20s that Afghanistan is the 'heart'
of Asia and if the heart is not well then the rest of the body suffers. Sir
Igbal's saying is ample proof of the impact of events in Afghanistan in
the recent past on the region and probably also on the World. Afghanistan
has to be kept 'healthy' and part of South Asia as South Asia stretches
from Oxus and not Indus.
Competing interests:
None declared
Competing interests: No competing interests
I completely agree with the views expressed in this editorial.
Healthcare system in India leaves much desired in spite of a comparatively
high GDP spending on health as compared to the other developing countries.
If we look back we can find the answers partly in the policymaking
decisions of past. Major Indian health policy recommendations since
independence included the following committees viz. Bhore committee 1946,
Mudliar committee 1961, Jain committee 1966, Kartar Singh committee 1974,
Shrivastava committee 1975, ICMR-ICSSR joint committee 1980, National
Health policy 1983, National Population policy 2000. All these panels have
focused on following variables:
1. Doctors, Nurses and health units per unit of population
2. Number of beds and hospitals per unit of population
3. Medical education
4. Expenditure as a percentage of GNP on health care.
This approach to health care is flawed and does not take into
consideration following peculiarities and inadequacies:
1. Economic inequality of population
2. Access problems to health providers
3. Under-utilization of public health services
4. Economic and political process
5. Rise of private healthcare and their participation
6. Community participation in health sector
7. Framework for assessment of failures
This has led to many gaps in the healthcare infrastructure. The
policy-makers have also ignored the developing private sector and possible
contribution that can be made by it. Inspite of all the subsidies the
private sector is getting it has played a very small role in embellishing
the public health.
Considering the present scenario of health care in India, certain
approaches to the healthcare reforms may help.
1. Decentralization of health services and Regional Health care
development
2. Community health financing and co-operative medical system within
Regional Health Care System.
3. Development of social health insurance and Regional health insurance
funds
4. Increased and organized Private healthcare and public health care co-
operation
5. Development of Regional paramedic network and referral system
Competing interests:
None declared
Competing interests: No competing interests
The special issue of the BMJ and several publications in the past
have highlighted Sri Lanka as a model in achieving exceptional health
status with relatively low investments (1, 2).
However, recent data suggests a stagnation of gains, for example,
infant mortality has slightly increased from 15.9 per thousand live births
in 1998 to 17 in 2001 (3). There also several emerging challenges
described in the special issue (1). This requires the model to be suitably
modified to lower the preventable morbidity and mortality further, and
respond to the emerging challenges.
The following data suggests that we are deviating from our own
successful model of a relatively equitable, grass root level preventive
programme targetting maternal and child health.
a) The once strong preventive sector shows progressive underfunding,
despite the need to strengthen it in order to meet the epidemic of non-
comunicable diseases: The percentage expenditures on preventive and public
health (from total health expenditues) have declined from 10% in 1993 to
6% in 1999 while expenditures dedicated to the curative sector have
maintained around 44% to 47% (4).
b) Human resource development is increasingly skewed towards training
of medical officers in curative sector rather than preventive sector and
other grass root level personnel and support staff. For example, from 1996
to 2001 the number of medical officers in curative sector increased by
71% , in contrast to an increase of 33% of medical officers working in the
community, and an increase of only 6.5 % in the number of family health
workers (5).
Sri Lanka therefore required urgent corrective action to build on its
strengths and gains. If not, we may end up as an example of a country
which dismantled its own pioneering model in an ad-hoc manner.
References
1. Bhutta Z, Nundy S, Abbasi K. Is there hope for South Asia? yes, if we
replicate the models of Kerala and Sri Lanka.BMJ 2004; 328: 777-9
2. The World Bank. World Devlopment Report 1993: Investing in health.
Washington, DC: World Bank 1993
3. The Sri Lanka data profile
http://devdata.worldbank.org/external/CPProfile.asp?SelectedCountry=LKA&...
(accessed 3 April 2004)
4. Ministry of Health, Nutrition and Welfare and Institute of Policy
Studies. Sri Lanka National Health Accounts: Sri Lanka National
Expenditured 1990-1999. Colombo: Ministry of Health, Nutrition and Welfare
2002
5, Ministry of Health. Annual Health Bulletins 1996, 2001. Colombo:
Ministry of Health 2002
Competing interests:
None declared
Competing interests: No competing interests
The well argued out editorial in the BMJ projects Kerala and Sri
Lanka as models of healthcare for other South Asian countries 1.
Unfortunately, the much hailed ‘Kerala model’ is facing serious threats.
There are disturbing trends that hold back the efforts to consolidate and
sustain the state’s hitherto health achievements. For example the medial
education sector had been in the public sector till recently and was
successful in keeping the standards of medical school admissions and
education reasonably high. Opening up of this sector to the private
entrepreneurs and the subsequent clamors of the government with them have
raised serious doubts about its future. Even after heavily subsidizing the
medical education, the state was finding it difficult to get sufficient
doctors for its rural areas. The high-cost medical education based on
capitation fee in the private sector is likely to worsen this situation.
Private practice of government doctors, right from the primary health care
levels up to the tertiary levels had been an enigma and the government is
yet to come out with clear-cut guidelines on this.
In a landmark event in the previous decade, the healthcare delivery
institutions up to the level of district hospitals were handed over to the
local self governments. Experiences show that the expected improvements
from such a revolutionary step are yet to manifest, given the current sad
plight of majority of public hospitals in the state.
Stupendous growth of private sector in the past few decades has
resulted in skyrocketing of healthcare costs and the public sector
hospitals cut poor and shabby figures amidst the posh and hi-tech private
hospitals. Lured by the hi-tech sophistication of private sector, people
are abandoning the basic principles of primary health care and public
health and spending more for curative services. Even the poor prefer
private hospitals and it had been shown that one of the major reasons for
sustaining poverty among the poor is the cost of health care2.
Fiscal crises over the past few decades and the dependency on
international funding and lending agencies are compelling the government
to cut short its investment in the health and education sectors. The local
self governments, who primarily hold the responsibility of healthcare in
the changed scenario, are fumbling on the face of increasing demands and
dwindling resources. Added to this is the burden of diseases resulting
from life styles and motor vehicle accidents. The state is actually facing
a triple burden of communicable, non-communicable and traumatic diseases;
the last being the result of ever increasing vehicular population,
especially two and three wheelers which are the only alternatives to a
poor public transport system. Paucity of time-bound health projects and
problems with long term planning are posing serious threats to health
achievements.
The state has ventured out to chart out a long term plan “Health
Vision Kerala- 2025” and a “State Health Policy”, both of which, to the
best of my knowledge, remain to be finalized. Realizing the necessity of
equipping the primary healthcare workforce to face the emerging
challenges3 the state has recently redefined the job responsibilities of
its primary health care workforce. It is a welcome step and several other
Indian states are likely to follow the cue, as evidenced by the interest
shown by some of them. The state is going ahead with health sector reform
initiatives, partially prompted by the European Commission supported
Sector Investment Programme (ECSIP).
All said and done, the ultimate success of any of these endeavors
heavily depends on the willingness of the state to learn lessons from its
glorious past. It is rightly observed that the “health developments in
Kerala were built on well-entrenched land reform, public provisioning, and
social mobilization” 4. Other factors that have played such crucial roles
are the historically prevalent social justice, strong political will and
commitment of governments in power irrespective of their political
leniencies to the health and education sectors, well streamlined primary
health care delivery system, and an organized labour sector. The state is
a good example of the strong determinants of health outside the formal
healthcare delivery system. Any deterioration in these contributing
sectors is likely to have a strong negative impact on the health status of
its populace. Unfortunately, the state is gradually drifting towards such
perils. Kerala should revisit its past and learn lessons to avoid the sad
plight of some of its north Indian counterparts and other non-
industrialized countries. Only then Kerala can continue to provide a
replicable model in health care.
Reference:
1. Bhutta Z, Nundy N, Abbasi K. Is there hope for South Asia? Yes, if we
can replicate the models of Kerala and Sri Lanka. BMJ 2004;328:777-778 (3
April)
2. Rajeev Sadanandan. Government Health services in Kerala- who benefits?
Economic and Political Weekly 2001; August 11, 2001, 3071-77.
3. Nair VM, Thankappan KR, Sarma PS, Vasan RS. Changing roles of grass-
root level health workers in Kerala, India. Health Policy and Planning
2001; 16 (2): 171-179, Oxford University Press 2001.
4. Chen L.C. In pursuit of health equity: the Kerala-Global connections.
TN Krishnan Memorial lecture at the Achutha Menon Centre for Health
Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and
Technology, Trivandrum, Kerala, India; 28 January 2001.
http://www.fas.harvard.edu/~acgei/Publications/Chen/LCC_TN_Krishnan_Memo...
Competing interests:
None declared
Competing interests: No competing interests
Sri Lanka's Health System : It it the most cost-effective in the world ?
Dear Sir,
Sri Lanka’s Health System : Is it the most cost-effective in the
world ?
I thank you very much for publishing the editorial titled “Is there
hope for South Asia ?” on the 3rd of April 2003 As a Paediatrician,
involved in primary health care in Sri Lanka for the last 9 years I would
like to share some of my experience and thoughts with the readers of the
BMJ.
I believe, my article merits publishing in the BMJ for the benefit of
the readers and policy makers, particularly those from developing nations
as there are lessons to be learnt.
I would like to draw my particular attention to authours’ sentence
“Sri Lanka has the best health indicators in the region (also beating
those of most other countries with comparable incomes)”. He has done very
well to spotlight Sri Lanka’s highly successful health indicators. I even
go further a step ahead and say Sri Lanka has the unique distinction of
having GNI per capita of less than thousand US dollars ( 850 US$, 2002
World Bank report ) and yet achieved this magnitude of success in health.
There is no other country (not most of other countries… as described by
the authours) in the world, with Infant Mortality (per 1000 live births)
being less than 20 and GNI per capita less than 1000 US$. This is even
further very significant when one considers the following:
Total expenditure on health as % of GDP, 3.6 and per capita
government expenditure on health at average exchange rate (US$) 15. (Ref.
2002 WHO report). These are in the developed countries around 10% (with
the exception of the USA – nearly 14% ) and in thousands respectively.
Another health indicator where Sri Lanka has done well, is the life
expectancy at birth. Being female life expectancy 74.3 years ( USA -79.5
years, WHO report 2002 ) it is just touching the figures of the developed
nations. This is truly amazing as a developing country, how such
relatively low investments in the health sector giving such wonderful rich
dividends, worth exploring.
• High literacy that prevails in the country. As stated, particularly
among females it has been 90%. This was a direct result of state free
education and health policy adopted in 1940’s fully implemented in 1950’s.
• Therefore, health education is made easy, any health message reached
even very rural parts of Sri Lanka and accepted by the rural community.
• Sri Lanka enjoyed, since independence 1948, democracy where successive
governments by and large recognised the importance of education and
health. As a result health and education budgets, in general, were
uncompromised.
• As a developing country it has a good health infrastructure, generally,
centrally controlled. (although at provincial level some autonomy is in
operation) All important health administrators were and are doctors. At
the Ministry of Health, the appointments of senior administrative
positions including the post of Director-General of Health Services are by
and large non political.
• Therefore, quite rightly, the health policies adopted were always
essentially in favour of Primary Health Care (PHC). Tertiary health care
has been never extensive in the public sector. For example there is not a
single Neonatal Intensive Care unit in Sri Lanka, which is equivalent that
of to a District General Hospital in the United Kingdom, yet, the IMR is
around 15 per 1000 live births(World Bank Report 2002) This highlights the
fact that at country level what is important is strong basic primary
health care, certainly, not the high tech intensive care units, in the
developing countries.
• This has resulted in reasonable distribution of health care throughout
the country. Even very rural villages for every few kilometres there is a
health centre.
• Sri Lanka has a reasonably good road network even in rural areas thus
time taken for transportation of patients in emergencies etc., acceptable
as a developing country.
• The country has progressed in terms of health despite over two decades
of one of the bloodiest civil wars in the world. The LTTE guerrillas,
otherwise very destructive, quite wisely, have relatively spared both
education and health in the war-torn areas. In fact, at times, they co-
operated with the government to carry out health programmes of national
importance. e.g. National Immunisation Day.
• Sri Lanka enjoys excellent Immunisation cover and family panning
(evident by relatively low (0.9%) growth rate when compared in the
region.)
• Unlike the sub-Saharan African countries where there have been major
shifts in both child and particularly adult mortalities due to HIV / AIDS
epidemic over the past 10 years, Sri Lanka has fortunately been spared.
This is perhaps another reason why the progress of the health of the
people is highly successful.
• Sri Lanka’s strength is primary health care and it should remain so
until it achieves GNI per capita income of at least 3000 to 4000 US $.
The other country in the world which also has similar a cost-
effective health system, is Cost Rica in the South America, between
Nicaragua and Panama. But it has a GNI per capita nearly five times that
of Sri Lanka.(US$ 4100 World Bank Report 2002) And it is in a region where
GNI per capita is much higher (Latin American average per capita is US$
3,280, whereas in the South East Asia it is US$ 460. (World Bank Report
2002). Therefore, Costa Rica is not comparable to Sri Lanka.
Hence, considering the levels of funds available to health sector, I
would quite justifiably say Sri Lanka has the most cost-effective health
system in the world.
Sri Lanka could have done better as it entered, open liberal economy
by the end of 1977. Now, 26 years on, it could have achieved high income
economy status in the world by now.
The ageing population in Sri Lanka is on the rise steadily due to
better health care. At present, the percentage of population aged 60+
years is 10.2 (USA- 16.2%, WHO Report 2002) This is even better than that
of Costa Rica.(7.9%)
The figure in Sri Lanka is expected to rise over the next decade. For Sri
Lankan health policy makers it is an issue to be addressed, without
further delay as the country is not geared to handle its increasing ageing
population. Perhaps, my letter could be considered a warning to the
Ministry of Health of Sri Lanka.
Many Thanks,
Yours faithfully,
Dr Ananda Jayasinghe
FRCP(Edin), FRCP(Lond), DCH(Lond)
Senior Lecturer in Community medicine
Faculty of Medicine,
University of Peradeniy,
Peradeniya, Sri Lanka
e-mail : ajaya@pdn.ac.lk
Competing interests:
None declared
Competing interests: No competing interests