Rescuing Maternal and Child Health-only systems, which have become
under-resourced and have built a very high-cost but low-performance
culture, will be a challenging task.
Given the rising burden of non-communicable diseases,
there is an increasing demand to build health systems that can address
these concerns. However, given how large the unfinished agenda of the
Millennium Development Goals is, the Indian government has chosen to
stay focussed on Maternal and Child Health (MCH). But is the most
effective way to deliver on the MCH goals to build an MCH-only health
system, or does it need a completely different approach?
Medical and staffing issues
Medically,
since the most important drivers of infant, child, and maternal
mortality are haemorrhage, sepsis, abortion-related complications and
hypertensive disorders, it is clear that it is no longer adequate for a
health system to focus on preventive-promotive messages and limited
facility-based treatment options. Instead, at the community level, there
needs to be clinic-based obstetric and emergency care on offer, and,
within a reasonable travel distance, hospital-based emergency care. If
recent data relating to infant mortality rate (IMR) and maternal
mortality rate (MMR) are examined, it appears that higher availability
of more advanced medical care at proximate hospitals in, for example,
Kerala and Tamil Nadu, is indeed associated with much better MMR and IMR
outcomes. Equally wealthy States such as Himachal Pradesh, which do not
have these advanced facilities at proximate locations, are not able to
show similar rates of improvement despite spending more money per capita
on healthcare.
Recognising this issue, the Indian
government has recently mooted the concept of a health and wellness
centre (HWC) that is intended to be more comprehensive rather than
merely connoting “first contact care or symptomatic treatment for simple
illness with some elements of care for pregnancy and immunisation
included”. And, if indeed the HWCs (the erstwhile sub-centres) are able
to address all of the necessary MCH conditions, then it becomes possible
for the next level centre to provide a much broader range of care upon
referral by the HWC. Clearly, building such a system to serve only MCH
needs will not be cost-effective nor will it keep all of the necessary
personnel gainfully employed. Having a much wider range of conditions
would be the only sustainable way to address this concern.
Building
such a broad-based system will need a substantial amount of investment
for which political commitment has not been very forthcoming. Because of
this, in addition to resource shortage, front line personnel such as
nurses and doctors often offer low-quality services and display a high
degree of absenteeism without fear of political reprimand. While there
are a number of reasons for this, one of them is the fact that the
Indian (MCH-focussed) health system is currently able to cope only with
conditions that account for fewer than 25 per cent of the Years of Life
Lost (YLL). Even in high-fertility States such as Bihar, in a typical
year, fewer than 20 per cent of the households are likely to have
maternity-related needs. Broader health systems which are able to
address a much larger proportion of conditions have the potential to
engage a much larger number of voters. Arguably, the politician under
such a system is much more likely to both allocate more resources as
well as monitor performance. The health system thus develops the
capability of handling a wider range of issues, while simultaneously
positively impacting the MCH agenda.
The difficulty
that health systems in India unfortunately face is that since they were
designed as MCH-only systems, they have become chronically
under-resourced and have now built a very high- cost but low-performance
culture and a concomitant reputation. Rescuing these systems may now
become very challenging. Politicians have shown a strong reluctance to
provide additional funds to the government-run health system “driven by
the idea that it does not make sense to throw money at a system that
hardly works, performs or is a big black hole.” They instead prefer to
put additional investments into fragmented and “cheap” in-patient
insurance and ambulance schemes that are operated by the private sector
but are funded by the government. Such an approach is resulting in
significant fragmentation of the health system, with a low-quality,
skeletal MCH-focussed government-run primary care and secondary care
system. There is also a separate, private sector-owned secondary and
tertiary care system with very high variations in the levels of quality,
which is accessed by low-income families through government-sponsored
insurance programmes and by everybody else using out-of-pocket payments.
This prevents the evolution of both an integrated government health
system or a privately run managed care system. This is an example of a
situation where building an MCH-only health system has actually hurt our
ability to grow it into a well-functioning health system of any kind,
including one that fully serves MCH needs.
For
various good reasons, 68 countries, including low income and middle
income countries, have chosen to use health-specific taxation such as
mandatory payroll deduction. For countries such as India and China,
which also have a large informal sector, since mandatory payroll
deduction is not an available option for a large segment of the
population, the direct sale of healthcare packages or insurance becomes
additionally necessary. This is much more difficult to do, but not
impossible. This is because while it is clear that health shocks have a
very large impact on those below the poverty line, it is also clear that
even those at the 90th percentile are not very far above the poverty
line, and a health shock can indeed quickly send such a family down to
the lowest one per cent in terms of income and wealth. However, unlike
families below the poverty line, those above it do have the financial
ability to pre-pay for healthcare services because it is not their
average out-of-pocket expenditure that is their problem, but their
inability to obtain proper care when needed and the high variability of
actual expenditures. However, getting the non-poor populations to
participate in financing through pre-payment (by, for example, requiring
the purchase of a comprehensive family health cover along with
auto-insurance for all vehicles, including two wheelers), an integrated
delivery system is going to need a much broader health system and one
that performs at a much higher level than it currently does. But,
unfortunately, once again the decision to build a MCH-only health
system, which performs at a poor level of delivered quality, has left
consumers with low confidence in government-run health systems. To now
persuade the non-poor to pay-in to a health system that is operated by
the government is likely to be an uphill task.
Historic opportunity
For
the States, the larger availability of untied funds from the Centre
presents a historic opportunity to design health systems that far more
closely reflect their own objective ground realities. While centrally
sponsored health schemes have offered a number of benefits, they also
came with the associated baggage of standardised design. Bihar, for
example, continues to battle with high levels of IMR and MMR and a high
level of poverty. Tamil Nadu and Kerala have brought those rates under
control but, unlike Bihar, are seeing a climbing suicide mortality rate,
particularly amongst their 15-25 year olds. Himachal Pradesh, which has
a much smaller and significantly wealthier population and over five
times higher per capita income, has very similar IMR and MMR numbers to
Bihar, combined with a high accident mortality rate. Building
comprehensive healthcare systems which reflect the realities of each
State will not only yield strong benefits on problems such as IMR and
MMR but will also, over time, help build health systems that respond to a
much a wider set of concerns. Narrowly focussed health systems on the
other hand risk falling short not only on their goals but also make it
difficult, if not impossible, to build broader health systems for the
future.
(Nachiket Mor is a Chennai-based economist. Email: nachiket@nachiketmor.net)
