Friday, July 16, 2004

Creaky public health in India 

The current UPA govt in Delhi has announced several steps to boost the public health system in India, especially to tackle the crisis of HIV/AIDS which is threatening to reach African proportions (5 million plus HIV infections at last count). The steps include increasing spending on health from the current 0.9% of GDP to 2-3% of GDP (compare with 11% in Germany and almost 15% in the U.S.), focussing on primary health care and making ARV drugs available at reasonable costs (compare with Brazil that offers universal free access to ARV drugs). Though one cannot say for sure whether the govt can pull off what it promises, the need for these steps are pressing as India's health system gets biased even further towards private provision. This Panos Features piece provides some numbers.

While health care facilities have grown substantially since the 1990s, they are mostly in the private sector – often beyond the reach of the poor. According to the Central Bureau of Health Intelligence at the Ministry of Health and Family Welfare, the private sector accounted for 57 percent of the 11,174 hospitals that existed in 1991. In 2000, however, the proportion of privately-run hospitals grew to 75 percent of a total of 18,218 hospitals.

Only 17 percent of all health expenditure is borne by the government, which makes India’s health sector one of the most privatised in the world. The World Health Organization standard for expenditure on public health is five percent of GDP. India’s 0.9 percent expenditure of GDP is less than the average for poor countries – 2.8 percent. Some critics say India’s health took a knock in the 1990s – the era of economic liberalisation, when stagnant public health budgets and decreasing government expenditure in public health facilities were worsened by the introduction of user fees at various levels of public health facilities.

The piece also has details on the three-by-initiative announced by the previous NDA govt specifically to provide access to ARV drugs.

After the Three by Five initiative the then health minister Sushma Swaraj declared a strong policy-cum-programme commitment to provide free ARV treatment to 100,000 AIDS patients. This began in April 2004. Government hospitals were to provide treatment in six high-prevalence states, and within them to three vulnerable groups: HIV-positive mothers; HIV-positive children below the age of 15 years; and AIDS patients who seek treatment in government hospitals. The number of patients who had received ARV treatment till June 10 was 874.

Not a very successful program, is it?

Current official estimates are that there are 5.09 million HIV-infected people in India – up from 3.58 million in 1998, 3.72m (1999), 3.86m (2000), 3.97m (2001) and 4.58m (2002). “These figures are a cause of increasing concern to the government because people infected with HIV during the 1980s and 1990s will progress to AIDS, resulting in a steep increase in the number of AIDS patients,” admits Datta Ghosh. Today access to treatment has become the subject of a major debate in India, fuelled by a public interest litigation filed in India’s highest court last August demanding treatment for HIV/AIDS patients and provision of infrastructure.

Shruti Pandey, a lawyer working for the human rights group that filed the petition, says: “Our principle prayer was that the government should provide ARVs within the public health system and create an infrastructure, as sticking to the regimen is important.” But the government’s position, Pandey says, is ambiguous: “It has not spelt out measures on how it plans to maintain confidentiality and manage toxicity (of drugs) and neither is it clear on how they plan to raise the resources.” “Where are the attempts to build a conducive atmosphere for AIDS patients?” asks Pandey. “Everyday, we hear of some instance of discrimination against HIV-positive people. They are being treated like untouchables. Their right to employment is being denied and the orphaned children are not given any support.”

These are urgent questions in India, which, along with China, is expected to emerge as the biggest Asian AIDS hot-spot in the coming years.“Ninetyfive per cent of people with AIDS are poor, and most of them do not even know about the first line regimen,” says Ricki Tombing from the state of Manipur – one of the six focus states in the government’s AIDS strategy.

In this seemingly bleak situation, any attention that the UPA govt manages to focus on public health is better than none at all. Here's hoping.