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Why pricing is a Red Herring in Herrin health care health-care access?



Indian Dream

How despite of law reforms female fem Ind foeticide is still prevalent in India?


Lack of central planning is depriving Indians of equitable access to health-care










I I P M T H I N K T A N K & G R E A T I N D I A N D R E A M F O U N D A T I O N J O U R N A L



S Chinnam Reddy Dean, Faculty of Management



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2249-5215 NOV-2011; ISSN SUPPLEMENT,


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Indian Dream


R Vishal Oberoi CEO, Market Xcel Joelle Burbank Associate, The Fund for Peace Marcin Menkes Analyst, PISM, Poland

The Great Indian Dream is one of the most intelligently written executive grade academic Journal. It offers latest and seminal updates in matters related to economic policies and their effects in India as well as the rest of the world. The Journal features the most concise, globe-encompassing wrap-ups of business and economies. The November issue of the GID provides an insight on the geopolitical shifts happening through out the globe. In my opinion, the GID is a very well written publication with valuable insights for readers. I would like to congratulate the IIPM Think Tank team for bringing out such a brilliant issue. All the best for the future issues.

The Great Indian Dream journal as a whole looks excellent and intellectual. As far as the content and coverage of topics go, I nd the journal quite fascinating to read. Wide range of topics coupled with sleek design is truly unmatchable especially if we compare it with other academic journals in the same league. In a way, it is an articulate journal addressing the germane issues in India. The journal comprises of analytical and cohesive articles which provide uninhibited global perspectives. I wish the entire IIPM Think Tank team all the success for their journal and hope that they continue to provide readers with candid informative platforms.

The November issue of the Great Indian Dream has exposed the failed states and how they could potentially disrupt world peace at large.

As an aspiring academic from the West, it is always refreshing to read content concerning Asia. The GID does a great job blending a diverse mix of topics.

Rok Spruk Economist, Slovenia

Amartya Mukhopadhyay Professor, University of Calcutta

Congratulation for truly high-quality editions of the GID that are of the prime importance to the future of Indias thriving economy.

With its gloss and colour the GID is a welcome change in the tradition of academic publishing. The list of contributors covers a wide area.

Please send your feedback to:

FOUNDER : Dr. M. K. Chaudhuri EDITOR-IN-CHIEF: Arindam Chaudhuri EXECUTIVE EDITOR: Prasoon S. Majumdar DEPUTY EDITOR: Sray Agarwal ASSISTANT EDITOR: Mrinmoy Dey CONSULTING EDITORS: Prashanto Banerji, K K Srivastava, Arindam Paul RESEARCH FELLOWS: Akram Hoque, Amir Hossain, Sayan Ghosh, Mahasweta D Saha, Manish Bhati, Nidhi Gupta COPY DESK: Charu GROUP DESIGN DIRECTOR: Satyajit Datta SENIOR DESIGNER: Shantanu Chatterjee DESIGNER: Karan Singh, Vikas Gulyani SENIOR ILLUSTRATOR: Shantanu Mitra IMAGE EDITING: Vinay Kamboj PRODUCTION MANAGER: Gurudas Mallik Thakur PRODUCTION SUPERVISORS: Digember Singh Chauhan, Soumyajeet Gupta, Satbir Chauhan CHIEF MARKETING ADVISOR: Amit Saxena THE GID ONLINE: Neel Verma, Anil Kumar Sheoran, Christopher Mani PRINCIPAL OFFICES Satbari, Chandan Haula, Chattarpur, Bhatimines Road, New Delhi - 110074 IIPM Tower, Junction of , 32nd Road & S.V. Road, Bandra (W), Mumbai - 400 050 IIPM Tower, 419 100ft. Road, Koramangala, Bangalore - 560 034 IIPM Tower, 893/4, Bhandarkar Road, Deccan Gymkhana, Pune - 411 004 IIPM Tower, 145, Marshalls Road, Egmore, Chennai - 600 008 IIPM Tower , 19, Inqulab Society, gulbai Tekra, Off C.G. Road, Ahmedabad - 380 015 IIPM Tower, 6-3-252/2, Erramanzil, Banjara Hills, Hyderabad - 500 082 ADDITIONAL THINKING PRINTED BY: Rolleract Press Servies, C-163, Ground Floor, Naraina industrial Area, Phase-I, New Delhi - 16 DISCLAIMER : All efforts have been taken to ensure the veracity of the information contained in the research, however the IIPM Think Tank expressly disclaims any and all warranties, express or implied, including without limitation warranties of merchantability and tness for a particular purpose, with respect to any service or material. In no event shall the IIPM Think Tank be liable for any direct, indirect, incidental, punitive, or consequential damages of any kind whatsoever with respect to the and materials, although the reader may freely use the research and material provided, the IIPM Think Tank retains all trademark right and copyright on all the text and graphics. We are keen to hear from anyone, who would like to know more about IIPM Think Tanks Publications. You can e-mail us on or alternatively call us at +91 9818244963

Continuous Learning in Medical Profession should be Made Mandatory! Prasoon S. Majumdar........................................................................................ Entry Prohibited Shivaji Sarkar....................................................................................................... Why Pricing is a Red Herring in Healthcare Access? Ashok Jinghan.................................................................................................... Burning a Hole in the Pocket Brijesh C. Purohit ............................................................................................... Cash Crunch Gautam Chaktraborty & Arun B Nair .......................... ................................. When will Womb be Safe for our Girls? Sukhamay Paul ................................................................................................... Cashing on the Tourist K R Bolton ............................................................................................................. Making Health Insurance a Reality Akash Acharya..................................................................................................... Health and System Challenges Sarit Kumar Rout ................................................................................................ Health Programmes: A Soft Insight to why We Fail S C Mohapatra & Archisman Mohapatra ..................................................... UHC could be the Next Big Social Trump Card Mohsin Wali Khan .............................................................................................. How much does AIDS Add up to? Vinod B. Annigeri ...............................................................................................
Cover Design: Satyajit Datta

05 06 10 12 16 18 22 26 30 34 38 40


The First Words and The Last Word


Prasoon S. Majumdar, Executive Editor

couple of days back, one of my colleagues went to Delhis one of the best nursing homes to consult a physician for his ulcer problem. The doctor during consultancy told him that ulcers are not curable and there is no permanent solution. However he was not very convinced and did a Google search and found that in 2004 two scientists were awarded Nobel Prize for their breakthrough solution for this so-called incurable disease. The moot point here is not that how the doctors are ill-informed but about the very mechanism that keeps or rather shall I say, forces the docs to keep themselves updated. Today, after completing their MBBS (or MD), most of the doctors rarely go back to books for updating their knowledge base. Most of the doctors in India are still relying on medicines and treatment they came across during their initial days of practice! Thus, the new discoveries and health research that are changing the very DNA of medicine and medical treatment are kept alien to the Indian masses. Conventionally, Indian doctors bank upon the medical representative and the brochures that they carry (again self-advertised) as source of information. Ive come across several occasions wherein doctors directly pick up these brochures and pen down medicines without referring back to medicinal developments that are taking place around the world. Medicine is one of those professions where the society believes that the person at the giving end would always uphold his professional competency and would serve his customers with best of treatment available. Given the pace of scientic research and breakthrough happening, it is impossible for a doctor to remain procient without undergoing a comprehensive and regular training module. Keeping this concept in mind, the Medical Council of India has proposed a bill to make continuous medical learning compulsory in India, but the law makers are yet to give it a nod. In the same light, Society for

Academic Continuing Medical Education ensures that such facility is extended to medical practitioners in the West and UK and some parts of Europe. Many states in the US have made it mandatory for medical practitioners to attend continuous medical education programs in order to keep practicing and maintain their licenses. The duration of the program varies from 40 hours to 60 hours and needs to be attended every 2-4 years. The old breed of doctors, who understand diseases and symptoms within seconds, all thanks to their years of experience, end up suggesting decade-old treatments rather than exposing Indian masses to the latest state-of-art health care updates! Given the fact that agencies across the world are investing millions in such researches, keeping masses bereft of these developments is nothing less than a crime. Medical fraternity and the health ministry should make continuous medical examination compulsory (every three years or so) and organise medical seminars across India every six months. Doctors who skip these exams should be legally and professionally prosecuted as well! This is more important in case of India, where majority of patients are suffering from diseases that are highly contagious and few of them have even been eradicated from the other parts of the world. Thus, continuous learning becomes more important for these strata of docs who serve this pocket of population, so that these patients can receive best available treatment and not remain a carrier of inections for long! Happy reading. Best,

Prasoon S. Majumdar



15 per cent of the Indian population does not have access to health care due to unavailability of resources



Senior Journalist; Ex-Sr. Editor, The Financial Express

he sudden deaths of scores of new-born and infants in one case 45 deaths in a week - at government hospitals in West Bengal exposed the chinks in the health care. Have we achieved nothing in 64 years since the country became independent? Thats possibly not true. Life expectancy has increased from an average of 38 years in 1950 to 63.2 years now. The government can claim that it has been able to take care of many universalised immunisation programmes, countered many infectious diseases and better health care in broader terms. Some of the diseases like small pox have been eradicated, polio incidence reduced to the minimum and many other killer diseases virtually eliminated. Despite this, infant mortality still remains high and according to Unicef, every fourth infant to die in the world is from India. The health sector is a contrast. Poor and average Indians nd access to medicare difcult, consultations expensive and medicines beyond their reach. On the other hand India is developing into a hub of medical tourism as it has the advantage of highly qualied professionals, varied health care programmes, and an affordable cost-effective treatment for foreigners. Indian medical tourism income is expected to reach upto Rs 8,000 Crore by 2012 on back of its low-cost medical treatment and a vast pool of well-qualied medical professionals, according to Associated Chambers of Commerce of Commerce and Industry of India (ASSOCHAM). But in terms of life expectancy, India

remains far behind Japan, US and Europe. Even China has leaped forward and is now only two years behind Europe. India remains eight years behind China, which has a life expectancy of 72 years. The private expensive health care sector has grown phenomenally. It caters to the afuent and some middle class people who can afford health insurance, an expensive proposition. The silver lining is Rashtriya Swasthya Bima Yojana (RSBM), presently restricted to the poor people and ensures health care upto Rs 30,000 for a premium of Rs 30. It has helped a large rural populace and women in particular, who go for medicare rarely in Indian homes. Statistically, India has one of the best health systems spread all over the country. As per health ministry, there are 137,000 sub-centres, 28,000 dispensaries, 23,000 primary health care (PHC), 3,000 centralised health care (CHC), and about 12,000 secondary & tertiary hospitals. The whole administrative set up may appear large but most of the health care facilities are under-staffed, and under-stafng is most prominent in the rural health care sector. It is also the worst administered and stated to be least honest. About 15 per cent of Indian population does not have access to health care due to reasons of unavailability or due to economic reasons. Expansion of health care in India has been mostly urban oriented while major part of population lives in rural or semi-urban locations. Mushrooming of private hospitals in India has been in the urban areas, and is highly prot oriented.


Public health care systems are becoming extinct by the day. Insurance system, often tried to be promoted by government ofcials do not suit Indian conditions since a very large section of rural and urban population would not be able to afford it, and the government may not nd the required budget to subisidise it. The allocation for the health sector in 2011-12 budget is Rs. 26750 crore. In real terms, it is a little over one per cent of the GDP calculated at Rs 89,80,860 crore. A survey by the Organisation for Economic Co-operation and Development says only seven countries in the world spend less money than India on public health. It is an irony that while engineering colleges have proliferated almost everywhere, there are not many medical colleges. It has created a shortage of doctors, hospitals and made health care difcult. The 12th plan paper, despite acknowledging the malaise, does not try to solve it. It has come out with a programme for free universal health coverage despite the experience that the government hospitals have not been able to provide it to most patients during the last many decades. It has also led to a thriving parallel market promoting corrupt practices in the government hospital system. The problem is so deep-rooted that it has led to murder of two chief medical ofcers in Uttar Pradesh during the last two years. As a policy, giving anything free from a government-run system may have populist value to garner votes but in real terms it has always been a disaster. The planning commissions concern is welcome but the prescription has least practicality. The malaise is deeper. It is not restricted to provision of free medicare. Even now states like Delhi is supposed to have the best system with New Delhi Municipal Committee (NDMC) and Municipal Corporation of Delhi (MCD) running many free dispensaries, but doctors often do not visit the dispensaries and the prescribed medicines are rarely available at the dispensaries. Similarly the primary health care centres are dysfunctional in most states. In places like UP and some other states, some8

times these are used as cattle sheds. The state government-run hospitals have lost credibility. Everyone wants to avoid these. The complaint is often not with doctors, but para-medics rarely give the service. Doctors may be conscience but they are far fewer in terms of the number of patients. The government-run systems are also facing exodus of top doctors as per a Delhi government statement. Specialists in gynaecology, anaesthetics, ophthalmology, ENT, paediatrics, neurology and pulmonary medicines are quitting as they do not nd service conditions conducive. The gain is that of private run hospitals. To our despair, Healthcare is ailing. It has become extremely expensive and it is not only making poor poorer, even cash rich Indian companies are grappling with an average of 10 per cent rise in costs over the last three years. While private spending on health in India is 4.2 per cent of GDP, public expenditure is estimated at a mere 0.9 per cent, among the lowest in the world and ahead of only four countries Pakistan, Burundi, Myanmar and Laos. According to a Planning Commission paper, private spending on health is 4.2 per cent of GDP. More than 70 per cent of all health expenditure in the country is paid for by people from their own pocket. This expenditure has been rising, particularly for the poorest. The plan panel estimates that it has pushed 3.9 crore people into poverty due to out-of-pocket medical payments. A corporate survey conducted by Watson Wyatt, a global consulting rm specialising in insurance, nancial services, human consulting and employee benets, has found that most Indian companies providing health care cover to their employees are grappling with an average of 10 per cent rise in premiums over the last three years. The main reasons for this are, the emergence of new medical technologies and overrecommendation of services, the survey said. A related discomfort is the rising cost of medicines. With multi-national corporations taking over Indian pharmaceutical companies, the health ministry is expressing concern of mo-

nopolisation of the sector and further rise in drug prices. The government policies vary from ministry to ministry. Drug farms, though cater to the health ministry causes are controlled by ministry of industry and ministry chemicals, who have different concerns and promoting foreign investment in the sector. The health minister speaks for the ailing populace and other ministers boast of bringing in more investment. The World Congress of the International Health Economics Association held in Beijing in July 2009 stated that India gures at the bottom if one takes the government share in total health expenditure. It is less than 25 per cent in India against 76 per cent in Europe and 34 per cent in South-East Asia. The ILO has called upon Indian government to rectify this as poor health care leads to lost years of income due to short and long-term disability family members, lower productivity, and the impaired education and social development of children. The ILO states that poor health care conditions have given rise to micro-insurers, who purchase products from state-run hospitals and facilities to provide service to deprived poorer sections. The


poor have to bear cost of transportation and loss of earnings as add-ons to illness. In reality, despite many pronouncements, health has been a low priority area for the government. It calls for a complete re-look, including recasting the central ministry of health. It remains a service-oriented ministry. Even its remote arm Medical Council of India, is a toothless wonder. The ministry suggests policies but these are either implemented by other ministries like industry or chemicals or even consumer affairs or if insurance it is the nance ministry. Some other functions are left to the states. The bias is always against the health ministry. As corporate enter the area, it is seen as a protable market and patients are nothing but a commodity for them. Corporate hospitals do not adhere to Hippocratic Oath. They function more like hotels catering also to health care needs and charge as per norms in the luxury hotel industry. The immediate need for the health sector is to take care of how it could be affordable for everybody. Higher cost is detrimental not only for the causes of health but it also mounts cost on entire economy. The government hospitals all over the

country need serious treatment to bring them back to health. But private business interests come in the way. So does the insurance companies. Low cost government hospitals are not good business models for them. It calls for introduction of a low-cost universalised health model. It does not need to exclude the private sector. It should also not be subservient to it. It is also true that the government alone cannot run the show countrywide. The universal health system has to begin with large investment in medical education and create a network of medicos that could spread to all over the country. There is no reason to restrict medical education to help the monopolies of many kinds. It also needs to allow proliferation of hospitals and dispensary systems to create a competition on the price front. Today a caesarean section surgery costs Rs 3500 to Rs 50,000 or more. A competitive medicare system could reduce the same and help the poor. Regulatory mechanism in India and China for drugs, hospital services or insurance has been one of the worst problems. In some cases the regulators are found to act not in favour of the sufferer. While considering health, physical culture, nutrition and various different systems indigenous, oriental and occidental need to be brought under one policy umbrella. Now many of these are away from the ambit of health ministry. Expecting a miraculous solution in a short span should not be the idea. But it must be a targeted approach to create a low-cost universalised overall health care to all Indians in a decade. A good health provider nation could hope to become the super power it has been aiming for the last many years. The solution in a country with such a vast expanse is not easy. Mere cosmetic increase in budgetary allocations would not solve the problem. The government has to initiate steps to resuscitate the system and delivery mechanism that it has built up and act ruthlessly so that the benet could reach the people. It should desist from promoting insurance business and provide direct relief to the people so that the nation could have healthy and productive people who would add to the GDP. (SHIVAJI SARKAR is a is a senior journalist, ex Sr Editor with The Financial Express, Delhi. He writes on socioeconomic and politico-economic issues and is an expert commentator. The views expressed in the article are personal and do not reect the ofcial policy or position of the organisation.)


Chairman, Delhi Diabetes Research Centre

Healthcare authorities should stop ogging the dead horse of pricing and focus on issues such as inadequate infrastructure to make healthcare access an accomplished mission
nlike most nations, in India, theres a general tendency to pass the buck. Over generations, this has become second nature, especially for people in positions of power. One way of passing the buck is by introducing a red herring something that diverts attention away from the real issue. A classic case is the Governments inability to ensure universal healthcare access even 64 years after Independence. Therefore, each time criticism swells about the sorry state of healthcare access, the authorities simply divert attention by introducing red herring high drug prices. Had high drug prices not played spoilsport, the ofcial refrain goes, healthcare access would have been a ground reality. The so-called solution: price control of drugs. The truth is pricing neither drives nor hinders healthcare access. Just as there is actually no sh species called red herring, pricing being liable for the lack of healthcare access is an absolute myth. If pricing could propel access, India would never have had a high percentage of anaemic women particularly since iron supplements are available for free in Primary Health Centres (PHCs)



across India. Clearly, pricing is not the problem. The actual issue is that India suffers from lack of availability of medicines, an insufcient number of doctors or absence of healthcare personnel, and inadequate healthcare infrastructure. In other words, even if the ofcial policy dictates free distribution of iron tablets, they rst need to be in stock. Doctors are then required to prescribe these for patients. Finally, PHCs need to be located within striking distance of rural or urban centres for patients to procure these free iron supplements. Therefore, though the ofcial policy of free supplements exists on paper, the ground reality of the other three conditions is rarely fullled in tandem. Even if one of the three requirements is missing availability of supplements, doctors on duty, PHC in the vicinity the chain is broken and delivery of free iron supplements never occurs. An analysis of prices of 53 drugs based on purchasing power parity revealed that India has cheaper drugs than other countries such as Pakistan, Philippines, Malaysia, China, Thailand and Indonesia. To quote specic rates, consider the prices of Diclofenac Sodium 50 mg (10-pack): in




India it costs Rs 3.50; in Pakistan, Rs 84.71; Indonesia, Rs 59.75; US, Rs 674.77, UK, Rs 60.96. Similarly, prices for Omeprazole, 30 mg capsules (10-pack): India Rs 38.40; Pakistan, Rs 578.00; Indonesia, Rs 290.75; US, Rs 2,047.50, UK, Rs 870.91. Moreover, ination for pharmaceutical products is much lower than that of other essential commodities. While, pharma prices increased barely 0.5% in 2010, food ination during the same year was 14.4%.The price rise index for essential commodities between 2006 and 2010 also bears this out. While oilseeds rose 11.2%, sugar 14.9%, onion 36.0%, potatoes 11.0%, salt 17.0% and food 9.4%, pharmaceuticals only showed a nominal increase of one of percent. It should be clear by now that since prices of medicines in India are amongst the lowest worldwide, pricing is not a barrier for healthcare access. In order to access medicines, Indias poor are largely reliant on the Government Healthcare Systems represented by PHCs. But with the system plagued by inadequate infrastructure, poor availability of drugs in PHCs and shortage of doctors, nurses and pharmacists, it is these issues that need to be addressed. To elaborate, it is estimated that across India, theres a cumulative shortfall of approximately 17,000 PHCs. Due to this, patients do not have an easy access to medical help, since the nearest PHC could be too far away to be reached on foot. Across PHCs in India, theres an estimated shortfall of 8,500 doctors, while 41% PHCs do not have health workers. As long as the authorities aunt the red herring of drug prices and keep bandying drug price control as an ostensible solution, healthcare access will always remain a mirage in India. The sooner they focus on the real issues by improving and augmenting healthcare infrastructure, increasing the number of medical personnel and ensuring year-round availability of drugs, the faster will India be able to fulll its mission of universal healthcare access. (DR. ASHOK JINGHAN is the Chairman, Delhi Diabetes Research Centre and is a member of IHPs Expert Panel. The views expressed in the article are personal and do not reect the ofcial policy or position of the organisation.)






Professor, Madras School of Economics, Chennai


The growing medical expenditure due to surfacing of private players is posing a threat to completely deny access to health care to the poor
t is now universally recognized that health of the people plays a signicant role in the overall development of a nation. Ever since Independence, Indian planners have aimed at achieving an efcient health system. Since the beginning, the Bhore Committee (Government of India, 1946) formed the basis for adopting a model of the health system which mainly relied on the States investment which in turn is determined by outlays allocated to health in the Five Year Plans. The three major players catering to the health of the countrys population include public sector (comprising Central, State and local governments and their institutions), private sector and NGOs. The public sector health serv-

ices are further categorized in terms of primary, secondary and tertiary care. The primary responsibility of health care in the Indian Constitution, however, rests with the States. In general, a major chunk of the public expenditure (almost 90 percent) on the health care sector in the country comes through the States budget. However, there is also a certain degree of nancial dependence of States on the Centre with regard to the health sector expenditures. First, Central funding helps the States to run the family planning programmes and centrally sponsored schemes like national disease control programmes (including leprosy, malaria, tuberculosis), immunization, nutrition schemes and the components

of primary healthcare, rural water supply and sanitation which fall under the minimum needs programme of the Centre. The funding from the Central Government to the States comes either as cent percent grants or partly through matching grants. In the latter, the States have to contribute through a matching contribution from their budgets. Secondly, the Central Government provides the total funds for medical research and education in the Centrally-funded institutions. At present, however, in the overall spending on health in the country, the share of all governments (Central, State and local) comprises nearly 23.8%. A major chunk comes from the household sector (68.8%) and others (including



corporate sector) comprise the rest. The health sector is indeed grossly under funded. The overall public sector spending on health in India, which on the revenue account was 0.22% of GDP in 1950-51, has remained merely around 0.9% of GDP.

The investment in the health sector has been through each of the ve year plans in the country. From First Five Year Plan (1951-56) which emphasized health-related issues like: malaria control, preventive care in rural areas, maternal and child health (MCH) services, family planning and population control, and water supply and sanitation and vertical programmes pertaining to preventable diseases; the subsequent ve year plans had their focus tuned to suit the contemporary requirements of the nation. Thus a major shift in focus from preventive programmes to family planning was witnessed in the Third Plan (1961-66). The strengthening of the rural PHCs and existing vertical programmes received the attention in the Fourth plan (1969-74). A slight shift in the Fifth plan (1974-79) occurred with an attempt towards integration of the peripheral staff engaged in vertical health programmes. Further, the Alma Ata declaration in 1978 and ICMR/ICSSR report (ICSSR, 1980) shaped the health sector priorities and had an impact on health priorities in the Sixth Plan (1980-84) which envisaged to integrate the development of the health system with the overall milieu of socio-economic and political change in the country. A major guideline for the health sector in the country evolved with the formulation of the National Health Policy in 1983. This policy reected the commitment of India to attain the goal of Health for All by the Year 2000 AD. The Seventh Plan (1985-90) and the Eighth Plan (1992-97) had a notable shift with major focus being put on rural health programmes and private sectors contribution to the health sector. The structural adjustments and less expenditure on health in the initial Plan years coupled with

international funding of vertical programmes changed the focus of the ve year plan priorities towards increased private sector participation in the health sector. The subsequent plan periods of 1997-2002 (Ninth Plan) and 2002-07 (Tenth Plan) emphasized primary care, referral services and decentralization in the health care sector. Again in 2002, GOI brought out a new National Health Policy (NHP 2002) which listed the achievements in the health sector between the years 1951-2001. Based on achievements so far and keeping in view new threats from diseases like HIV and AIDS, NHP 2002 listed the new goals to be achieved between the years 2000-15. Some of the other notable features of NHP 2002 were: the need for: enhanced health facilities, organizational restructuring, more equitable access to health care facilities, emphasis on control of diseases contributing to high mortality (e.g., Malaria, HIV/ AIDS) and designing of separate schemes tailor made to the health needs of women, children, aged persons, tribal and other socio-economically backward sections of society.

Notably, India has achieved important milestones due to sustained planned efforts. As a result, during 1947 to 2011, life expectancy has more than doubled from 32 years to 66.8 years. Diseases like smallpox and guinea worm are non-existent. Leprosy and polio will soon be eliminated. Despite all these achievements with the prevailing National and State health policies and the systematic ve year plan health sector priorities, there are numerous disconcerting features and new emerging issues in the health care sector in India. The distressing facts that emerge are:

our total population (16.5% of global total population) accounts for one fth of the worlds share of diseases; a third of the diarrhoeal diseases, TB, respiratory and parasitic infections; a quarter of maternal conditions; a fth of nutritional deciencies, diabetes, venereal diseases; and the second largest number of HIV/AIDS cases after South Africa (GoI 2005). Besides this high disease burden, the overall state nancing of health care sector in India, as noted earlier, has been inadequate resulting in an unsatisfactory distribution of infrastructure and resources in the health care sector. This has lead to undesirable outcomes



like a wide spread disparity across rural and urban areas, poor and rich States and neglect of some of the emerging health needs of the society. Instead of playing a major role, public sector investment has set up a less efcient health care system thus providing a major impetus to the private sector for an investment which is more inequitable and less regulated. Even the low public investment is largely spent (nearly 70%) towards recurring expenditure (including wages and salaries). Thus, actually a very small amount is spent on medicines and drugs for patients care. The overall low spending in public sector has affected the availability and quality of health care in the public sector. Based on nal outcome indicators, concern is being raised regarding efcient utilization of this low public sector spending. Thus, not only the inefciency but also the overall inadequate and inequitable availability of resources in the public sector had an adverse impact on

the poor. Consequently, within the country, there has emerged considerable inequity in terms of health achievements. There is a notable disparity between better performing States like Kerala, Maharashtra and Tamil Nadu (TN) and lower performers like Orissa, Bihar, Rajasthan, Uttar Pradesh (UP) and Madhya Pradesh (MP). Benets from the public health system have also been uneven across different segments of the society. Particularly women, children and socially disadvantaged sections like scheduled castes and scheduled tribes have not received the health benets in an equitable manner and this is reected in higher values of IMR for these groups in the society. Indeed the private sector in India has gained prominence particularly after liberalization. It has catered to every segment of the health sector, viz. general and specialized care, diagnostics, hospital planning and construction, pharmaceuticals, technology development, training and education. An estimated 98.68% private institutions, however, remain in the for prot sector (GoI 2005). In terms of total investment, a study by CII-Mckinsey (2004) estimated it to have an overall worth of Rs. 69,000 crores which is projected to be doubled by 2012. This investment is further supported by an additional health insurance of Rs. 39,000. As such, the private sector currently absorbs nearly 3/4th of human resources and technology, 68% of 15,047 hospitals and 37% of 623,819 beds in the country (GoI 2005). In the absence of a satisfactory public sector performance in providing health care, the health services from these private providers is expanding at a fast pace and these are becoming providers of health care for the upper income groups. With their high tech care, these providers are also making India a potential hub for medical tourism. However, this increasing trend in health insurance and an increased role of corporate hospitals may result in considerable increase in cost of health care. This may further lead to an increased dependence of the majority in the poor and lower middle income

groups on the public health sector. Moreover, there has been a major policy directive that curative care could be left to the market forces and resources thus released could be dedicated to primary care. This is observed in both the National Health Policies (NHP 1983; NHP 2002). The same emphasis in health policy is seen on the part of the Central and State governments that have extended a number of exemptions in the last decade and half. These have been mainly in the form of excise and import duty exemptions, land subsidy and concessional bank credit. However, if we presume that private for prot sector is going to be a replacement for the public sector provider in the delivery of curative health care, the ndings of some empirical studies restrict such optimism and possibly indicate a high cost even in the presence of universal insurance. Given these equity, efciency and cost implications of sole dependence for health care on private for prot sector, it is pertinent to look into the possibility of enhancing efciency in the public sector or achieving an optimal mix of public and private sector as well as other alternatives like not for prot community based organizations to bring better health care facilities in the country. Moreover, health system in India is more focused towards the rural areas and there is a huge deciency in health system both in rural and urban areas. Majority of health care in urban area is served by the private sector but its costing, distance and many other factors make private sector facilities out of reach of most urban poor residents. (BRIJESH C. PUROHIT is currently a Professor at Madras School of Economics, Chennai. He has published widely and has held various academic positions at different institutions including CPR, New Delhi ; NIPFP, New Delhi; IIHMR, Jaipur; IDS, Jaipur ; QEH, University of Oxford; Central University of Rajasthan. The views expressed in the article are personal and do not reect the ofcial policy or position of the organisation.)



To achieve better health outcomes and reduce catastrophic health expenditure, the government is infusing hefty amount. But is it enough?
ealth Financing deals with the sources of funding the health expenditures. At the macro-economic level, the pattern of nancing the health expenditure determines whether the arrangement is efcient and equitable. A higher out-of-pocket (OOP) expenditure on healthcare, especially by rural population, accompanied by lower proportion of public funded healthcare delivery, is considered to be inequitable. As reported by a WHO technical brief in 2005, every year, approximately 44 million households throughout the world face catastrophic expenditure, and about 25 million households are pushed into poverty by the need to pay for services. India is a typical case of lopsided nancing of healthcare, as is evident from the National Health Accounts (NHA) report pertaining to the year 2004-05. As per the NHA (2004-05), the total health expenditure in India, from all the sources was Rs. 1,337,763 million, constituting 4.25% of the GDP. Of the total health expenditure, the share of private sector was the highest with 78.05%, public sector at 19.67% and the external ows contributed 2.28%. The provisional estimates from 2005-06 to 2008-09 shows that health expenditure as a share of GDP has come down to 4.13% in 2008-09. Though health expenditure has increased in absolute terms, the proportionately higher growth of GDP has resulted in a moderate increase in the share of health expenditure to GDP over the years. Kerala has the best achievement scores for HDI, IMR and for life expectancy, three related indices of

Advisor Health Care Financing, NHSRC, New Delhi

Consultant Health Economist, NHSRC, New Delhi

health outcomes. The OOP in the government hospital is twice as much as Tamil Nadu has but certainly much lower than the other states. Punjab has the next highest HDI and life expectancy but an IMR signicantly higher than both Kerala and Tamil Nadu, and many other service indicators of health care where it is not within the rst four or ve. Also, like Kerala, it achieves this health outcome for a much higher public and private expenditure on health, the latter representing 84% of the total health expenditure. What is much more important is the huge OOP on hospitalization in the public sector , almost nine times the Tamil Nadu gure. Tamil Nadu and Maharashtra have almost similar gures on life expectancy, HDI, and even on IMR. However, in Tamil Nadu, the per capita private expenditure on health is signicantly less and forms only 76% of the total health expenditure as compared to 80% for Maharashtra. Also, the total out-of-pocket expenditure in the public hospital is the lowest for the nation in Tamil Nadu. Looking at the signicance of public health expenditure in achieving better health outcomes and reducing catastrophic health expenditure, the central and state governments in India have been increasing their expenditure on health, especially since 2005-06, coinciding with the launch of the National Rural Health Mission (NRHM). The central government budgetary expenditure for health increased by 21.45 per cent per year (compounded annually) in the post NRHM phase (2005-06 to 2009-10) as compared to 10.85 per cent per year in the pre-NRHM period




(2001-02 to 2004-05). The increase was from 9650 crores in 2005-06 to 20,996 crores in 2009-10 and this includes the NRHM. In 2009-10, the NRHM release was Rs. 11,225 crores and this comes to 53.46 % of the central government health budget. It can be seen from the RBI (study of budgets) data for the state health expenditure details that the utilization of revenue expenditure of state health budget for all states increased from 91.4% in 2001-02 to 93.8% in 2004-05 and marginally declined to 92.1% in 2007-08. Utilization of capital expenditure for all states is more signicant

with an increase from 40.7% in 2001-02 to 90.3% in 2004-05 and to 95.1% in 2007-08. The increasing trends in general health expenditure, and more signicantly, the capital expenditure, reects an increased capacity of states in not only absorbing funds, but also make signicant improvement in assets creation in the public health sector. This is a welcome trend that addresses the decades of neglect faced by the public health sector, especially since the decade of nancial crisis and structural adjustments in the 90s. Apart from increasing public expenditure on direct provision of health-

care, the central and state governments have also initiated various innovative schemes to increase access and choice of healthcare provider (public or private) to the people, especially in the form of various subsidized health insurance schemes. In order to reduce the out-of-pocket expenditure of poor sections of the society especially the unorganized sector which constitutes 93% of the total work force, the XI Plan envisages effective risk pooling arrangements at the state level. A lot of health insurance schemes have been launched in the recent past, with Rashtriya Swasthya Bima Yojana (RSBY) being the most important one announced in the Union Budget 2007-08. The scheme also has a provision of smart card to be issued to the beneciaries to enable cashless transaction for health care. The cost of smart card would also be borne by Central Government. Many state governments have initiated health insurance schemes for the BPL population and unorganized workers. The major focus of these schemes are to cover identied tertiary care diseases which involves catastrophic expenditure and are not covered under any other pre-existing health programmes. Thus, together with increased health outlay for direct (public) provisioning of healthcare services to the people, the innovative and subsidized health nancing and insurance schemes launched by central and state governments aim at increasing the total proportion of public health expenditure and reduce the outof-pocket expenditure by the people for enhanced access, equity and nancial protection along with achieving better health outcomes. (GAUTAM CHAKRABORTY is currently working as an Advisor, Health Care Financing, NHSRC, New Delhi. ARUN B NAIR is currently working as a Consultant - Health Economist, NHRSC. The views expressed in the article are personal and do not reect the ofcial policy or position of the organisation.)




Reforms and law enforcements claim their strong foothold in the society but ground reality is way below expectations and the situation is just getting worse by every passing year




Chairman, Coochbehar Jan Shikshan Sansthan (Institute of Peoples Education) under Ministry of H.R.D. Govt. of India

ni nited Nations says an estimated 2, 2,000 unborn girls are illegally ab aborted every day in India. In m most parts of India, sons are viewed breadwinners who will look view as b wed after their p r parents and carry on the famn ily name, bu daughters are viewed as but nanc liabilities for which they will have nancial liab cial to pa subst pay substantial dowries to get married ay off. Increas Increasing female feticide in India coul could spark a demographic crisis where ld fewe women fewer wome in society will result in a rise er in se sexual vio exual violence and child abuse even as well as wife wife-sharing. D Demogra Demographers warn that in the next twen year there will be a shortage of nty twenty years brid brides in th marriage market mainly des the beca because of t adverse juvenile sex ratio, ause the com combined with an overall decline in mbined ferti fertility. Wh fertility is declining more ility. While rapi rapidly in u idly urban and educated families, neve nevertheless the preference for male erthele child children re dren remain strong. For these families, moder medical technologies are modern with within easy reach. Thus selective aborhin tion and s selection are becoming n sex mor common. more comm re So Some of the worst gender ratios, indiome catin ng cating gross violation of womens rights, f are found in South and East Asian countries such a India and China. In India, s as the availabl legislation for prevention of a available sex determi d determination needs strict implementatio alongside the launching of protation, alon on, gram grammes ai mmes aimed at altering attitudes, includ cluding tho prevalent in the medical ding those prof profession. Most of those in the medical fession. prof profession, being part of the same gender fession, biased society, are steeped in the same biased soci attit attitudes co tudes concerning women. It is scarcely su surprising that they are happy to fulll urprising the deman of prospective parents. demands

Medical malpractice in this area is ourishing. In many states, these acts have had little effect. Female infanticide was prohibited through legislation in pre-independent India. However, the law was toothless and there were few, if any, convictions. The Act has a central and state level Supervisory Board, an Appropriate Authority, and supporting Advisory Committee. The function of the Supervisory Board is to oversee, monitor, and make amendments to the provisions of the Act. Appropriate Authority provides registration, and conducts the administrative work involved in inspection, investigation, and the penalizing of defaulters. The Advisory Committee provides expert and technical support to the Appropriate Authority. Contravening the provisions of the Act can lead to a ne of Rs 1,00,000 and up to ve years imprisonment for the rst offence, with greater nes and longer terms of imprisonment for repeat offenders. The Appropriate Authority informs the central or state medical council to take action against medical professionals, leading to suspension or the striking off of practitioners found guilty of contravening the provisions of the Act. Women and Developments in Reproductive Technology Abortion was legalized in India in 1971 (Medical Termination of Pregnancy Act) to strengthen humanitarian values (pregnancy can be aborted if it is a result of sexual assault, contraceptive failure, if the baby would be severely handicapped, or if the mother is incapable of bearing a healthy child). Amniocentesis was introduced in 1975 to detect foetal abnormalities but it soon began to be used for determining the sex of the baby.

Ultrasound scanning, being a non-invasive technique, quickly gained popularity and is now available in some of the most remote rural areas. Both techniques are now being used for sex determination with the intention of abortion if the foetus turns out to be female. These methods do not involve manipulation of genetic material to select the sex of a baby. Recent preconception gender selection (PCS), however, includes ow cytometry, preimplantation gender determination of the embryo, and in vitro fertilization to ensure the birth of a baby of the desired sex without undergoing abortion. Ironically, it is being used in India to avoid giving birth to girl children. The killing of women exists in various forms, in societies, the world over. However, Indian society displays some unique and particularly brutal versions, such as dowry deaths and sati. Female foeticide is an extreme manifestation of violence against women. Female fetuses are selectively aborted after pre-natal sex determination, thus avoiding the birth of girls. No moral or ethical principle supports such a procedure for gender identication. The situation is further worsened by a lack of awareness of womens rights and by the indifferent attitude of Governments and medical professionals. The pregnant woman, though often equally anxious to have a boy, is frequently pressurized to undergo such procedures. Many women suffer from psychological trauma as a result of forcibly undergoing repeated abortions. As a result of selective abortion between 35 and 40 million girls and women are missing from the Indian population.




In some parts of the country, the sex ratio of girls to boys, has dropped to less than 800 : 1000. The United Nations has expressed serious concern about the situation. The impact on society should not be underestimated. According to India estimates, by 2020 there are likely to be 40 million unmarried young men.


The adverse sex ratio has always been linked with the low status of women in Indian communities, both Hindu and Muslim. It is deeply inuenced by the beliefs and values of the society. Islam permits polygamy and gives women fewer rights than men. Among Hindus, preference for the male child is likewise deeply enshrined in belief and practice. The Ramayana and the Manusmriti (the Laws of Manu) represent the ideal woman as obedient and submissive, and always needing the care of a male: rst father, then husband and, then son. The birth of a son is regarded as essential in Hinduism and many prayers and lavish offerings are made in temples in the hope of having a male child. Modern medical technology is used in the service of this religiondriven devaluing of women and girls. Religion operates alongside other cultural and economic factors in lowering the status of women.

of families is that having at least one son is mandatory in order to continue the familial line, and many sons constitute additional status to families. The nal factor of female deselection is the religious functions that only sons are allowed to provide, based on Hindu tradition, which mandate that sons are mandatory in order to kindle the funeral pyre of their late parents and to assist in the soul salvation. The most important task is to control population and increase awareness on the benets of controlled human population which includes better lifestyle, education, environment, health and well being of every individual. We two, ours one. Girl or Boy, let there just be one child are awareness campaigns started by the government of India, but there is lack of laws that enforce single child. The British medical journal, The Lancet reported in early 2006, that there may have been close to 10 million female fetuses aborted in India over the past 20 years. This is extrapolated partly on the basis of reduction of female-to-male sex ratio from 945 per 1000 in 1991 to 927 per 1000 in 2001. Ultrasounds are meant to monitor the health of unborn children, so doctors always know their sex, but they

of families in the next generation.


There is a need to encourage and motivate the population and specially farmers for being interested in having the girl child birth by assistance, mainly for the marriage of their daughters. The Ministries of Govt. of India has launched different schemes favouring the same . Ladli Scheme Rules, 2005 is applicable throughout the State of Haryana. The aim of this scheme is to combat the menace of female foeticide which has devastating demographic and social consequences, to restore the demographic sex ratio imbalance, to facilitate the birth of more girl children and to meet the felt needs of women and girl children for which these rules have been framed specially for Hariyana State. There are many other supports to facilitate girl child through different Govt. schemes by central and different state Governments. But the support status is very poor in terms of need. Within the framework of a democratic polity, our laws, development policies, Plans and programmes have aimed at

The practice of female deselection in India could be attributed to socio-economic reasons. There is a belief by certain people in India that female children are inherently less worthy because they leave home and family when they get married, a system known to anthropologists as patrilocality. Studies in India have indicated three factors of female deselection in India, which are economic utility, socio-cultural utility, and religious functions. The factor as to economic utility is that studies indicate that sons are more likely than daughters to provide family farm labor or provide in or for a family business, earn wages, and give old-age support for parents. The socio-cultural utility factor of female deselection is that, as in China, in Indias patrilineal and patriarchal system

inform the parents, a practice that is illegal in India, yet common. womens advancement in different spheres. In recent years, the empowerment of women has been recognized as the central issue in determining the status of women. The National Commission for Women was set up by an Act of Parliament in 1990 to safeguard the rights and legal entitlements of women. The 73rd and 74th Amendments (1993) to the Constitution of India have provided for reservation of seats in the local bodies of Panchayats and Municipalities for women, laying a strong foundation for their participation in decision making at the local levels. The evolution of property rights in a

Sex-selective abortion has been seen as worsening the sex ratio in India, and thus affecting gender issues related to sex compositions of Indian households. It has been argued that by having a one-child policy. India has increased the rate of abortion of female fetuses, thereby accelerating a demographic decline. As Indian families are allowed only one child, they would end up preferring at least one son over a daughter, thus preventing the formation of a greater number


patriarchal system has contributed to the subordinate status of women. The Policy would aim to encourage changes in laws relating to ownership of property and inheritance by evolving consensus in order to make them gender just. But in some of the cases, the hard acts of Indian Penal Codes are misused and receive the highest media attention these days. Two of these famous acts are the Dowry Prohibition Act of 1961 and 498a of IPC . The Dowry Prohibition Act is a related law which denes giving, abetting and taking of dowry as criminal acts, and it also prescribes many rules as to the exchange of gifts, expenditure at the time of marriage and declaration of the same to the Government. The purported aim of the Act is to curb the practice of dowry and to prevent extravagant marriages. 498A of IPC refers a husband or relative of husband of a woman subjecting her to cruelty. Whoever, being the husband or the relative of the husband of a woman, subjects such woman to cruelty shall be punished with imprisonment for a term which may extend to three years and shall also be liable to ne.

Gender disparity manifests itself in various forms. It is very clear that even after decades of independence, we are unable to provide social security to women. It is an abject truth and a horror to feel that: women are not safe even in the womb. The principle of gender equality is enshrined in the Indian Constitution in its Preamble, Fundamental Rights, Fundamental Duties and Directive Principles. The Constitution not only grants equality to women, but also empowers the State to adopt measures of positive discrimination in favour of women. The womens movement and a wide-spread network of Non-Government Organisations which have strong grass-roots presence and deep insight into womens concerns have contributed in inspiring initiatives for the empowerment of women. However, there still exists a wide gap between the goals enunciated in the Constitution, legislation, policies, plans, programmes, and related mechanisms, on the one hand and the situational reality of the status of women in India, on the other.

The underlying causes of gender inequality are related to social and economic structure, which is based on informal and formal norms, and practices. Womens equality in power sharing and active participation in decision making, including decision making in political process at all levels will have to be ensured for the achievement of the goals of empowerment. All measures will be taken to guarantee women equal access to and full participation in decision making bodies at every level, including the legislative, executive, judicial, corporate, statutory bodies, and also the advisory Commissions, Committees, Boards, Trusts etc. Afrmative action such as reservations/ quotas, including in higher legislative bodies, will have to be considered whenever necessary on a time bound basis. Womenfriendly personnel policies will also to be drawn up to encourage women to participate effectively in the developmental process. It is evident that there is a need for reframing the policies for access to employment and quality of employment. Benets of the growing global economy have been unevenly distributed leading to wider

economic disparities, the feminization of poverty, increased gender inequality through often deteriorating working conditions and unsafe working environment especially in the informal economy and rural areas. Strategies will have to be designed to enhance the capacity of women and empower them to meet the negative social and economic impacts, which may ow from the globalization process. It is a stark and naked truth that the nation will have to set off in a new way to ferret something to save our women in the womb. (SUKHAMAY PAUL is the Chairman of Coochbehar Jan Shikshan Sansthan (Institute of Peoples Education) under Ministry of Human Resource Development , Govt. of India. He has also worked as Director of Collaborative organization of CHILDLINE India Foundation (CIF) under Ministry of Women and Child Development, Govt. of India. The views expressed in the article are personal and do not reect the ofcial policy or position of the organisation.)



Because of lack of central planning, the Indian masses are denied the excellent facilities and expertise that are sought out by medical tourists




Fellow of the Academy of Social & Political Research, Athens

ndias burgeoning population is generally looked upon as a nightmarish problem, particularly in the West where the converse problem is that of declining birth rates and aging populations. The problem, however, is not that of a large population, but with the lack of an orderly infrastructure and national plan to turn the problem into Indias greatest resource. The approach to Indias problems, including those of healthcare, need to be treated holistically.


India should not look to failed Western economic and political paradigms. Its belligerent neighbour, China, has shown what can be achieved when a large population is mobilised under a national economic plan directed by a strong central political authority. India, of course, need not indeed, must not follow the communist nor even the social democratic path. No nation can claim to be a world power nor even a real nation while a large proportion of its population is diseased and malnourished and living in poverty. Such a condition is a standing disgrace and a conspicuous sign of a nations lack of resolve. Indias problems are not unique in this; the problems are however a matter of proportion due to the inability to resolve rapid population expansion. The problems of poverty, slums and hygiene faced by India were also faced by England during her analogous period of economic modernisation starting from the era of the Industrial Revolution. At that period, a former rural population became proletarianised; uprooted rural workers became urbanised, with the resulting problems

of slums, disease, overcrowding and lack of sanitation. While England presented itself as a great nation that ruled a large proportion of the world, a large element of its population lived in degradation. It should be noted that the economic model that ruled England was the Free Market or Free Trade. Friedrich Engels wrote for example of the slum dwellings of 19th Century Manchester: Of the irregular cramming together of dwellings in ways which defy all rational plan, of the tangle in which they are crowded literally one upon the other, it is impossible to convey an idea. Below the bridge you look upon the piles of debris, the refuse, lth, and offal from the courts on the steep left bank; here each house is packed close behind its neighbour and a piece of each is visible, all black, smoky, crumbling, ancient, with broken panes and window frames. The background is furnished by old barrack-like factory buildings. (Slum Housing, Cotton Times). Yet despite the failed 19th century model of Liberal economics, over the past several decades in the West it has been revived as a panacea. The socio-economic problems are however caused by a failure of the nancial mechanism: that of debt to the international banking system that is based on usury. Hence governments are selling their national assets and state owned enterprises to pay off the interests on debt in the short-term but will in the long term be left with no assets and there will be a new cycle of debt.

International companies are looking to



Indias health system as a potential source of prot. Indias people will be treated not as a resource that can be mobilised for great national purposes but as an economic commodity from which prot can be accrued for foreign investors. Once a state opens itself up to free trade it no longer has control over its own destiny, which is determined by outside companies. A 2007 report by Price Waterhouse Cooper is tellingly entitled Healthcare in India: Emerging Market Report. That is the bottom line as far as private investments in health are concerned: health problems are looked upon as an emerging market. The gures collated for this report are informative: In 2007, the total, value of the healthcare sector was $34 billion; 6% of the GDP. This is projected as $40billion in 2012. The private sector accounts for 80% of the total healthcare spending. Unless, there is a considerable decline in federal and state decits, the opportunity for signicantly higher public health spending will be limited. (Healthcare in India: Emerging Market Report 2007, Price Waterhouse Cooper, p. 1). Yet, the report, citing Goldman Sachs, states that Indias economy is growing in tandem with the population, projected to expand by at least 5% over the next 45 years, as the only emerging economy to maintain such a robust pace of growth. However, according to 2004 gures, 27.5% of Indian lived below the poverty line, 300,000,000 live on less than a dollar a day, and more than 50% of all children are malnourished. (Healthcare in India, ibid., p. 2). These gures indicate something radically wrong with the nancial and economic mechanisms, when a large proportion of Indias population lives in destitution, despite the economy increasing in tandem with the population. What the private overseas investors are looking at is Indias expanding middle class, with more disposal income to spend on healthcare. (Healthcare in India, ibid., p. 3). According to the Free Market model, what seems to be indicated by the Reports projection for investments into private healthcare for the middle class is the accentuation of dis24

parity in healthcare among those of variable per capita incomes. Private foreign investment is therefore directed towards the expanding middle class as a matter of simple protability. The problem at issue is that of the awed nancial system, which is a complex issue that must remain outside the scope of this article. What can be said, however, is that, as stated, an economy that is expanding at the same rate as the population, should potentially be the source of strength and not one of growing economic disparity. (K R Bolton, State Credit and Reconstruction: The First NZ Labour Government, International Journal of Social Economics, Issue 1, Volume 38. 2011; and The Global Debt Finance System, Veritas, St Clements University, Vol. 2, No. 1, December 2010). The State needs to resort to the Keynesian method of vast public works projects that deal with the problems of hygiene, housing, fouled waterways, sewage, rodents, and lack of healthcare centres and hospitals. It needs to inject state credit into these schemes. India has

the people in abundance; what is required is the organisation to mobilise them. Slum clearance should not uproot communities that have developed over generations, nor create high-rise apartments. A State Labour Corps should be created to undertake these vast public works, utilising Indias population as a valuable resource.

There is another debilitating factor that India is importing from the West, and again the problem comes back to Free Trade. The Price Waterhouse Cooper report refers to the adoption of unhealthy Western diets that are high in fat and sugar, causing a rise in lifestyle diseases such as hypertension, cancer, and diabetes, which is reaching epidemic proportions. Over the next 5-10 years, lifestyle diseases are expected to grow at a faster rate than infectious disease in India and to result in an increase in cost per treatment. Presently an estimated 41,000,000 Indians are diabetic, and this is projected to rise to 73.5


million by 2025. During the 1970s only 2.1% of Indians in urban areas had diabetes; now the gure is 12.1% for adults over the age of 20. Indians have a genetic susceptibility toward diabetes, which has been triggered by the change in both diet and lifestyle. (Healthcare in India, op. cit., p. 4). The Free Market model that is recommended by the Price Waterhouse Cooper report refers optimistically to the growth of Indias pharmaceutical industry. One of the problems for investors is that the Indian Government increases the number of medicines brought under price control, which adversely impacts on investment opportunities. (Healthcare in India, ibid., pp. 4-5). Here again the State must consider whether it is to pursue a Free Market economy that adversely impacts upon the health of its people, or to look for new directions that place the interests of India rst, which therefore places India outside the push for Free Trade. India should also reconsider whether joining Free Trade agreements is desirable, as such FTAs undermine the States authority to intervene in the market and in this instance in controlling the price and type of pharmaceuticals, or in keeping out undesirable corporations, such as fast-food chains. As the Price Waterhouse Cooper report indicates, global investors win in two ways to the detriment of India: (1) The fast-food chains prot from access to the Indian market, (2) The pharmaceutical and private healthcare companies prot by treating the symptoms of unhealthy foreign diets. What is eliminated from the equation is prevention, by the State intervening in the national interest and by not allowing fast food chains to literally poison the population. The decline in health, and the rise in cancers, diabetes, and obesity that infects the West due to the decline in dietary standards should serve as a warning to India. Both traditional and technological methods of work also contribute to physical debilitation among both the menial and the managerial and clerical professions. Posture and osteopathic problems in particular can be expected

to become widespread among classes other than the menial, as well as among the young. Computers and computer games are causing widespread health problems among the young and those with occupations that increasingly revolve around the use of computers, including: overuse injuries of the hand, obesity, muscle and joint problems, eyestrain, and spinal curvature. Again, there is a question of the shortterm versus the long-term perspective. Employers should regard the long-term health of their workforce as more important that trying to eke out every last hour of labour, like some 19th Century English merchant out of a Charles Dickens novel. The State should design national programme, coordinated by a workplace tness authority. Japan provides a model in this as it does in the manner by which State and private enterprises are coordinated. The Japan Industrial Safety and Health Association (JISHA) has wide-ranging inuence over industry, including physical exercise, nutrition guidance, health guidance or counselling, and/or sends experts to enterprises upon request for practical in-house training of the instructors JISHA also provides a health-advice service that has been developed in the form of health guidance tools to promote workers self-awareness. JISHA implements regular health examinations. JISHA also implements special health examinations for workers dealing with chemical hazards, engaged in VDT work, or working amid vibration or noise, and gives overall advice on health management that takes into consideration each type of working environment. the nest doctors, medical specialists and researchers in the world. The 2007 report alludes to Indias growing medical tourism, where Westerners come to take advantage of Indias well-educated English-speaking medical staff, state-ofthe-art private hospitals and diagnostic facilities, and relatively low cost in comparison to the high costs of healthcare in the West. (Healthcare in India, op. cit., p. 10). Medical tourism is projected to reach $2billion in 2012. Many Westerners are also seeking Indian traditional medicine. (Ibid., p. 11). Because of lack of central planning, the Indian masses are denied the excellent facilities and expertise that are sought out by medical tourists. The state has a duty to enact longterm national planning, in conjunction with private enterprise. Japans revival from wartime devastation provides a successful example of this method. Large-scale public works are required for slum clearance, the construction hospitals and clinics, and projects for sewage and garbage disposal, water quality and rodent control. India has the population to undertake such public works schemes. (DR K R BOLTON is a contributing writer for Foreign Policy Journal, and a Fellow of the Academy of Social & Political Research, Athens. He is widely published on a range of subjects by scholarly and other media, including: World Affairs; India Quarterly; International Journal of Russian Studies; Geopolitica (Moscow State University); Journal of Social, Political & Economic Studies; International Journal of Social Economics, etc. The views expressed in the article are personal and do not reect the ofcial policy or position of the organisation.)

While healthcare for the Indian masses is in disarray, India produces some of



ealth is a critical factor in the development of any country, for two reasons, rst, health status is a key indicator of populations welfare (Sen 1985) and second, improving the health status of the population leads to greater economic productivity (Strauss and Thomas 1995) and can also positively affect education outcomes (Glewwe et. al). Theoretical work as well as empirical evidence clearly show the linkages between good health, well being of individuals and overall economic development. Today, the health status of population is considered an important indicator of development and widely recognized as both an input and an outcome of broader social and economic developments. In India, states with better equity in public spending have better health status outcomes and states with higher morbidity and mortality are underdeveloped. States with high access and utilization rates reveal lower mortality rates (Dreze and Harris 1996). Ill health and poor health services are increasingly recognized as major dimensions of poverty. Commission on Macroeconomics and Health (CMH) says that health improvements lead to economic growth and that in turn leads to further health improvements. Thus, reduction in poverty is probably not possible without signicant improvements in health condition of people.

Assistant Professor, Centre for Social Studies (CSS), VNSGU Campus, Surat


only do they have to spend a large amount of money and resources on medical care but also they are unable to earn during the period of illness. Moreover, rural people have signicantly higher burden of almost all components of indirect cost (such as expense on transport, food/stay, tips given to get access to any person or facility, opportunity cost to the sick as well as the accompanying person etc). Very often, the poor have to borrow funds at a very high interest rate from money lenders to meet medical expenditure as well as other household consumption need, which in turn puts them into indebtedness. This can lead to pauperization and indebtedness for generations. More than 40 per cent of

With a very low income at its disposal, will it be easy for the poor section to enroll for this scheme or will it compromise again with the miseries?
individuals, who are hospitalized, borrow money or sell assets to cover the cost (World Bank 2001). Between 1986 and 1996, those sick but not availing treatment for nancial reasons increased from 15 per cent to 24 per cent in rural areas and doubled from 10 per cent from 21 per cent in urban areas (GoI 2000). Evaluation reports of the department of rural development indicate that health expenditure, particularly for hospital treatment, is major cause of rural indebtedness. Thus, ill health disproportionately affects the poor, leading to higher morbidity and mortality. One possible consequence of this high medical expenditure could be the pushing of these families into a


The evidence available from the National Sample Survey (NSS) indicates that healthcare expenditure is one of the fastest growing components of household consumption even among the poor. On an average, about 5.3 percent (13.7 percent of nonfood expenditures) of annual household expenditure in India is spent on health care (World Bank 2001). Expenditure on health is often unexpected and can be catastrophic in nature. This is even truer for the poor where even a temporary incapacity of the breadwinner to earn due to illness can drive a family into destitution. It cuts poors household budget in both ways, not



zone of permanent poverty (UNDP 2001). More than a quarter of all hospitalized Indians fall below poverty line as a direct consequence of the medical expenses they pay, out-ofpocket, after being hospitalized (World Bank 2001). Professor Peter Berman of Harvard School of Public Health estimates that out-of-pocket health expenditure contributes more than two per cent to the Indias poverty ratio (Berman et al. 2002). This enormous nancial burden arises because poor are not insured. A large majority of the rural and urban slum population in India remains excluded from the health insurance system and has low protection from risk.


Given the rising expenditure on health care and the state as well as the markets inability to protect the vulnerable section of society, it becomes increasingly important to look at various alternatives for including the excluded. An important part of health nance in India is the service provided by voluntary and charitable organization commonly known as Non Government Organisations (NGOs). Learning from their experiences from micro credit programmes (e.g. health expenditure a major cause of default), some NGOs have started micro insurance programmes. Community-based health insurance (CBHI) or Micro Health Insurance (MHI) is a mechanism that allows for pooling of resources to cover the costs of future, unpredictable health-related events. It offers individuals and households, protection against the uncertain risk of catastrophic medical expenses in exchange for regular payment of premiums. This mechanism, under which the healthy, can cross subsidise the poor, may make a positive impact on equity. The World Health Report 2000 noted that prepayment schemes (like is the case with micro health insurance) represent the most effective way to protect people from the costs of health care, and called for investigaTHE GRE AT INDIAN DRE AM



tion into mechanisms to bring the poor into such schemes (WHO 2000). The WHOs Commission on Macroeconomics and Health (CMH), for example, recommends, that out-ofpocket expenditures by poor communities should increasingly be channeled into community nancing schemes to help cover the costs of community-based health delivery.


As per recent ILO estimates, there are about 90 micro health insurance schemes in India covering about 85,00,000 people. However, the schemes are diverse in nature ranging from few hundred to more than 1,00,000 members. One can see some kind of geographic clustering/concentration in South India perhaps because of higher number of micro nance institutions (MFIs) in this region. Existing micro health insurance schemes differ in terms of their design and management, number of members, target population, pattern of enrolment, unit of membership, level of premium, as well as scheme benet package. This makes it somewhat difcult to compare the schemes. Each scheme is unique in nature and has its own strengths and weakness. This section presents some important characteristics of Indian micro health insurance schemes for the poor. SIZE AND AGE OF THE SCHEME: The smaller schemes covered only hundreds of people (AKHS in Gujarat), while larger schemes like SEWA covered more than one lakh members. The schemes, also varies tremendously in terms of their age, the oldest starting in 1955 (SHH, Calcutta) and

the youngest within the last few years (Dhan foundation, WWF and Yeshashwini in Karnataka). Many more NGOs are in process of developing schemes. SCHEME OWNERSHIP AND MANAGEMENT This aspect is very important as often the success or failure depends on scheme design and management. Three main patterns of scheme ownership and management have emerged. Firstly, in many schemes the NGO running the insurance scheme


is also the health care provider. Secondly, there are several NGO-owned schemes where the NGO is the insurer, but does not provide health care itself. Thirdly, several of the schemes involve an NGO acting as an intermediary between the target population and insurance company (public or private). This seems a reasonable strategy given that NGOs generally dont have the actuarial skills required for setting premium and benet package. On the other hand, insurance company can reduce its administrative cost by piggy backing on NGO structure. Another important feature is that all of the NGOs that own and manage schemes provide services other than just insurance. For example, some of the NGOs are involved in various developmentoriented activities, including education, micro-credit, micro-savings and


work-generation. UNIT OF MEMBERSHIP Most of the Indian schemes enroll households or families may be to avoid the problem of adverse selection (a phenomenon where only the sick or high risk people join). There are only a few schemes where enrolment is of groups larger than the household, such as Sevagram hospital in Wardha where entire village in enrolled into the scheme if this is agreed upon in gram sabha meetings. PREMIUM AND BENEFIT Premium amount ranges from zero to Rs. 365 (one rupee a day) per person and is at (one rate for all) in nature except in scheme of sevagram hospital where the premium is based on ability to pay. Almost all of the schemes collect the premium during an annual membership drive. Very few schemes allow individuals/members to join the scheme around the year. Some schemes cover inpatient (hospitalisation) services only, and some both outpatient and inpatient services. Almost all of the schemes that restrict their benets to inpatient services are associated with insurance companies and they also exclude certain medical conditions from coverage like preexisting conditions, chronic conditions, treatment related to pregnancy/ childbirth, and HIV/AIDS and its complications. Almost all of the schemes that cover the costs of hospitalization provide coverage only to a predened limit or ceiling. Moreover, in most schemes, the insured must pay for care out-of-pocket and then seek reimbursement from the insurer. FINANCIAL SUSTAINABILITY Most of the schemes received some form of external support or nancial subsidy at some point of time, without which they could not have survived on their own. This means making these schemes nancially viable is an uphill task especially because in process of making these schemes nancially viable, premiums usually go up which adversely affect the equity. Thus, there is a trade-off between

nancial sustainability and equity. COMMUNITY RESPONSE Faith and trust in the leadership seem to be the two most important factors in acceptability of the scheme. In most cases the people are happy with the scheme but they feel frustrated when their claim is rejected. This happens because the awareness regarding exclusions and other guidelines is quite low among the community (Acharya and Ranson 2005). cannot be termed as panacea for health problem of poor. Overall NGOs seem to have been a relatively successful platform for providing health insurance services to the poor as they can address many of the felt needs of the population and community trust them. However, even if these NGOs have been successful in increasing the access to health care, the whole issue of quality of the care provided, remains unanswered. It seems that the NGOCorporate Partnership (NCP) is most rational model for extending health insurance to the poor as NGO alone doesnt have actuarial or nancial expertise to set premiums and in case of sudden claims load. NGO wont be able to cope with it without backing of corporate insurer which will have a larger and diversied risk pool. NCP strategy also gels well with the Corporate Social Responsibility (CSR) debates as through NCP route corporate can serve a large community by taking care of their health care needs. (AKASH ACHARYA is a faculty at Centre for Social Studies (CSS), Surat. He has an interdisciplinary academic background in Economics and Management. He has worked on collaborative research projects with Universities in West and his papers have been published in international peer-reviewed journals like Social Science and Medicine, Health Policy and Planning and Health Policy. On invitation, Akash has visited Universities in the USA, UK and Germany. The views expressed in the article are personal and do not reect the ofcial policy or position of the organisation.)

Micro health insurance is still a relatively new concept and it is difcult for the poor to comprehend that money has to be prepaid for a possible sickness which may never come and in that case the premium is not returned. Since poor has many other competing priorities, the motivation for joining a health insurance programm is low (Acharya 2006). The overall assessment of the NGO managed schemes is that they have so far reached only a very small part of the poor in the unorganized sector in terms of coverage. It seems unlikely that such a scattered and piecemeal movement can lead to universal coverage. Even where the schemes have reached, there are not enough statistics on inclusion of the poorest of the poor, increased access to health care, extent of protection to the poor from medical indebtedness etc. There is a need for health insurance services among the poor but it remains to be seen whether the poorest in society will be able to afford the insurance premium, even when it is low by market standards. Many questions remain pertaining to the ability of such schemes in catering to the health needs of the poor and they



Reeling Reeling under ailing health and social protection schemes, India has one has one of the lowest public spending on health care in the world





Economist with specialization in health economics, PHFI

ealth system includes all activities whose primary purpose is to promote, restore or maintain health. Assessing the performance of health system is difcult here, given the interplay of various factors within and outside the health inuencing health. However, health status, nancing, disease prole and public sector delivery are certain important parameters of health system which are discussed briey. The health care system of the country has witnessed substantial changes since the time of independence. Life expectancy and mortality indicators have improved over the years. At less than 32 years of life expectancy in 1946, it is now almost doubled to reach at 63.5 years now. Infant mortality rate (IMR) has come down to 50 in 2009 from 146 in 1951 and the maternal mortality ratio has reached 212 for one lakh child births. The progress made over the years is comparably low as compared with the achievements noticed in Asian regions especially in China, Sri Lanka and the South East Asian region. In China, an average individual lives up to 74 years, 71 years in Sri Lanka, and 65 years on an average in South East Asian region. Similarly, probability of a child dying before the age of one year is 17 per 1000 live births in China, 13 in Sri Lanka, and 45 in South East Asia. This makes Indias position unequivocally low. Within the country there is uneven progress across the states. Kerala and Tamil Nadu in the South have made good progress in comparison to Bihar, Assam, Madhya Pradesh, Rajasthan, Uttar Pradesh, and Orissa. For example, there is a 16-years difference in life expectancy of Madhya Pradesh (58) and Kerala (74). The difference in IMR in between Kerala (12) and Madhya Pradesh (67) is 552. Evidence indicates that poor are disproportionately benetted from the progress made in health sector. For instance, a child born in a poor family has two and half times less chance of survival under the age of one than in a rich family. This signies increasing inequity across income groups and among different regions of the country. The disease burden is changing with more proportion of people suffering from cardiovascular diseases, cancer, diabetics, blood pressure etc. With high prevalence of communicable diseases, rising non-communicable diseases pose a new threat to the




health system. Slow progress in health outcomes and rising inequality across the population groups and states to a large extent lies with the countrys health system which has been facing with several constraints including low public spending, governance and management problems. India has one of the lowest public spending on health care in the world and this is around 1.2% of GDP recently. The government expenditure as a share of total health expenditure in India was 32.4% in 2008 in comparison to average 41.3% in South East Asian Region, and 40.5% in low income countries. A large proportion of health care is nanced from out of pocket and this constitutes around 71% of total spending. Expenditure on medicine constitutes a signicant proportion of out-of-pocket expenditure. Low public expenditure has resulted in a number of constraints in the health system and one of the consequences is the rise in poverty. A recent study has estimated that increase in out-of-pocket expenditure has resulted in 39 million people being pushed below poverty line. Due to nancial reasons, many people do not avail medical care and this varies from 15% in Orissa to nine percent in Assam and North East states. Financial protection through insurance mechanism is also limited. The efforts made through the Rashtriya Swasthya Bima Yojana (RSBY) and the Janani Suraksha Yojana (JSY) under the National Rural Health Mission have not reached millions of poor people. The social protection schemes of the government: the Employees State Insurance Scheme and the Central Government Health Scheme also have limited coverage. Inadequate physical infrastructure and man power at the primary care are the main barriers to access to health

care. Around 56% of sub-centers function in the government building and 58% of the ANMs are staying in residential quarters indicating the gaps in physical infrastructure. It is observed that in many of community health centers (CHCs) Gynaecologist positions are lying vacant and only 25% of the CHCs have Obstetricians/Gynaecologists. Among many other factors inadequate physical infrastructure causes low outputs in the health system. For instance,


only 47% of the delivery takes place in a health care institution. This proves to the fact that a large number of children are born without any medical support risking the lives of mother and children. Traveling long hours to reach the health care institutions and many a times absence of doctors at the health centers adds to the misery of the rural population. The recently launched National Rural Health Mission (NRHM) though is making efforts to address the gaps, several constraints are affecting the health system to function effectively especially in Bihar, Orissa, Rajasthan, Uttar Pradesh etc. The inability to develop an effective public health system led to unprecedented growth of private sector. From only eight percent of medical institutions in private sector at the time of independ-


was guided by the recommendations of various committees and ve year plans. The rst NHP reafrmed its commitment to provide health for all by 2000 as per the Alma Ata declarations. These could not be achieved due to many reasons and one among them was inadequate resource allocation. Thinly spreading the meager resources among the multiple objectives neither strengthened the system nor helped in achieving the objectives. Moreover, the emphasis on vertical disease control programmes resulted in the role of the state being conned to selective diseases rather than adopting a comprehensive primary health care for well being of people. Inviting private sector to have a level playing eld in health sector in this policy without regulations and controls proved to be detrimental in the latter years. In 2002, the country declared its second National health policy giving priority on increasing access to health care services across the social and geographical expanse of the country with signicantly increasing public spending on health. The unnished agenda of universal primary health care was further emphasized. During this period, the country witnessed higher economic growth and rapid urbanization resulting from a decade of economic reforms adopted since 1991. Along with the changes in the economic environment, the demographic and epidemiological prole of the population witnessed changes. The above mentioned shift necessitates additional resources and strong health care systems. In order to address the challenges in the public health care systems, especially at the primary level, the government announced National Rural Health Mission (NRHM) in 2005. This programme aims at providing universal access to equitable, affordable and quality health care by addressing the gaps in public health infrastructure and enhancing public spending on health care. This focuses on 18 low performing states of India. Changes have been introduced in the organizational structure and nancial management systems for implementing the programme. States are gradually developing infrastructure and building systems and processes for effective implementation of the programme. The level of progress at the state level varies and one positive indicator is that low performing states show some progress in health outputs. However, strengthening existing infrastructure and enhancing capacity for better service delivery in these states need higher focus for improving health indicators. Health system challenges are enormous. At the policy front adequate nancing, strengthening service delivery, judicious balance among primary, secondary and tertiary care and regulatory mechanism for private sector are major issues that need to be addressed. These need to be designed to inuence health inequities across income, caste and regions, provide nancial protection to the poor, and improve health outcomes. (SARIT KUMAR ROUT is an economist with specialization in health economics. Presently he is involved in research related to economics of tobacco in PHFI. He has prior experience in National Health Account process with the Ministry of Health and Family Welfare, GoI, as a lead researcher and was instrumental in bringing out the second round of national health account for the country. The views expressed in the article are personal and do not reect the ofcial policy or position of the organisation.)

ence, this has increased to 68% of all hospitals. The dependence on private sector has gone up for both outpatient and inpatient care. Currently, around 42% and 38% of inpatients in rural and urban areas respectively utilize government health care institutions. The private sector participation is not only more in high income states of Punjab, Haryana and Gujarat but also is high in low income states of Bihar, Rajasthan and Madhya Pradesh. No regulation on prices and treatments provided by the private sector is an area of concern. Given such developments in health sector as it happened in last six decades, misplaced priorities in the health policy caused many of the failures. After independence and until the declarations of the rst National Health Policy (NHP) in 1983, the policy stance




Reforming healthcare is a tough challenge and the country needs impeccable planning against the background of scarce resources
ealth care delivery in India has molded over years of experiences and experimentations. Sadly, the Midas touch of Health For All remains a eeting dream in trance as we keep wondering as to why our programmes fail. The suboptimal performance of many of our national programmes animates our inability to predict and hit the bulls eye in time and sustain along with. It has become almost legendary that we are excellent planners but bad implementers, bearing in our minds that providing for the dream picture in a country like While political empowerment emerges as the most important determinant for the success of our programmes, the squalor swathed agenda of our polluticians is even more obvious than ever before. But again, can we blame them entirely for the failure or under-performance of programmes? Certainly, not! Let us analyze the reasons for programme debacle. Any programmes inadequacy in achieving its goal can be attributed to one or more of the following: 1) Technical insufciency, 2) Administrative inanity and 3) Operational incapacity. Even a single distraction of any of these determinants can be enough deterrent causing programme-failure. 1) Technical insufciency is a reec-

Professor, Institute of Medical Sciences, Banaras Hindu University, Varanasi

Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University

tion of inexperienced strategists designing programmes without an insight of what would happen on the ground or failure of some technique adopted eg.mosquitos developed resistance to DDT or chloroquin in NMEP. The Anganwadi worker (AWW) has been asked to maintain about 24 registers. The difculty in managing these registers along with activities simultaneously is a stupendous task under the sun. The assistant of AWW is incapable to provide any technical help. Apart from this, the AWWs are utilized for many nonICDS duties which adversely affect their performance. The journey of the Auxiliary Nurse Midwife (ANM) is also fascinating. The ANMs services revolve around Maternal and Child Health (MCH) care. She is expected to reside in the subcentre built in her service area. Usually, we nd the subcentres having poor road connectivity, no electrication socially unsafe without water & sewerage facility or school for her children. The Medical Ofcer posted at the Primary Health Centre is another pitiable soul. Invariably, he is busier with administrative renderings than patient care despite the fact that he was never trained for resource man-









agement during his MBBS education. Whatever management in health is being taught in medical schools, it is not done properly. Moreover, the system has started behaving in such a way that most authoritative powers are now vested either with the local leaders (a cost for decentralization and community ownership) or babus (administrative one-upmanship and browbeating) making the medical ofcer a vulnerable soft target for all criticisms. At times, technical insufciency is due to ceiling of scientic knowledge. We have seen that after promising success with our attempt for malaria elimination, there has been a resurgence of the disease with amplied mortality. Vector resistance to insecticides like DDT and agent resistance to drugs like chloroquine is the understood reason. But of course, changes in vector bionomics and agent behavior cannot be ruled out. 2) Administrative inanity has on many occasions led to chaotic deadlocks for health programmes. We have already witnessed how forced vasectomy in late 1970s (a classic for administrative blunder) had boomeranged back on the Government of India giving a massive jolt to our family planning programme. A few enumeration of the similar situations may be considered here. The National Rural Health Mission (NRHM) was launched for a period of seven years (2005-2012) while the recruitment of ASHAs continued as long as up to 2010. As is available from the ofcial website, till 30th June, 2010, 809637 ASHAs had been recruited of which 763560 had received the training and only 553061 were in position with their drug kit. The initial ASHA training modules were planned with intelligent sequencing but it has been seen that the content of the modules available at the NRHM ofcial website does not coincide with the training that has been imparted to the ASHAs. Another administrative issue is whether community level workers be paid a xed remuneration or per36

formance-linked incentive or just be asked to work as volunteers. Volunteerism naturally lacks sustainability given the fact that community health workers are poor and expect and require an income. The Janani Suraksha Yojana (JSY) has caused an iconic upsurge in institutional delivery. It has helped in exemplary reduction in infant and maternal mortality from 73 and ~254 in 2005 (pre JSY) to 63 and 212 (2009), respectively. However, The JSY management needs strengthening through attention towards preparing JSY plans (facility, district and state), proper and periodic monitoring for adherence to the guidelines and strong nancial planning and developing robust communication activity plan for community mobilization. The anti-tubercular therapy administered as DOTS is one of the costliest drug regimen (somewhere around Rs. 10 to 15 thousands per patient) provided absolutely free of cost to the needy. We have also afxed some incentive for the DOT provider upon successful completion of therapy per patient. So, apart from the medicine, the cost of incentive is

another overload on the Government/ task payers. But what are missed in DOTS are two Is. They are Intensive case follow-up and Integrity of the DOT worker. Lack of managerial insight has marred the programme with the connotation of increased non-acceptors and defaulters since the two Is lacking in DOTS i.e., Intensive case follow-up & Integrity of the DOT provider were never addressed to. The programme does not talk on these two issues and we justify if its free, it is accepted by the people. The Child Survival and Safe Motherhood Programme (CSSM) is one of the most successful health programmes, the onus of which was carried by skillful and motivated eld staff, with technical support from medical colleges and Unicef. The programme almost touched its pinnacle when it was replaced with the Reproductive and Child Health (RCH) programme making all efforts of CSSM lost to dust. We had about 85% coverage of immunization through CSSM, when we introduced Pulse Poliowe had booths, staffs reached peoples homes if they


did not come. The National Nutritional Anemia Prophylaxis Programme, functional in one form/ name or the other for several decades, has largely been unsuccessful with just coverage of 23% of the pregnant women. As on date, 80% of pregnant women are anemic, IFA tablets are mostly not consumed since its thought to be Free and will not work. The extra attention to programmes like the National AIDS Control Programme has led to increased awareness among the masses and hence increased adoption of safe practices. This highlights the role of political support for the sustained functioning of health programmes. On the contrary, the opportunity cost to programmes for other diseases like diarrhea, malnutrition, RCH related morbidities, etc remains to be calculated could be enormous and intimidating. In most of our programmes, we do not follow a supervision style that exudes positivity; supervision in India means Scolding / punishing or some kind of negative action. Delay in decision making towards programme initiation, implementation and rectication, and non-percolation of the same to the lower administration are conspicuous potholes. Logistics supplies in consonance with managerial decisions are also largely unaccomplished. It is not a rare outcry that medicine, Vitamin A, IFA tablets or even vaccine stocks at health facilities or with health workers have not been replenished for quite a while. Similarly training of staff, availability of documents, record forms and registers are yet to arrive in Integrated Disease Surveillance Programme uniformly, which was a vertical programme but now handed over to NRHM. All

programmes clubbed under a common umbrella NRHM qualies it to defend the old saying a lady with seven children is mother of none. 3) Operational incapacity is perhaps the conduit through which technical and administrative aws seep into programmes and paralyze them. The reason for poor performance of workers could be many. Inadequate or delayed remuneration (monetary, recognition, reward), inadequately trained/motivated staff, recruitment of staff in deance to the requisite qualication, lack of monitoring and supervision, job-overloading, and little job and career enhancement opportunity, etc. are a few to account. The trainers for the grass-root workers do not maintain a uniform quality either. The involvement of the NGOs as a public-private-partnership endeavor under NRHM/RCH-II for providing hands-on technical support to the eld staff is a commendable strategy but this also, if without the supervision of medical college teachers, could result in poor training performance mostly proving counter-productive. At many places in our country, the health worker female (ANM) have been directed to motivate people for sterilization, prepare blood slides, provide chloroquine in fever cases and what notwhy did we forget the health worker male or health education ofcers, who rarely involve themselves in implementation of direct health activity? Intersectoral coordination is expected at the grass root level. For e.g. between ANM & AWW while many-atimes the portfolio ministers do not coordinate with each other. An underperforming or controversial programme does receive attention for a while from all circles. The best examples for this are enumerated by the numerous semantic changes to family

planning programme and the launch of different generations of malaria or tuberculosis control programmes. However, a programme that fails to get a face-lift loses the affection of administrative spheres and despite the huge infrastructural built-up already accomplished, spirals downwards. The sociocultural and demographic divides across India cannot offer us the luxury of a blanket programme for one and all. Clearly, the strategy has to be different for the Empowered Action Group states and the rest of India. It is remarkable that we have understood this challenge and responded to it fairly well. However, the core issues do not require out of the box thinking. Working out to solve the problems which have proven remedies is more important than to launch fresh programmes that coincide with the existent ones. Similarly, incentive based programmes should be implemented with care as long term feasibility of such exercises is questionable. The political leaders starting from the village to the parliament must be made answerable, accountable and responsibly punishable for any programme failure in their area because it is political will that provides the greatest mileage to any programme. (PROF. S C MOHAPATRA is the seniormost professor in the Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi. Prof Mohapatra has been the recipient of the prestigious MK Sheshadri Award from ICMR, New Delhi for his contribution to Community Medicine in India. He has been a visiting teaching faculty to the Liverpool School of Tropical Medicine (England). Dr Archisman is a MD nal year resident in the Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University. He has been working extensively on community health and health programmes. The views expressed in the article are personal and do not reect the ofcial policy or position of the organisation.)




Padma Shri Awardee ; Consultant, Post Grade Institute of Medical Research and Education

Increasing public spending on health-care is important but what is even more crucial is to ensure optimal utilization of the scarce funds

GID: Do we really need private sector participation to increase healthcare access to the bottom of pyramid in rural India? How would the PPP model help to bridge the demand-supply gap? M A Khan: India is drawing global attention, not only because of its population explosion but also because of its prevailing as well as emerging health prole and profound political, economic and social transformations. It will be best done by private sector through providing infrastructure facility in India, especially in rural sector through PPP model which can be well adapted for this purpose. GID: India invest merely one per cent of its GDP in health care in spite of the ve year plans suggesting an increase to at least 3-4%. This is very less as compared to the developed countries. So, what according to you should be the ideal/optimal policy as far as funding is concerned? M A Khan: The idea of Universal Health Coverage (UHC) was discussed by national and international health experts at the Planning Commission in a two day meeting which concluded on Tuesday 29th November, 2011. The issue will be discussed in the steering committee on health in the Commission, which is in the process of nalizing the next plan. The government had set up a High Level Expert Group (HLEG) in October last year to prepare a blueprint for UHC and spell out a strategy for its

implementation. China and Mexico are close to achieving 100 per cent universal health coverage, while Thailand has already done so. Universal healthcare for all, funded through increase in public expenditure from 1.4% to 3% of GDP will be an ideal solution. However, it is very unfortunate that even the low amount of public health-care spending is not managed properly. So, even before increasing the amount of spending it is very important to implement a mechanism to ensure optimal utilization of the fund and bring in accountability in the public health-care sector. GID: Preference of private hospitals over government-run hospitals has become a trend today. Is it not an indication of governments failure to provide proper healthcare? M A Khan: The government has not failed but its the people who are failing to avail the infrastructure facilities sometimes due to lack of information and uniform distribution. The present UPA government has provided many schemes to cover rural population as Gramin Swasth Yojna, National Rural Health Mission and Janani Surakha Yojna. People go to private sector when they get nervous by seeing huge ques at government run hospitals, but mind it that long ques are proof that good work is being done there. Government has been ghting successfully HIV, Tuberculosis, Infectious disease, Gastrointestinal diseases, Malaria, Filarial diseases,

Leprosy and Kala Azar through its various Programs. After the employment guarantee scheme and right to education and food security Bill, UHC could be the next big social sector trump card of the ruling UPA. At present, most of the healthcare expenditure in India is Out-of-pocket or money spent by people themselves. The central and state governments together only spend about 1.4 per cent of the GDP on healthcare, while the money spent by aam admi (common people) amounts to over three per cent of the GDP. In order to provide a minimum package of health services universally, the HLEG has recommended that


the government should increase public expenditure on health from the current level to at least 2.5 per cent of the GDP by the end of the 12th ve year plan and to at least three per cent by 2022. This would result in a sharp decline in the proportion of private spending on health from 67 per cent currently to 33 per cent by 2020. GID: How a comprehensive health insurance policy can improve the scenario? Should government provide the insurance cover for the people or it should be left with the private sector? M A Khan: Yes, insurance is a right answer to this problem. Government has provided large benets of free health care to all its central and state government employees and workers through Employees Insurance Schemes (ESI). Modalities of such comprehensive insurance are being worked at government level. Health for all by 2000 AD remains as a distant mirage and the slogan has been rephrased as Health for all in 21st Century. Primary health care, as a paradigm, has been lost on the way. The failure of the Alma Ata Declaration in fullling its objectives to shift resources from urban to rural scene, reiterates the urgency of looking for alternative strategies at the national and local level. To improve the prevailing situation, the problem of rural health is to be addressed both at the macro (national and state) and micro level (district and regional), in a holistic way, with genuine efforts to bring the poorest of the population to the center of the scal policies. A paradigm shift from the current biomedical model to a sociocultural model is required, to meet the needs of the rural population. A comprehensive revised National Health Policy addressing the existing inequalities, and work towards promoting a long-term perspective plan exclusively for rural health is the need of the hour. GID: What do you prefer a Government controlled medical system with nationwide income or a private control with private income? M A Khan: I would prefer government controlled medical system with nationwide income (a model that prevails in Canada). The UHC has been dened as ensuring equitable access for all Indian citizens, regardless of income level, social status, gender, caste or religion, to affordable, accountable and appropriate, assured quality health services, with the government being the guarantor and enabler, although not necessarily the only provider, of health and related services. GID: Chief Economic Adviser Kaushik Basu recently said that the government should consider providing free health care for the poor and signicantly increase its spending on the health sector. Is it just a political game or will be implemented very soon? M A Khan: No, it is a political will. Planning Commission is serious on this. A national health package of essential primary, secondary and selected tertiary healthcare services funded by the government has been suggested. It can have some state specic variations and will be periodically dened by experts. No user fee would be charged for these services and no insurance companies would be involved. We must be able to provide access to good healthcare without involving insurance companies or other intermediaries because independent agents fragment the nature of care being provided and this, over time, leads to high healthcare costs and lower levels of wellness, explained Dr K. Srinath Reddy, chairman, Public Health Foundation of India and head of HLEG. GID: What are the prerequisites on the policy front to improve the dismal of health-care in India? Universal healthcare for all, funded through increase in public expenditure Strengthening public services at primary health centers and district hospital level Contract private providers (as per need and availability) with dened deliverables Streamline medical education; create new cadres for rural healthcare Government should procure all essential medicines, ensure quality control, transparent procurement and prompt payment Set up National Health Regulatory and Development Authority and state authorities



Professor, Center for Multicisciplinary Development Research (CMDR), Dharwad, Karnataka


Poorly managed resources and funds are the prime reasons for the dismal state of HIV/AIDS prevention and awareness in the nooks and corners of India
very one wishes to be away from disease, disability and premature death. Substantial evidences are now available regarding the fact that good health is an important contributor to economic growth in any nation. In this background, both policy makers and researchers have recognized the importance of investments in health. Public spending on health and education has brought tremendous change in incomes among the poor. Such investments also seem to be the major determinants, which would further contribute to the better health status of the community. India had adopted the goal of Health for All by the year 2000 A.D. Presently new targets have been set forth as Millennium Development Goals to be achieved by the year 2020. These goals have been reiterated in the National Health Policy of 2002 that has been already adopted by the Indian Parliament. The country has been spending signicant amounts of its resources for the provision of health and medical care services, but there is still a large demand supply gap accompanied by problems of inequitable access to facilities and a virtual absence of low-

cost risk-pooling mechanisms for the poor and vulnerable groups of the population. There is a growing realization among administrators and researchers that a major cause of implementation slippages of the policy proclamations relate as much to the problem of non-availability of useful data as to the non-use of available data on the health sector. In other words, pronouncements of desires have not been supported by suitable informational structures and databases for effective health sector governance in India. In such a context, health sector accounting is visualized as a tool for efcient governance. By facilitating greater transparency in the ow of resources from sources to uses, health sector accounts enable health sector managers to get a clear idea about the incidence and impacts of targeted policy interventions. Further, the dynamic benets from health accounting ow in the form of critical informational inputs to policy makers for appropriate moulding of health delivery systems taking into account budgetary innovations, structural and health sector reforms, decentralization of governance, equity and gender interven-




tions, disease burdens, risk pooling and health sector research requirements. As per the Constitution of India, the provision of health care by the public sector is a responsibility shared by State, Central and local governments, although it is primarily a State responsibility in terms of service delivery. A careful understanding of nancial ows of the health sector seems to have emerged as an important policy tool in the recent times. The earlier attempts in developing countries were restricted to the estimation of health expenditures from the public sector only. This was obviously due to data limitations experienced in such countries. To have a comprehensive picture about health expenditure, we must take into account not only public sector spending but also private sector contributions in this regard. This gives us a form of accounts for the health sector, which may be the national health accounts.

A study was undertaken to overhaul the HIV/AIDS accounts at the district level and the following are the major ndings of the study. It is a modest attempt to develop HIV / AIDS accounts for a district in the state of Karnataka. One hundred HIV/AIDS patients were surveyed as part of the study and message from the prole such patients reveals that the disease of HIV/AIDS makes no discrimination and treats everyone at par. It appears that those that above the poverty line and socially progressive are more prone to the disease. At the same time the education factor seems to be the dominant factor as far as the spread of the disease is concerned. Those who are educated or at least literate would understand the advocacy campaigns and would bring in a change in their life styles and thus would stay away from the deadly disease. In all, about 295 millions of Indian rupees were spent in the district. At the outset, if one considers the overall HIV/ AIDS related expenditure, it can be observed that the total resources owing towards HIV/AIDS account for about 0.5 per cent of the district income. This would certainly indicate the meager amount of resources owing towards the prevention as well as management of the disease in the district. If one looks at the breakup of the expenditure by broad sources of funds, it is note worthy to observe that a signicant burden of the expenditure relating to HIV/AIDS falls on the households who shouldered about 91 per cent of the expenditure. Public and External / NGOs shared about four per cent respectively. Thus the pattern which has evolved indicates as well as supports the ndings of the other health nancing studies in the Indian context which have shown time and again that it is the household expenditure which has a signicant share in the total health expenditure. Out of the household expenditure, care and treatment consumes more than 90 per cent. The major issue that has been at the centre of discussion as far as HIV/ AIDS related expenditures is about the share of Health and Non Health Components. Our analysis shows that within the domain of public and NGO (External) expenditures such a argument has come out to be true. For example, the non-health expenditure accounts for about 83 per cent of the resources while only about 16 per cent of the resources do get utilized for health as per components. As far as the total expenditure is concerned, the NGO (External Sector) and the Public appear to be the marginal players. Hence, the need is felt to enlarge the resource envelop of the public expenditure and also to enhance and strengthen the network of facilities for the effective prevention and management of the disease. A look at the expenditure arranged by the Financing Sources and Health Care Functions show that Prevention receives about eight per cent of the resources. Care and treatment got the highest spend with about 84 per cent of the share. (PROF. VINOD B. ANNIGERI is a professor at Center for Multicisciplinary Development Research (CMDR). He has also worked as a consultant to World Bank, WHO, USAID, UNDP, Government of India on various occasion. He has written several books and articles in matters related to health economics. The views expressed in the article are personal and do not reect the ofcial policy or position of the organisation.)



Since its incorporation (1973), IIPM has been an institution with privileged traditions, in the diversity of its fraternity, its global outlook, its world class research and its commitment to alternative national economic planning process. It can be said, without much oversimplication that there are no underdeveloped economies. There are only under managed countries. Japan 140 years was ago was an underdeveloped country by every material measurement. But it very quickly produced management of great competence, indeed of excellence. The policy inference is that management is the prime mover and development is the consequence. At IIPM, every one considers that development is a matter of human energies rather than economic wealth. And the generation and direction of these human energies is the task of management. Accordingly, we formed The Great Indian Dream. Unlike any other dream, this is one dream which each one of us are determined to realise and that too in our own lifetimes. Each bit of cynicism and condemnation from pessimists makes us evolve even stronger and determined. All our endeavours and initiative is towards realisation of this dream, where in we produce committed bare foot managers and entrepreneurs who are needed by nation, on an insistent basis. As an educational institute, we aim at initializing a three dimensional personality in IIPMites, viz. Pursuit of knowledge in economics and management Commitment to economic, social, political and technological upliftment of masses and Cultivation of taste for literature, ne arts and etc. Economists often have limited access to the practical problems facing senior managers, while senior managers often lack the time and motivation to look beyond their own industry to the larger issues of the global economy. It has set before it the twin tasks: to reorient education and research towards the needs of both the private and public sectors and to establish the link between the National Economic Planning and the development of private enterprises in Indian economy. IIPM dares to look beyond, and understands that what we teach today, other adopt tomorrow. IIPMs service output (education, research and consulting,) is a unique combination of two distinct disciplines: economics and management. Through this integration, IIPM helps guide business and policy leaders in shaping the Indian and global economy, bringing together the practical insights of industry with broader national and global perspectives. A hall mark of IIPM is that it is armed with the comparative advantage of engaging the committed, passionate and brightest management post graduates and undergraduates, who pursued the education at IIPM and subsequently joined it, to realise the dream. IIPM alumni, spread across the globe, holding crucial decision-making positions in the corporate sector, are bonded by the one ideology of making a positive difference, turning that ideology into a movement itself. The Great Indian Dream is another humble initiative towards the realisation of the same and more distinctly, engaging the broader publics and pertinent stakeholders.


After 8 years of bringing out The India Economy Review as a quarterly journal, weve decided to rechristen it as The Great Indian Dream and make it monthly with an idea to have a more regular impact on the Indian economy and realise the Great Indian Dream of an educated, healthy and employed India. In economics, like in everyday existence, it is imperative to hear, perceive and consider what others have to say. Each issue of The Great Indian Dream brings together a selection of important contributions on a particular theme, authored by some of the brightest minds in different areas of Indian economics. The provocation for publishing these issues arises from the fact that over the years economic journals have become copious, exclusive and expensive. Most of the journals and a good many of the books have gone beyond the cerebral and nancial reach of general students and other scholars. It is for them that these issues are primarily being raised and debated here. Much about India is transparent enough. One does not require detailed criteria, cunning calibration or probing analysis to pinpoint Indias problems and recognise its antecedents. There is in fact much that is perceptible about India. But not everything about India is even if simplistic is so simple. The learned reader would appreciate the fact that India is like an elephant that looms too large to be grasped within a distinct structure and paradigm the constituent parts of which would fail to reveal the entirety. Obviously and observably, no suggested solution to any protracted and complex socio-economic problem will satisfy all sides and stake-holders evenly. Consequently, there exists an enormous diversity in economic thinking and perspectives, as is also reected in the viewpoints of different expert contributors in this issue. The intended outcome of this exercise is to facilitate the invention, improvement, deliberation and dissemination of innovation in economic thinking and national economic planning, insisting merely on well-grounded, open and unbiased debates, without predetermined outcomes. It is impossible to do justice to the entire eld of Indian economics in a single issue. The topics selected for this issue are those which are of critical and immediate importance to India. Majority of them were freshly and exclusively written. Encapsulated, it is a constructive attempt aimed at helping India actualise its promises and potential. The editors hope that this issue of the GID proffer the reader a avour of dynamism and excitement and persuade her/him to participate in the journey towards realising The Great Indian Dream. At the same time, it illuminates the terrible, practical problems of India and Bharat.

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Cognizant UTI BANK UTI Securities Vishal Megamart Vodafone Wacorp Hyundai India Ltd. Walldrof Walsons Securitas Way2Wealth Welspun West End Club Whirlpool WIPRO Wipro

Weich Technologien

KPO WNS Global Services XEROX Yamaha Motors Yes Bank Yes Bank Retail Banking ZEE Network Zydus Cadila * This is just a shortlist of the companies where our students got PLACED in the last five years!! We are thankful to them and to all others too!!



100% of students who undergo IIPMs flagship Programme in Planning and Entrepreneurship go for a Global Orientation Programme to USA/EUROPE etc. They further spend a week in one of the Top B-Schools of the world like DARDEN, NYU STERN etc.


IIPM GOTA* programmes are held in the following institutions abroad, leading to Certification in Global Management from them Participating B-Schools in India

International Residency

Participating B-School:

Affiliate B-School:

Participating School for GOTA:

Strategic Marketing Programme

Wealth Management Programme:

20000+STUDENTS SENT ABROAD FOR GLOBAL EXPOSURE 20 TOP MOST B-SCHOOL/ UNIVERSITY PROFESSORS HAVE COME TO TEACH!! 1800+ Students, as part of IIPM programme, did GLOBAL CERTIFICATION PROGRAMMES from Darden School of Business, Haas School of Business - UC Berkeley, Judge Business School- Cambridge, Mc Combs School Of Business- UT Austin, ILR- Cornell University and NTU Singapore 350+ Students did CERTIFICATION PROGRAMMES in India with HAAS School of Business and NUS !! 250+ INTERNATIONAL PLACEMENTS IN LAST 3 YEARS & Winner of Dewang Mehta Best B-School Award 2008 & 2009 for HIGHEST INTERNATIONAL PLACEMENTS IN INDIA for 08(165) & 09(55)!! 200+ EDPs WITH INTERNATIONAL PROFESSORS organised for INDIA INC. jointly with IIPM faculty! 150+ ORGANISATIONS visited globally! 100+ INTERNATIONAL STUDENT EXCHANGE PROGRAMME participants on campus from 10 different Universities! 15+ COUNTRIES VISITED by IIPM students including Australia, Germany, Austria, Belgium, France, Turkey, Italy, Japan, UK, Norway, Finland, Spain, South Africa, Sweden, Switzerland and United States! 12+ GLOBAL MANAGEMENT GURUS like Philip Kotler, Stephen R. Covey etc. came to teach! 6+ GLOBAL MANAGEMENT events with International student

Constantly Ranked at the Top

IIPM has been Ranked the No.1 B-School in India, ahead of all the IIMs in Global Exposure as well as Intellectual Impact by Zee Business Best B-Schools Survey 2011 and ranked the 5th Best B-School Overall as well as 5th Best in Placements. IIPM has been Ranked No.1 in International Exposure (ahead of all the IIMs) and the 9th Best B-School in India by DNA Best B-Schools Survey 2010 IIPM has been ranked the No.1 Private B-School of North India by the Hindustan Times Best B-Schools of India Survey 2010. IIPM was also ranked the 8th Best B-School in the country that students aspire for and the 9th Best Private B-School in India in the same survey. IIPM has been ranked the No.1 B-School in Delhi NCR by Mail Today Best B-Schools Survey 2010. The same survey also ranked IIPM No.1 in 25 Top of the Mind Institutes, No.1 in International Exposure, No.2 in Placements and Potential to Network and No.3 in Faculty.


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