part0014

In the mid-1970s, I happened to spend a year at Harvard University in the US working at the Kennedy School of Public Administration, from where I took a course on ‘The Economic Bases for Population Growth’ at the School of Population Studies. The substance of a full semester course could be summarized as: ‘There is direct correlation between economic development and reduction in rate of population growth'; the relationship is not in terms of GDP or per capita growth—it relates to the rate of growth of the poorest segments of the population. In particular, the key factors that directly correlate with population control relate to female literacy, mother and child health, nutrition levels as well as public hygiene—these have the direct maximum impact on reduction in population growth. All the reader needs to do to empirically test the validity of this thesis is to refer to the population growth of different states in India in the first decade of this century—Kerala’s population grew by 4.9 per cent, while that of Bihar by 25 per cent; the Bimaru states (Bihar, Madhya Pradesh and Uttar Pradesh) showed the maximum ‘buoyancy’!

The policy implications for India are obvious. Mahatma Gandhi, without studying at Harvard or Princeton understood this fully. He postulated that every policy decision taken at the highest level should answer only one question—‘will it benefit the poorest person?’ Alas, our great economists and post-independence leaders have not grasped this single fundamental. The mantra has been growth, with no concern for lifting the poor. No doubt, we are enjoying the benefits of the ‘population dividend’ today but without giving them education and health, this asset can turn out to be a major liability—indeed a catastrophic disaster. Their unemployability in an increasingly knowledge-based society can be highly counter-productive for national interest. Besides, 20 years from now the population will age, the average national age will sharply increase with massive attendant large-scale problems. Sometimes one is astonished at the vacuum in national policymaking. To put it simply, India and China started their development path about the same time. In the first two decades China focused sharply on education and public health and rural roads/electricity, then embarked on a massive urban development programme. We started in the other direction, and can now see the results 50 years later.

In any democracy, the most fundamental issues relate to the education and health of a citizen. On the specious ground that these are state subjects, national attention to these basic aspects of a citizen’s welfare has been tardy—it is neither on the radar of the Centre nor of the states; citizens are the sufferers. India’s current rank is a lowly 110 in the International Human Development Index; education and health make a huge contribution to this index.

According to the Nutrition Barometer report released by the International NGO Save the Children, India ranks with Congo and Yemen at the bottom of the 36 developing countries studied, which have 90 per cent of the world’s ‘stunted’ children. The other South Asian countries, Bangladesh, Pakistan and Nepal fare much better in this regard .

Every third woman in India is undernourished; every second woman anaemic (55.3 per cent); three out of four children are anaemic. The child nutrition status has declined in many north Indian states; 53 out of 1,000 infants die within a year of birth. At least 44 per cent of the kids sleep hungry. Immunization levels which ought to be close to 100 per cent, at least upwards of 99 per cent, stand at around 52 per cent in India. These are appalling statistics which are unacceptable. Forty per cent of the world’s undernourished children live in India; 48 per cent of Indian children below 5 years are stunted and 42 per cent are under-weight. All this is the result of poor nutrition.

The latest ‘Lancet’ report indicates that 45 per cent of deaths of under-5 children in India are caused by malnutrition. According to a WHO estimate, 26 per cent of maternal deaths globally occur in India. The Indian ‘mother and child’ care situation is rated to be at the bottom of the international pile.

Sixty-two per cent of the children under 5 years of age are vitamin A deficient; 31 per cent of school age children are iodine deficient. These deficiencies cause death and disability and retard brain development, IQ, cognitive skills, energy levels and productivity. India’s performance on these crucial outcomes is among the worst in the world. Our nutrition indicators are far worse than those of even our neighbours Bangladesh, Pakistan, Sri Lanka and Nepal.

There is no awareness of the essential requirement of micronutrients for healthy growth of a body and mind, even among concerned national and state officials, not to speak of the population at large. Folic acid, vitamin A, iron, iodine, zinc (for diarrhoea), at minimum requirement levels are critical for health. According to a World Bank estimate, India ranks along with sub-Saharan Africa in this regard; it will take at least 25 years more to catch up with average African standards at present rates of growth!

Seventy-five per cent of an average Indian’s healthcare expenditure is spent in the last 15 days of his life, based on a research paper discussed in a CII-Indus Entrepreneurs Healthcare Seminar recently. This cruel statistic illustrates the near-total absence of basic healthcare, insurance, availability of medicines and basic treatment in large parts of India. In most district and tehsil hospitals expensive equipment rusts and lies unused for want of spare parts or lack of minor repairs. The absence of medicines at the right time is chronic. A Union minister recently declared that ‘India’s public health system has collapsed’; can there be a more damning indictment of the present state of affairs?

In all civilized countries, healthcare for the public is placed at the highest priority in public policy. For instance, in the UK, the National Health Service provides free quality medical advice and treatment to all citizens. The public healthcare systems in the Scandinavian countries, fully free of charge, are of the highest quality, comparable to the best available. The situation is similar in most European Union countries. In many developing countries, public policy accords high priority to citizens’ health and has many programmes to support these, nearly all free of cost. In South Korea, for instance, nearly every community (equivalent of our Gram Sabha) has a two-bed mini nursing home, with a trained nurse in attendance, and electronic/ video connectivity with a major hospital. The first Obama elections in the US four years back saw, as one of the main issues, better healthcare coverage and affordable health insurance for all. During the election campaign in Brazil, President Lula promised delivery of measurable improvement in nutrition levels and micro-nutrient indices in the population; in the event, during his term in office, he gave personal attention to this element as a high priority and was able to achieve 90 per cent of the promised targets. President Rajpaksha in Sri Lanka made micro-nutrients a major policy issue in his governance. Over time, due to his personal commitment, the quality of life in Sri Lanka has significantly improved in this regard. It is an index of the contempt that our successive governments have had for citizens that Indian facilities in this regard are abysmally poor. Indian expenditure of 1.87 per cent of GDP for healthcare would rank among the lowest in the world. The Indian medicare system has been designed to benefit the top 10 per cent of the population (as are so many other ‘public interest’ arrangements), to meet the need of rapacious hospital interests—devil take the hindmost 90 per cent.

Nearly 80 per cent of the population lives in rural areas with poor access to healthcare and medical facilities; reinforced and perpetuated by the lack of skilled service providers and the virtual absence of accountability in the public health system. As a result, there is a huge unmet need for health services, with children and women being the major sufferers. According to the latest National Family Health Survey (NFHS) and District-Level Household Survey (DLHS) data an average of 15 per cent of the population that seeks healthcare services accesses government health facilities, while 85 percent opt for private providers—a sad commentary on the quality of our field governmental machinery.

A study has found that perceived quality of services was an important determinant of the pattern of utilization. Private practitioners were perceived to be providing better services because they included injections as part of every treatment and were willing to make home visits which were convenient, especially where transportation was inadequate. Government health services were not popular because of the longer waiting period involved, the attitude and behaviour of the staff and lack of medicines. Several other deterrents, such as bad roads, the unreliability of finding a health provider and costs for transport and wages foregone, make it cheaper for a villager to get some treatment from the local practitioner or ‘quack’, who may have limited knowledge and skills in either modern or traditional medicine. Taking good quality healthcare to the doorsteps to reach many of these under-served areas is thus very important. Initiating innovative public-private partnership models to capitalize on the preference for private sector services has not even been considered.

Elementary preventive medical advice and primary treatment facilities ought to be available to all, even in the remotest areas, of minimal acceptable quality and free of charge. Secondary and tertiary (specialist) hospitals could be left to private sector enterprise. The basic care of acceptable quality is the responsibility of the state. There are many healthcare programmes (mother and child, family planning, immunization, etc.) sponsored and funded by the state and central governments. However, these are department-centric, riddled with turf wars between various state government departments. At the field level, this ‘specialization’ is startlingly evident, when a worker popularizing the use of condoms cannot reach the women of the household; and with different departmental workers, crowding each other out, confusing the citizen, and being thoroughly ineffective. Departmental tussles at the secretariat, directorate and field levels are paramount—the citizen is nobody’s concern. Trained multi-purpose para-medic workers, with capability of providing basic consultancy and facilities over the normal range of issues affecting a household has not been thought of seriously.

In recent years, I had the opportunity to become familiar with the progress in implementing public health programmes in different parts of the country. Nearly in every state, most senior officials, Chief Secretary downwards have scant concern for public health and nutrition/micro-nutrient issues. Even in the medical or public health or rural health departments, the focus is on hospitals, supplies and equipments, as well as on postings and transfers of doctors—all ‘lucrative’ in their own right. However there is little interest or care in issues like anaemia, mother and child condition, and immunization levels relating to preventive or primary healthcare issues. In one state, for example, in a meeting called on my initiative by the Chief Secretary, the four secretaries concerned and their directors argued that the immunization levels in their state was 99 per cent and anaemia less than 10 per cent. When I remonstrated, quoting NSS data for the state, I was pooh-poohed—the state produced ‘its own authenticated data’ showing nearly 100 per cent success! They openly said that the published figures of the Government of India were incorrect. There was nothing further to discuss or argue. Nobody in the state was interested in any innovation, improvement or enhancement of their programmes, they just wanted the money from the Government of India.

Fifty years ago Tamil Nadu started the mid-day meal programme in government primary and secondary schools. One is told that thanks to a persistent Education Secretary in the state government this far-reaching idea was introduced and implemented successfully, despite strong opposition mainly because the chief minister of the day, M.G. Ramachandran supported the idea. One is not surprised as my grandmother, with Kerala origins, in the early 1950s would talk of narishmandu , referring to ‘nourishment’; such was the awareness those days. Clearly we have regressed in many areas in the past decades. Indeed our own Constitution, in its Directive Principles commands the state to raise the ‘level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties’—injunctions, as so many others, that have been so conveniently ignored by our political executive. One may surmise that the current pre-eminent position of Tamil Nadu in the Information Technology field could possibly be related to the foresight of one official in the state government decades back.

Thank goodness, the mid-day meal scheme in our schools is now a national programme. The overwhelmingly poor children, especially in our rural areas, do need the nutrition through this route as a minimum investment in the country’s future. Besides, this is also an excellent vehicle for providing the children with essential vitamins and micro-nutrients through supplements in the mid-day meal. The technology is available; it is only that casualness and tendency for resistance to change at the Centre and in the states, which has not allowed a full focus on this vital programme to make it a significant engine for the nation’s growth.

There have occasionally been mishaps, some very serious, in the mid-day meal scheme. In summer 2013, in one village in Bihar about 30 children died due to food poisoning. Other such events of lesser magnitude are quite the norm in India, sadly given the scant regard and care to field implementation issues. Indeed many ‘arm chair’ nutrition experts in India have advocated that food supplementation is not required; what is required, is providing a balanced diet—a strong motherhood statement akin to saying, ‘if they can’t afford bread, let them eat cake’. Surely if one can provide milk, eggs and green vegetables to every citizen the national nutrition levels will shoot up. If every poor person becomes rich, he would get good food! Till the population can afford natural nutritive food, supplementation is the second best alternative; the mid-day meal is an ideal vehicle. Asking for the scheme to be terminated because of implementation difficulties is like arguing for ‘throwing the baby with the bath-water’. There are so many fatal railway accidents—do we close down our railways? Shall we ban trucks due to road accidents? The mid-day meal scheme needs to be improved, made efficient, implemented much better, with provisions for proteins and nutrients and supplements. This is the best investment that is possible in our country at this stage.

Till recently, I was the chairman, currently Chairman Emeritus, of the Micronutrients International Trust India, a subsidiary of the Micronutrients International (MI) based in Ottawa. MI in Ottawa, mostly funded by the Overseas Aid Programme of the Canadian government, is headed by Dr Venkatesh Mannar, of Indian origin—he has been conferred with the highest honour of the Canadian government for his services in improving nutrition in developing countries. MI’s largest programme is in India. I have a clear picture of the attention to these matters in our states. Despite tardiness at the Centre, many states on their own have taken major steps to provide nutrient supplements to their populations. Particularly noteworthy is Gujarat’s initiative of introducing vitamins supplements blended into the atta (wheat flour) supplied to the public, as well as promoting iodized or double-fortified salt (iodine plus iron) to combat anaemia. Many other states have similar programmes, on their own initiative. In many western countries ‘fortification’ of bread and milk with supplements has been standard practice for decades. In India, the Modern Bread brand used to be fortified with vitamins, so long as it was a Government of India company—they probably followed the British specifications; after it was denationalized and purchased by a private company, this practice, which adds a miniscule amount to the cost has been discontinued—clear proof of great corporate concern for the public weal!

There is no question that major, far-reaching reforms are urgently required. There is no reason why available electronic technology (V-SAT, 3-G, etc.) cannot be used for well-equipped mobile vans, with real-time connectivity with a bank of doctors, say at the divisional or state headquarters to facilitate onsite basic tests (blood, ECG, eye-testing, etc.), and provide instant advice, with periodical (say, every three months) visits, starting with primary schools and reaching village mandis and in due course covering the entire population. These are entirely doable, and the cost implications are not likely to be mind-boggling; it is just that the system is too lethargic to innovate and come up with new solutions to old problems—there is just no political will.

One wonders why healthcare has not been made a major public election issue. Every party’s election manifesto blandly talks of poverty reduction, welfare of the kisan or the jawan, good education and healthcare, etc.etc. It is time now to demand that before every national election, every major national party should commit itself to a detailed healthcare agenda, promising what it will do over the 5-year period, and specifying the objectives and targets against which they will be measured at the end of five years. Civil society organizations and other public workers should now demand these from major parties, and ask for implementation of major innovations and reforms in this sector.