People's Democracy

IN recent years there has been increasing focus on what are termed as "lifestyle diseases". These are diseases that are brought on by an unhealthy lifestyle - sedentary habits (low physical activity), preference for unhealthy "junk foods", over-indulgence in addictions like tobacco and alcohol, etc. MNCs led globalisation encourages trade in unhealthy products - alcohol, tobacco, and baby foods. As a consequence people in the third world are suffering from the ill effects of "development" superimposed on the problems of underdevelopment. The WHO estimates that approximately 2 million deaths every year are attributable to physical inactivity; and preliminary findings from a WHO study on risk factors suggest that sedentary lifestyle is one of the ten leading causes of death and disability in the world.

In a country like India a large percentage of the population suffers from under nutrition and are forced into long hours of backbreaking physical labour. But at the same time there is a significant section of the poor who are prey to lifestyles diseases because of changes in the work environment and conditions of living. In the rapidly growing large cities of the developing world, physical inactivity among large parts of the population is assuming alarming proportions. Crowding, poverty, crime, traffic, low air quality, and a lack of parks, sports and recreation facilities, and sidewalks make physical activity a difficult choice. Even in rural areas of developing countries sedentary pastimes, such as watching television, are increasingly popular. Inevitably, the results are increased levels of obesity, diabetes, and cardiovascular disease. In the entire world, with the exception of sub-Saharan Africa, chronic diseases (a majority of which are related to changing lifestyles) are now the leading causes of death.

It is thus not possible to argue that lifestyle diseases are a concern of the rich and the public health system need not respond to the challenge posed by them. In fact recent studies have shown that South Asians are more prone to diseases like heart disease and diabetes. The question then is, how should the creation of medical infrastructure reflect the changing pattern of disease among large sections of the population.

While the concern on lifestyle diseases is correctly premised, the prescriptions from a public health standpoint have often been misplaced. Lifestyle diseases mean diseases like heart disease, diabetes, cancers, etc. As a result, a perception has been created that any strategy to tackle these problems needs to look at the creation of "super-specialty" hospitals with "state of the art" facilities. This is an erroneous perception that has been carefully orchestrated to develop a "market" for expensive health care. The fundamentals of public health apply as much to lifestyle diseases as to communicable diseases. In both cases, greater emphasis on improved services at the primary level, that is the level where the patient first comes in contact with the health care provider, is the most effective.

There is a trend today towards creation of facilities for treating lifestyle diseases, which are distinct from the existing infrastructure. In recent years there has been a mushrooming of such facilities, especially on metropolitan centres and large cities. Many of these have been set up by the corporate sector, with large dollops of help from the government in the form of land at concessional rates, concessions on imported equipment and other forms of tax relief. On the other hand the New Health Policy explicitly states that the private sector would play an increasing role in providing tertiary care, that is care in large institutional settings. The combination of a private sector trying to create a market for high cost care and the government’s support is creating a class divide in health care. What is not understood is that lifestyle diseases do not affect only those who are rich.

What we need to understand is that medical infrastructure needs to be structured like a pyramid. In this pyramid the maximum emphasis has to be at the primary level, i.e. at the level of first contact that should be easily accessible (both physically and in terms of affordability) by everyone. Thus the first contact would be at the village (or panchayat) level, and in urban areas through dispensaries that are widely dispersed. From here there should be successive rungs of the infrastructure, at the sub-Block, Block, District, State levels. Each successive rung needs to be equipped to perform more complex tasks and take care of more complex conditions. This has to be followed up with a referral system along this pyramid. Such a system minimises waste (viz. in the form of trivial or self-limiting illnesses being treated at District or state level hospitals) and enhances accessibility.

In India we, on paper, have such a system in operation. Unfortunately, on the ground, this system is woefully inadequate. Thus the infrastructure below the District level is non-existent or rudimentary. This places enormous burden on patients who have to travel large distances and a huge load on the facilities available at state and district levels. The reason for this is two-fold. First, while in a pyramid the strength of the base is most important, we somehow have this erroneous notion that the excellence of the system depends on the apex—i.e. specialty hospitals in metropolitan centres. The other reason is that India (among any country of significant size) has the most privatised health system in the world. Private expenditure accounts for 84 per cent of health care costs in the country. In contrast in most of the developed world it is as high as 70-90 per cent, even in the US (with the most privatised system in the North) public (i.e. government.) health expenditure is 44 per cent of the total. In GDP terms too, at 0.9 per cent of the GDP health care spending in India is one of the lowest in the world. Significantly there has been a decline in this from 1.3 per cent during the last decade, i.e. the decade of economic reforms.

The above has many implications. As far as the government sector is concerned, health care expenditure tends to be skewed in favour of the metropolitan centres (i.e. the apex of the pyramid), because this is the most visible part. Spending on large hospitals and super-specialties satisfies, to an extent, the vocal elite and middle classes. On the other hand low government expenditure leads to a proliferation of the private sector. Interestingly the latter is the largest unregulated sector of the economy, with a turnover that exceeds 30,000 crore. In recent years this has spawned interest by the corporate sector, aided by the government in the form of tax concessions, land at subsidised rates, freedom to import equipment without duties, etc. The entry of the corporate sector has further skewed medical infrastructure creation towards super-specialty hospitals, because that is really where big money lies. Further the lack of basic facilities in the government sector, especially in the districts, has led to medical manpower being concentrated in big cities and metropolitan areas.

The issue of medical infrastructure creation needs to be located in the above background. While we cannot argue that we do not need super-specialties, we need to argue that we need primary care more, and super-specialty hospitals should not be built at the cost of such care.

Interestingly the National Health Policy Draft, 2001, talks about using Indian health facilities to attract patients from other countries. It also suggests that such incomes can be termed "deemed export" and should be exempt from taxes. This formulation draws from recommendations that the industry has been making and specifically from the "Policy Framework for Reforms in Health Care", drafted by the prime minister’s Advisory Council on Trade and Industry, and headed by Mukesh Ambani and Kumaramangalam Birla. Such a proposal, termed by many as "health tourism", will divert our best resources to serve the interests of the global health market and create islands of brain and resource drain within the country.

The issue of lifestyle diseases is being projected as though they can be treated only in tertiary high technology institutions. It is true that as India passes through a phase of demographic transition (with people living longer) incidence of diseases like heart disease, diabetes, cancers, hypertension, will increase. But the same pyramid analogy, used earlier, applies here too. These diseases can be tackled at an early stage only if facilities at the primary and secondary level are improved. The cost of treating many of these conditions becomes prohibitive (and unaffordable for most) if they are encountered late and have to be treated in super-specialty centres.

All the above, of course, requires a complete overhauling of the medical infrastructure in the country, and above all greatly enhanced public spending on health care. It also requires a change in the mindset, which posits that good health care is always synonymous with super-specialties and high technology.