State’s Public Health Services need to work better

by A Special Correspondent

A NITI Aayog survey, in collaboration with the World Bank, published in February 2018 ranks Tamil Nadu as the third best State in India for 2015-16 in terms of medical infrastructure. At the ground level, however, results of a grassroot study by an NGO reveals unsatisfactory working conditions in Primary Health Centres and tertiary hospitals.

In Tamil Nadu, according to the local study, state-run hospitals are not the first choice for treatment of TB. In rural areas, especially, three out of five, that is, 60 per cent, go to private hospitals before enrolling in public centres/hospitals for free treatment. By then people have spent considerable sums of money besides losing valuable time in early detection and timely treatment. Delay could lead to complications besides communicating the disease to others in the community. Quite often what seems like minor features have an important bearing on the usefulenes of the service to the beneficiary – example: working hours of the facility. A pre-project sociological survey ensures that every feature of the project recognises the target beneficiaries’ needs, cultural compulsions and habits.

The report of the local NGO records that 49 per cent paid bribes for service, 73 per cent experienced poor/average drinking water availability, over 45 per cent had to suffer long wait and most said that public health centres are not open in the evenings. It must be said, however, that as high as 69 per cent were satisfied with services by doctors.

The report of NITI Aayog focuses on one aspect of health – child health, i.e., neo natal mortality, under-5 mortality, etc. This basic aspect of health could well serve as a reliable proxy for all other facets of public health. The Study has compiled index numbers for performance by States for three components – Health Outcomes, Key Inputs and Governance. Based on the index scores, it has ranked the States.

The NITI Study assigns Tamil Nadu an Overall score of 63.28 in 2014-15 and 63.38 in 2015-16, the two years being the Base Year and the Reference Year respectively. Based on the index score, it is nationally ranked second for overall performance in Health and Family Welfare services.

On Health Outcomes, the State fell from 64.04 in the Base Year to 62.56 in the Reference Year and is ranked third.

On Key Inputs, Tamil Nadu scores 78.06 in 2015-16 and is ranked Number One.

On Governance aspects, no index score could be compiled by the Study due to limited data availability, but several indicators of governance have been rated wherever data was available.

On overall performance, Kerala got 82.89 compared to Tamil Nadu’s 63.38, the latter still getting second rank and that a far second. Kerala has set the benchmark indicating that there is much room for Tamil Nadu to raise performance – by about 30 per cent.

There is an interesting angle on the Key Inputs scores. Tamil Nadu getting Rank 1 is laudable as it sets the benchmark for other States. Kerala with a lower score of 74.17 on Key Inputs has been able to make the Number One spot for Health Outcomes with a score of 82.89. With less infrastructure Kerala has been able to perform better on outcomes. Management and monitoring, making possible a high quality of service, has made the difference between Kerala and Tamil Nadu.

Tamil Nadu numbers show that on Health Outcomes, low weight at birth is as high as 13 per cent compared to 5/7 per cent in Telangana. Sex ratio at birth is 911 girls per 1000 boys born, whereas it is 967 in Kerala suggesting that sex-selective abortions on a significant scale were probably happening unchecked.

Regarding Key Inputs, Immunisation coverage is 82.7 per cent in Tamil Nadu whereas several states in the country have completed 100 per cent or over 95 per cent. Institutional delivery in maternity cases has the effect of lowering maternal and infant mortality and on such an important aspect only 81.8 per cent go to institutions for delivery whereas nearly 100 per cent has been recorded by more than one state. Percentage of districts with functional cardiac units is woefully low at 56.3 per cent in the State compared to a benchmark of 76.9 per cent in West Bengal. The ease of effecting improvements over a very short period is illustrated by Rajasthan’s determination – from 2.9 per cent in 2014-15, they made a sustained effort and equipped 76.9 per cent of the districts with cardiac units in one year. Primary Health Centres functioning24/7, on a norm of one per 100,000 population, is 35 per cent of the norm whereas States like Assam and Haryana set the benchmark with 76.9 and 77.6 per cent coverage respectively

Governance of infrastructure determines outcomes. Here is only one example of governance deficiencies. The continuity of District Medical Officers, who are the frontline force for implementation, is an abysmal 7.3 months compared to 25.4 months in Chhattisgarh and 18.1 months in Gujarat.

The foregoing analysis shows that there is no contradiction between the NITI Report assigning high ranks to Tamil Nadu and the grass-root level surveys by local NGOs reflecting serious deficiencies at the ground level. The first measures the infrastructure quantitatively and the second qualitatively.

Going by the Funds assigned for Health for the years 2010-11 and 2017-18 as cited in Budget Speeches, Rs. 7265 crores were earmarked in 2010-11 and Rs. 32,231 crores in 2017-18, reflecting a 4.44 times increase; as share of total expenditure, it grew from approximately 9 per cent to 16 per cent. The importance accorded to the health sector and the resultant infrastructure are well up to the mark. The focus should, therefore, be on making things work better. Effective governance comes out as an area for major improvement. Honest feed-back on efficiencies and outcomes at predictable periodicity, preferably, every half-year should be obtained. This would help the departments concerned to make course corrections and ensure compliance.

Above all, public health needs a sanitary environment which pervades many aspects – water quality, slaughterhouse hygiene, food safety. Experts emphasise that safe drinking water and sanitation are critical determinants of health, which would directly contribute to 70-80 per cent reduction in the burden of communicable diseases.

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