Opinion Health,wealth,and wisdom

There are inter-state and intra-state variations. However,that earlier question is unlikely to be asked now. There has been a sharp increase in school enrolments,particularly for primary school. We should ask why improvements in educational indicators have not been matched by improvements in health indicators. This is true of supply-side improvements,as well as demand. Understandably,health outcomes are more complicated than trickle-down benefits of growth leading to reductions in poverty,or even targeting school enrolment through SSA (Sarva Shiksha Abhiyan) and midday meals. And perhaps there is some hierarchy of needs at work too.

We know what needs to be done. The Ministry of Health and Family Welfare informs us that since 1946,there have been 21 commissions and committees directly connected with health — several more if one counts those indirectly connected. Admittedly,there are sometimes differences across recommendations on the extent to which private entry,competition and choice are allowed. But in the context of the public health service,consider the following quote. “The following questions seem,at the outset,to require an answer: (1) Whether the service should be free or paid for by the recipient: if the latter,whether it should be a graded scale of payment so as to suit the level of the patient’s income and whether such payment should be made for each occasion when service is rendered or through some form of sickness insurance; (2) Whether our scheme should be based on a full-time salaried service of doctors or on private practitioners resident in each local area or settled there on a subsidy basis; (3)Whether,in either case,some measure of choice can be given to the patient as regards his doctor.”

This isn’t something the Planning Commission or Department of Economic Affairs (DEA) has produced now. It was written by the Health Survey and Development Committee,better known as the Bhore Committee,in 1946. It is not that there haven’t been instances of reform. HS-PROD (Health Sector Policy Reform Options Database) lists some isolated instances.

Despite the agenda of health sector reforms being known,why have necessary reforms stagnated?

First,there is an impression reforms are system-driven. Irrespective of that ideal,reforms have never been system-driven. They have been individual-driven and health ministers since 1991 have not been noted for leaving their marks. Stated differently,the Ministry of Health and Family Welfare has not been perceived to be an “important” ministry. It has typically been a ministry where ministers have been accommodated for political reasons,in sharp contrast to economic ministries proper,or ministries connected with infrastructure. Second,even if ministerial performance has been lackadaisical,health sector reforms might have been triggered had the push come from elsewhere — the DEA,the Planning Commission or the PMO. But health economics is imperfectly understood and imperfectly researched,compared,say,to education. Consequently,though one has to be careful about generalisations,in none of those three channels has health received the importance it should have. The DEA’s Economic Survey is a case in point. Its discussions of social sectors are limited,reflective of historical biases. But to the extent there are such discussions,they have a greater emphasis on education than on health. In the course of the Ninth and Tenth Plans,the Planning Commission undertook several studies on education and skills. Health was relatively ignored. It has been no different for the PMO. Has there been anything comparable to the National Knowledge Commission? The proposed Right to Food may be indicative of a change in mindsets.

Third,the pay-off periods for health outcomes are longer than for education and do not necessarily fit neatly into political-cum-electoral cycles. Improvements in health outcomes also seem to be a trifle more distant than improvements in educational outcomes. This is not a Central issue alone,but also affects states,which is where the blunting edge of health reforms really is. Donor involvement has also tended to place an emphasis on improving governance,rather than the narrower domain of health. But perhaps the demand shift is coming.

The writer is a Delhi-based economist express@expressindia.com