The Mess in India’s Public Health Care

“Eleven women die after sterilisation surgeries…” the newspaper headlines leap out at you first thing in the morning. The location does not matter, what matters is one more instance of how India’s public health system is miserably failing in its duties to its customers, largely the poor and disadvantaged. Amidst the glowing official reports of eradication of polio and reductions in child and maternal mortality rates, these news items serve as a rude reality check on the vast gap between the promise and performance of the Indian health system.

The designation Department of Health and Family Welfare carries, in the Indian context, its own peculiar meaning. What was originally “Family Planning” was converted to “Family Welfare” after the Emergency sterilisation excesses of the mid-1970s, in an apparent bid to allay public anxieties about the mandate of the health department. But talk to any official in the health department, or, for that matter, any politician or high-level bureaucrat in the government and you realise that family planning — limiting the size of the family — is the topic uppermost in their minds. The entire development literature on how reducing infant mortality, promoting livelihoods and income and giving girls greater access to education and empowerment can bring down population growth rates has apparently bypassed the entire swathe of the politico-bureaucratic elite in the country. Instead of focusing on these long-term (and admittedly more difficult) policy objectives, you find a maniacal, mindless obsession in government with setting ambitious sterilisation targets year after year. It is this preoccupation with family planning targets that has skewed the approach to a rational management of public health issues. Three unfortunate consequences have arisen out of this misguided emphasis:

  • Achieving the sterilisation targets has become the be-all and end-all of the public health machinery at the district level and below. Unfortunately, IAS officers, at the level of District Collector and even at the senior levels in the Secretariat, have been responsible for encouraging this mindset. I have seen the unedifying spectacle of District Collectors competing for the top spot in sterilisations in the state. One major outcome of this unhealthy competition among districts has been the tendency to focus on the easiest method for reaching the target. As always, it is the Indian woman who bears the brunt: having gone through the nine months of child-bearing, she is now required to go through the travails of an operation to stop having further children. Medical experts are agreed that male vasectomies are far easier to carry out and less complicated. But, in a patriarchal society and with the dominant male ego coming into play, there is little hope that the woman will be spared this additional burden. Hence, the chilling statistic that 0.44% of sterilisations are vasectomies and female sterilisations account for over 99.5% of all sterilisations.
  • Cash incentives for the woman undergoing sterilisation prove to be a big draw for families which are at the edge of poverty and induce them to persuade their female members to go in for sterilisation. There is also the incentive for the government functionary who participates in this exercise. District Collectors who organise big camps are seen as “go-getters” and are regarded highly in the government system. Medical Officers and other frontline staff who do not achieve the targets set for them are punished with poor confidential reports and postings to hardship areas. With such a skewed incentive pattern, it is little wonder that this task becomes one of the major annual preoccupations of the health department, to the exclusion of other, far more important tasks like antenatal care (ANC) for women and newborn child care, even though India (and particularly its worst districts and blocks) have appalling rates of neonatal and maternal mortality.
  • With non-health actors, like bureaucrats, enforcing the whip to achieve sterilisation targets, the process moves into a campaign mode rather than into a patient exercise to convince the woman (and her family) that sterilisation is in the interests of the woman and her children and carrying out the operation in an orderly, routine manner, after ascertaining that the woman is in a condition to go through the operation. The “camp” atmosphere also militates against ensuring safe hygiene levels and proper post-operative care. No effort is made to look at alternative, safe methods of birth control, such as counselling on birth spacing and the use of intra-uterine and oral contraceptive methods.

In the recent tragic occurrence in Bilaspur district of Chhattisgarh, questions are also being raised about the quality of the drugs supplied at the camp. This issue of procurement of medicines for the public health system is itself a topic for research. Most states in India have no laid-down policy for buying drugs and equipment, with interference at the ministerial and political level being the norm rather than the exception. Medicines are procured without any analysis of the disease patterns in different areas of the state and often without satisfactory pre-qualification of suppliers. The result is the accumulation of stocks of useless/sub-standard/dangerous medicines, many of which may have reached or passed their expiry dates.

The ultimate casualty in this frenetic exercise to control population through overuse of just one policy tool is the collapse of all protocols for guiding the mother through a safe pregnancy and ensuring the health of the mother and child in the post-partum period. ANC procedures are one of the most neglected areas in the public health arena in India. Ask any doctor in a Primary Health Centre (PHC) about high-risk mothers and you will most likely get a blank look. Even if there is a list of such pregnant mothers, with a history of medical problems and/or previous obstetric issues, chances are that this list does not lead to any proactive action on the part of the PHC doctors. An analysis of data shows that, in many cases, ANC visits simply do not take place. Where they do, it is often a mere formality. The required tests during the ANC visit are generally not carried out; where some tests are conducted, no follow up action is initiated on the basis of the tests. Weight gain by the mother during the gestation period is ignored; it comes as no surprise that the delivered child has very low birth weight, leading to high mortality in the neonatal period. Efforts in recent times to introduce mobile and computer-based systems to track the health and nutrition status of mothers and children have foundered on the unwillingness of the health bureaucracy to expose themselves to an audit of their performance in the first two years of a child’s life. The reason is obvious: no doctor or other frontline health worker has ever lost their job on account for the unconscionably high rates of maternal/neonatal mortality in their areas.

Public health systems will improve only when public functionaries are held accountable for measurable outcomes. It is astonishing that, even after so many years of emphasis on sterilisation as the primary tool of population control, no authoritative finding that rebuts its effectiveness is as yet the subject of public debate. As long as public policy goes in for quick-fix solutions rather than for long-term involvement with communities and families, we will be forced to echo (with some modifications) the poignant words of Bob Dylan:

“How many deaths will it take to be known,

That too many children (and mothers) have died?”

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