Do We Care? India's Health System

Do We Care? India's Health System. K. Sujatha Rao. Oxford University Press, New Delhi, 2017. 446 pp, ₹895. ISBN 978–0190125318.

The book with the rhetoric question as a title is Sujatha Rao's analysis and commentary on India's impoverished and dysfunctional health system. As the former secretary of health for the Government of India, she was an insider and understands the system well and is in a position to offer suggestions for improvement.

The book contains six chapters, one each on the evolution of India's health system, health financing, health governance, the response to HIV/AIDS, the national rural health mission and on the future.

The first chapter sets the stage and makes it abundantly clear why, to paraphrase quantum mechanics and particle physicist Werner Heisenberg, who once said ‘Not only is the universe stranger than we think, it is stranger than we can think,' not only is it difficult to understand India's health system, it is more difficult than we can imagine it to be. The other chapters deal with the role of the governments––state and Central––as well as the private sector, non-governmental organizations, international organizations, public–private partnerships as well as the financial and logistical considerations which decide what approach is ultimately taken to combat disease. The structure of our health system is explained in considerable detail in the book. This includes the medical education system, recruitment and transfer policies, the pharmaceutical industry, corruption and related topics. For obvious reasons, much of the discussion revolves around this century (up to 2016).

The committee headed by Sir Joseph Bhore gave recommendations for health policy in 1946––as did other committees (as many as seven committee in seven decades)––but most of these recommendations have not been followed. Instead, we have moved from the Fabian socialist state to private enterprise––as in following the American model of healthcare––and in being influenced by the liberalization policy of the early 1990s.

Why did India not follow the British system in which the government takes care of the health of the people? After all, we follow their system of parliamentary form of government, law and order and even driving on the left side of the road. But because we have not, we have the resulting inadequate health system. The coexistence of public and private healthcare right from independence with its increasing dependence on private healthcare, the lack of leadership and interest on the part of government (because it has not been considered important from the point of view of garnering votes during elections) and the fact that the Constitution of the nation has not stated that health is a fundamental right, have meant that health has always been considered a non-essential subject.

We learn during the course of the book that India is one of the only 15 countries in the world that spends <1% of its gross domestic product on health. As many as 3.5% of Indians become impoverished every year and 5% face catastrophic expenditures because of medical bills. Uttar Pradesh and Kerala have a four-fold difference in their maternal mortality rates. Which is why the author states that it is meaningless to look at such indices at the national level. Such figures should be seen at the state or local level and should be addressed locally.

Rao hits the nail on the head when she states that it is the rich versus poor divide which is largely responsible for the mess that we are in today. And that it is the absence of guilt and loss of values on the part of those in power, which is the cause for the lackadaisical approach of the government towards health.

The problems as she explains, include poor financing, a low priority for health in the eyes of the government, weak governance across the system and, finally, an indifferent leadership. All of these are, of course, interlinked. What needs to be done to change all these? Increased public spending and improving accountability are key to this. She argues that there should be decentralization of health services (‘easier said than done,’ p. 389) and policy. The public and private health systems as well as the entire delivery structure have to be revamped if we are to achieve the ideal of Health for All, or universal healthcare. This will require a drastic change in our thinking and approach to healthcare. Civil society, institutions and the law will have to play a major role. Fortunately, technological advances in the past are such that they can impact directly and immediately on improving healthcare.

One wishes that the author had elaborated on some of her specific difficulties and differences with the government, with perhaps, thoughts on how to overcome them in the future. While I concede that HIV-AIDS is a good example of how the government managed to control the disease, I felt that the chapter devoted to it did not fit into the general scheme of this book.

There are minor errors in the book. The General Medical Council is the medical council that rules physicians in the UK— not the British Medical Council, as she has referred to it. Apollo Hospital was established in 1983 and not in 1984 as stated on page 16. A typo on page 189 puts the Alma Ata conference in 1976 while it took place in 1978 (as is correctly stated elsewhere in the book).

For reasons that I cannot fathom, the prefix Dr is seldom used while referring to physicians. Thus, it is only if you happen to know or know of (Drs) Thelma Narayan or Ravi Narayan or Devi Shetty, that you would know that they are doctors and are thus qualified to make the points that they make in the book. Readers who are not familiar with the health system, and its many players, would be unable to put these names as well as that of so many others, in the proper perspective. Likewise, the book refers to (Prof) Amartya Sen and (Sir) Joseph Bhore and (Dr) Ketan Desai.

The list of references and the index are adequate and relevant.