One of the major successes
claimed by the present Government is in the field of Healthcare. At every
opportunity the “success” of the National Rural Health Mission is publicized. Schemes
like the Janani Suraksha Yojana and the Rashtriya Swasthya Bima Yojana have all
apparently made a significant impact on the quality of Healthcare that the
Government is delivering. At least that’s what they would like us to believe.
How much of this is spin? Is it true that
there has been a transformational impact in the quality of care delivery across
the country as a result of these schemes?
When an attempt is made to measure the efficacy of any Government Health
program the standard method is to look at the relevant Health Indices in the
period before the program was launched and compare them with those during the
program period. This is not a perfect method but is still the only reasonable
means of objectively measuring the results.
Let us do this for some of the major indices that the State measures and
examine the results.
Let us start with the Infant
Mortality Rate. In the six year period
from 2000 to 2005 the Infant Mortality Rate dropped from around 68 to
approximately 58, a drop of around 14.8%. In the six years between 2006 and
2011 (after the NRHM was launched) the decline was to around 47, a drop of 18.9%.
Over a six year period that’s an additional improvement of 0.68% per year!!! The
goal of the NRHM was to achieve an IMR of 28 by 2012. It is clear that the rate
of decline of the IMR has not been dramatically altered by the NRHM program and
that the goal is far from being achieved.
Regarding the Maternity Mortality
Rate the comparison is even starker. In the seven year period before the NRHM
the MMR dropped from 407(1998) to 254(2004), a drop of over 37%. In the six
years of NRHM so far the MMR has dropped to 200 a further fall of just 23%. The
rate of decline of the MMR appears to have actually slowed after the NRHM was
launched. Admittedly there is still a year of data to add for the seven year
period but it is clear that there is no significant improvement in the rate of
decline. The Target set was to reach an MMR of 100 by 2012!!!
The Fertility Rate in India
dropped from 3.11 to 2.78 between 2000 and 2005. In the next six years it has
fallen only to 2.6 indicating again that the rate of decline has slowed after
the launch of these “transformational” schemes. The target set for achievement
by the end of 2012 was 2.1.The Crude Birth Rate in the decade between 1995 and
2004 dropped from 28.3 to 24.1 but in the seven years thereafter the fall has
been only to around 22. So what dramatic changes are we talking about?
It is important to remember that
even if there was a statistically significant decline in the indices (here
there don’t seem to be any) there could be a number of other causes responsible
for these declines. For example a decline in IMR could be due to the emergence
of better antibiotics to treat infections, reduction in the incidence of
superstitious practices (oil bath , blowing into the nose etc.) that exposed
the infants to risk and so on. Establishing the cause and effect relationship
linking these schemes with the improved outcomes, if any, needs to be done.
Admittedly one cannot
continuously expect significant falls in healthcare indices, as over a period
of time, once the “easy to do” things have been done the rate of decline usually
slows. So it may not be the fault of these programs that the indices are not declining
at the same pace as earlier but equally, there is little evidence to say they
are transforming Healthcare in India. In any case the targets set have all been
missed by big margins.
What is undoubtedly true is that
more money has been spent on these schemes than ever before. In Uttar Pradesh
they are still trying to find out where nearly 10,000 crores of it went!!! For all the vast sums being spent on these
schemes there are few independent studies being done to know if we are getting
value for money. Could these funds have
been spent differently to get better results?
Schemes like the RSBY(the free
Health Insurance scheme) may even be downright dangerous as illiterate and poor patients are being delivered to the mercy of
the rapacious private sector with no standard treatment protocols, no
regulatory body and virtually no grievance redressal mechanism.
A thorough audit needs to be done
of all the major Healthcare schemes in the country by a Team of independent Healthcare
experts together with the audit agencies (The CAG has been auditing the NRHM). An
honest assessment of whether the objectives of these schemes are being met
needs to be made. Course corrections are required within many schemes. In the
absence of such an audit it could just be a case of throwing more good money
after bad.
