EMERGING SCENARIO

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What then can we conclude about the prospects of health care in India in 2020? An optimistic scenario will be premised on an average 8% rate of economic growth during this decade and 10% per annum thereafter- If so, what would be the major fall out in terms of results on the health scene? In the first place, longevity estimates can be considered along the following lines. China in 2000 had a life- expectancy at birth of 69 years (M) and 73(F) whereas India had respectively 60 (M) and 63 (F). More importantly, healthy life expectancy at birth in China was estimated in the World Health Report 2001 at 61 (M) and 63.3 (F) whereas in Indian figures were 53 (M) and 51.7 (F). If we look at the percentage of life expectancy years lost as a result of the disease burden and effectiveness of health care systems, Chinese men would have lost 11.6 years against Indian men losing 12.7 years. The corresponding figures are 13.2 for Chinese women and 17.5 for Indian women. Clearly, an integrated approach is necessary to deal with avoidable mortality and morbidity and preventive steps in public health are needed to bridge the gaps, especially in regard to the Indian women. Taking all the factors into consideration, longevity estimates around 20-25 could be around 70 years, perhaps, without any distinction between men and women.

This leads us to the second question of the remaining disease burden in communicable and non-communicable diseases, the effective of interventions, such as, immunization and maternal care and the extent of vulnerability among some groups. These issues have been death with in detail earlier. Clearly an optimistic forecast would envisage success in polio, yaws, leprosy, kalazar t'ilaria and blindness. As regards TB it is possible to arrest further growth in absolute numbers by 2010 and thereafter to bring it to less than an million withm internationally accepted limits by 2020. With regard to Malaria, the incidence can be reduced by a third or even upto half within a decade. In that case, one can expect near freedom from Malaria from most of the countries by 2020. As regards AIDS, it looks unlikely that infection can be leveled of by 2007.  The prognosis in regard to the future shape of HIV / AIDS is uncertain. However, it can be a feasible aim to reduce maternal mortality from the present 400 to 100 per lakh population by 2010 and achieve world standards by 2020. As regards child health and nutrition, it is possible to reach IMRV30 per thousand live births by 2010 in most parts of the country though in some areas, it may take a few years more. What is important is the chance of two thirds decline in moderate malnutrition, and abolition of serious malnutrition completely by 2015 in the case of Cancer, it is feasible to set up an integrated system for proper screening, early detection, self care and timely investigation and referral.  In the matter of disease burden as a whole, it is feasible to attempt to reach standards comparable to china from 2010 onwards.

Taking the third aspect viz fairness in financing of health care and reformed structure of health services, an optimistic forecast would be based on the fact that the full potential of the vast public health infrastructure would be fully realized by 2010. its extension to urban areas would be moderated to the extent substantial private provision of health care is available in urban areas, concentrating on its sensible and effective regulation. A reasonably wide network of private voluntary health insurance cover would be available for the bulk of the employed population and there would be models of replicable community based health insurance available for the unorganized sector. As regards the private sector in medicine, it should be possible in the course of this decade to settle the public role of private medical practice - independent or institutional. For this purpose, more experiments are to be done for promoting public private partnerships, focusing on the issue of how to erect on the basis of shared public health outcome as the key basis for the partnership. A sensible mixture of external regulation and professional self-regulation can be device in the consultation with the profession to ensure competence, quality and accountability. The future of plural systems in medical understanding and evaluation of comparative levels of competence and reliability in different systems - a task in which, the separate department for Indian systems of medicine and homeopathy will play a leading role in inducting quality into the indigenous medical practices.

The next issue relates to the desirable level of public expenditure towards health services. China devotes 4.5% to its G-DP as against India devoting 5.1%. but this hides the fact that in China, public expenditure constitutes 38% whereas in India, it is only 1S% of total health expenditure. An optimistic forecast would be that the level of public expenditure will be raised progressively such that about 30% of total health expenditure would be met out of public funds by progressively increasing the health budget in states and the central and charging user fees in appropriate cases. The figure mentioned would perhaps correspond to the proportion of the population which may still need assistance is social development.

Finally it is proper to remember that health is at bottom an issue in justice. It is in this context that we should ask the question as to how far and in what way has politics been engaged m health care? The record is disappointing. Most health sector issues figuring in political debate are those that affect interest groups and seldom central to choices in health care policy. For instance conditions of service and reward systems for Government doctors have drawn much attention often based on inter service comparison of no wider interest. Inter-system problems of our plural medical care have drawn more attention from courts than from politics. Hospital management and strikes, poor working of the MCI and corruption in recognition of colleges, dramatic cases of spurious drug supply etc have been debated but there has been no sustained attention on such issues as why malaria recrudescence is so common in some parts of India or why complaints about absence of informed consent or frequent in testing on women, or on the variations in prices and availability of essential drugs or for combating epidemic attacks in deprived areas seldom draw attention. The far reaching recommendations made by the Hathi Committee report and or the Lentin Commission report, have been implemented patchily. The role to be assigned to private sector in medicine, the need for a good referral system or the irrationality in drug prescriptions and sue have seldom been the point of political debate. Indeed the lack luster progress of MNP over the Plans shows political disinterest and the only way for politics to become more salient to the health of the poor and the reduction of health inequalities is for a much greater transfer of public resources for provision and financing - as has happened in the West, not only in UK or Canada but in the US itself with a sizable outlay on Medicaid and Medicare.