The India Health Report (by Rajiv Misra, Rachel Chatterjee and Sujatha Rao) was undertaken as a background study for the World Health Organization’s Commission on Macroeconomics and Health. The CMH was established by the former WHO director-general, Gro Harlem Brundtland, in January 2000 to assess the importance of health in global economic development. It is an impressive book, fully justifying the endorsements it has received, especially from Jeffrey Sachs, chairperson of the CMH. It has been a critical input in the formulation of the final CMH report. Apart from providing the most comprehensive exposition on the health system in India, its great strength is the clarity with which the authors present complex technical material and analyze the issues of healthcare finance and reform in India.

The IHR points out that the biggest problems with the Indian health system are the lack of government spending in the health sector (0.9 per cent of the gross domestic product versus the 2.2 per cent on an average spent by lower-middle-income countries) and the inefficiencies and misuse of the meagre resources that are available. Since 84 per cent of healthcare is “out of pocket” expense, the system is geared to favour those who can pay. The ambitious goal of providing universal healthcare for all was far from achieved. As the document suggests, the current system needs to be overhauled, both in terms of financial and human resources.

The IHR says, “If the state has universal healthcare and poverty alleviation as its basic objectives...if there are systems in existence though not actually thriving, why is the current health scenario so bleak?” The IHR points out that this is due to the mismatch between the objectives and the resources being spent to achieve them. Policymakers need to define realistic goals and allocate much higher levels of resources to the health sector. As the IHR indicates, the foremost aim of the Indian health system should be financial protection of the poorer and weaker sections of the population.

While the IHR describes the potential use of Central levies, state levies, and user fees to finance health-sector expenditure, one additional mechanism to raise much-needed resources for enhancing health-sector expenditure could be the following. After careful analysis and background work, the government should work out a major programme of disinvestment and inform all sitting members of parliament that each will be given an equal share of the proceeds, but with the specific purpose of using it only for spending on primary health and education in their constituencies.

Of course, it will require strict monitoring to ensure that funds are properly utilized. Such a scheme is likely to help bring together MPs across party lines since they will see a gain for themselves (irrespective of party affiliations) as well as their constituencies, and possibly unite them to support disinvestment on the floor of the house.

Should such a scheme work, it will not only help the government withdraw relatively easily from the loss-making public sector but will also help divert much-needed resources to the areas of primary health and education.

The IHR points out that India has the largest number of active tuberculosis patients worldwide. It discusses the directly observed treatment, short course strategy and the revised nations TB control programme in detail. As for malaria, as per the report, the number of cases decreased to about 2 million, but as a result of local outbreaks, there was high mortality. The IHR suggests that outbreaks from the Plasmodium falciparum parasite has been rising, accounting for almost half of the malaria cases in 2001. It suggests many reasons for the failure to reduce malarial prevalence (like parasite resistance) and suggests practical ways to deal with the problem.

The resurgence of communicable diseases, such as malaria and TB, has partly been due to the low levels of public expenditure in India. Another factor in this resurgence is extreme poverty. In 1994, over 1,000 people died in Rajasthan of a malaria epidemic, and during the same time in Delhi over 300 deaths were attributed to haemorrhagic dengue fever. The resurgence of malaria in India prompted the formation of a Malaria expert group, which met in 1996 to formulate an appropriate malaria control strategy. An estimated 20-30 million cases of malaria occur in India each year. Since malaria is an exclusively local phenomenon, strategies should be responsive to the epidemiological characteristics of the different ecotypes. Most malaria deaths are attributable to delayed diagnosis and treatment. Furthermore, integration of malaria control into India’s primary healthcare system will require community participation, appropriate technology, inter-sectoral coordination, and social equity.

An assessment of the utilization patterns of public and private healthcare providers shows that despite the provision of free or low-cost services at government health facilities, the demand for public-sector out-patient services is low even among those below the poverty line. The poor are increasingly turning to private providers, even for infectious diseases such as TB and malaria, which are the primary responsibilities of the public health system. This suggests that the government health system is not adequately fulfilling the needs of the poor. This has resulted in spiralling medical-care costs and rural indebtedness. Further, studies of the distribution of government health subsidies show that such subsidies benefit higher classes much more.

In terms of the emerging challenges, the IHR is of the view that HIV/AIDS has not received the attention it deserves (long gestation period and non-diagnosis because of deaths from opportunistic infections like TB). In 2000, an estimated 3.86 million Indians were infected with HIV. Also, the IHR points out that the low income levels of the infected along with the lack of resources in government-funded programmes (despite the drugs being manufactured and available in India) preclude widespread use of highly active anti-retroviral therapy. Awareness is low despite the National AIDS Control Programme and the state AIDS control societies. The IHR rightly points out that information; education and communication are crucial elements in this regard.

While health is primarily a state subject in India, health-sector spending at the state-level is far from what is needed.

One of the areas the IHR could have perhaps dwelt more on is primary health centres, which should function as the first level in a hierarchy of healthcare facilities. They should play two equally important roles — first, diagnosis of diseases based on symptoms and simple laboratory tests, and their treatment. Second, health education leading to family planning, better hygiene and sanitation, and prevention of communicable diseases, especially sexually transmitted diseases. At present, the major problems at this level can be attributed to the shortage of qualified doctors to be posted at the primary health centres; non-availability of proper infrastructure including equipment and consumables; poor motivation of the public to seek timely help from the centres due to superstitions or lack of health education.

The result has been that in many cases, diseases are neither diagnosed in the early stages nor are they treated. Often the rural populace has to travel to urban areas when they can no longer bear the suffering, thus increasing the load on hospitals in the cities. They end up with serious complications that, in many cases, could have easily been treated in the early stages.

The IHR, thus, is a comprehensive document. Its authors have studied a wide spectrum of issues and recommended very useful policy options to the government. The document will contribute to greater public awareness and informed debate on health issues. From the global point of view, it has been instrumental in helping the United Nations, in general, and the WHO, in particular, focus on the key issues of health-sector reform and financing in developing countries.