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The challenge of public health in India

In June 2014, days after it assumed office, the Narendra Modi-led government announced plans to open 10 more institutions like the All India Institute of Medical Sciences (AIIMS) across the country.

Can more AIIMS really be the panacea for India’s health problems? There are several reasons to be sceptical. One reason for scepticism springs from a recent internal study of the AIIMS trauma centre in New Delhi. The study found that failure to provide nutrition and hospice facilities led to the death of nearly 50% of patients with head injuries discharged from the hospital. The lack of nutrition and nursing care, and the exposure to an unhygienic environment in their homes meant many poor patients succumbed to infections despite successful surgeries.

The AIIMS report highlights the importance of acknowledging factors beyond the realm of medical treatments in developing a healthy society. The excessive focus on curative medical care also detracts attention from the much more cost-effective and efficient option of preventive public health investments that can stem the spread of infectious diseases and improve nutritional outcomes in the country.

As an earlier Economics Express column pointed out, there is a growing body of research that shows how eradicating open defecation and improving sanitation can improve health outcomes greatly, especially among children. Not only does improved sanitation bring immediate returns in terms of reduced incidence of illnesses such as diarrhoea, it also leads to long-term gains such as reduced stunting and better cognitive abilities among children. A World Bank study had estimated that costs due to poor sanitation facilities were to the tune of more than 6% of India’s gross domestic product in 2006.

A recent research paper by Marcella Alsan of the Stanford Medical School and Claudia Goldin of Harvard University shows that the provision of safe water and better sewage facilities reduced infant mortality significantly in the greater Boston area between 1880 and 1915. Alsan and Goldin use their findings to underline the importance of providing proper sewage facilities in a rapidly urbanizing Third World.

In today’s world, the importance of sewage facilities extends beyond curbing infant mortality. The use of untreated sewage water for irrigation and the contamination of water bodies and contiguous areas is fast emerging as a health and environmental hazard in several countries, including India. Such findings corroborate earlier research that underlines the importance of public health interventions such as sanitation and waste management.

What then explains the abysmal state of public health infrastructure in developing countries such as India? The answers seem to lie in the realm of political economy. According to Shanta Devarajan, the World Bank’s Middle East and North Africa economist, medical unions and the elite in the developing world have a better ability to lobby for claiming a greater share (from a finite pool of government’s resources) towards tertiary healthcare at the cost of sanitation programmes.

According to historian Sunil Amrith, the diversion of public health resources towards population control and the use of technocratic drug-based interventions to tackle specific diseases were responsible for the lack of adequate investments in public health infrastructure in India.

While India has been sporadically successful in combating diseases such as malaria in the years after Independence, the absence of an overarching public health network has ensured that the country’s disease burden remains extraordinarily high, wrote Indian epidemiologist T. Jacob John and his colleagues in a 2011 Lancetresearch paper.

In a 2005 paper, sociologist and demographer Monica Das Gupta of the University of Maryland argues that investing in preventive public health infrastructure may be politically less rewarding in a democracy such as India in comparison to providing private goods such as specialized healthcare. Achievements in preventive public health such as the absence of epidemics are by definition negative in nature, unlike achievements in the provision of specialized curative care.

The history of India’s evolution and its extraordinary diversity may have something to do with the inadequate provision of public goods such as public health infrastructure in the country, according to research by economists Abhijit Banerjee of the Massachusetts Institute of Technology, Lakshmi Iyer of the Harvard Business School and Rohini Somanathan of the Delhi School of Economics.

In a co-authored paper they show that “regions that were under British colonial power in the pre-Independence period and those where agrarian power was concentrated in the hands of landlords have lower access to these goods as do areas with high levels of social fragmentation”.

The thesis that fragmented societies find it hard to invest in public goods is an old one. In his 1965 book, The Logic of Collective Action: Public Goods and the Theory of Groups, American economist and political scientist Mancur Olson first argued that complex societies see the rise of sectional interests who aim to grab public resources to their advantage.

Later research by other economists showed that the provision of public goods tends to be lower in areas with high ethno-linguistic diversity or polarization because it is difficult for people to agree on the provision of public goods that benefits everyone. Banerjee and his co-authors argue that decentralizing administration of public goods in such areas can do more harm than good as seeking retribution for past injustices might outweigh the motivation to stick together and bargain effectively for the common good.

A lot of economic research has focused on evolving policies that can address the challenges to effective provision of public services in the health sector. The 2015 World Development Report titled Mind, Society and Behaviour has a separate chapter looking at such studies in the health sector. The discussion includes providing appropriate incentives for both service providers and seekers to pursue desired behaviour as well as recognizing the stigma certain communities or diseases might face.

One such example is a case study by Banerjee that cites an increase in the immunization of children in Rajasthan when parents were offered 900g of lentils for turning up for the first dosage and a steel plate for completing all necessary vaccinations. Banerjee has described the exercise as cost saving in his 2011 book, Poor Economics: Rethinking Poverty and the Ways to End it, given that the nurse whose time had already been paid for was being kept busy.

While such research holds important insights, there is another stream of work that goes beyond the provision of public goods or behaviour-based explanations of differing health indicators among societies. The crux of such arguments is differentiating between what are called downstream and upstream determinants of health.

The upstream factors—people’s socioeconomic conditions—are given more importance in determining health outcomes than downstream factors, such as the behaviours discussed above. A 2008 report, released by the World Health Organization and the Commission on Social Determinants of Health provides a useful overview of such research. The report argues that both health status and behavioural outcomes such as ensuring vaccination or prenatal care depend on socioeconomic conditions.

The report cites a study of poor mental health among manual workers in Spain, showing a higher prevalence of the problem among workers as the quality of contracts deteriorated from permanent to fixed-term temporary to non-fixed-term temporary to no contract. Another study, which examined evidence from more than 50 countries, showed there was a significant difference between the lowest and highest income quintiles across countries in the use of basic maternal and child care facilities.

The report makes a powerful point: “In countries, at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health. It does not have to be this way and it is not right that it should be like this. Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair.”

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