Illustration: Jayachandra/Mint
Illustration: Jayachandra/Mint

Hidden hunger and the Indian health story

India needs to find better value for money in the health sector

According to the World Health Organization (WHO), there are three goals a country’s health system must aim for: to improve health, to be responsive to legitimate demands of the population and to ensure no one is at risk of serious financial losses because of ill health. Given this framework, the fourth National Family Health Survey (NFHS-4) released last week gives India plenty of reasons to cheer.

The extensive survey, covering 13 states and two Union territories, shows improvement on a number of parameters—total fertility ratio, infant mortality rate, under-five mortality rate, percentage of institutional births, nutritional status of children and increased reach of Janani Suraksha Yojana (a safe motherhood intervention) and health insurance.

However, a number of areas of concern remain.

Despite the declining percentage of the number of women and children suffering from anaemia in the past few years, the high absolute numbers are worrying. Incidentally, anaemia accounts for 20% of the maternal deaths that take place in the country. According to the Rapid Survey on Children, 2013-14, around 40% of India’s children under the age of five are stunted (low height-for-age), nearly 15% are wasted (low weight-for-height) and 30% are underweight (low weight-for-age).

Over the years, India has implemented numerous health-related schemes. The Integrated Child Development Scheme was started in 1975 to look into the health and well-being of mothers and children. The National Mid-Day Meal Scheme, the National Rural Health Mission and the Public Distribution System have had overlapping nutrition objectives. The National Nutritional Anaemia Prophylaxis Programme meant to maintain the adequate amount of iron and folate in expecting lactating mothers, children from aged 1-5 and anaemic adolescents was implemented as early as 1970.

Unfortunately, efforts to spread awareness and widen the reach of these programmes progressed at a snail’s pace and supply of low-quality food and drugs as well as leakages due to corruption remained inherent in the system. The infamous incidents of midday meals poisoning children cast these latter problems in sharp relief.

Taking its cue from NFHS-4 and the recently published India Health Report and Global Nutrition Report, the Indian health system needs to address its structural and operational deficiencies. In the latter instance, millets and fortified food should be incorporated in midday meals to tackle the problem of hidden hunger (micronutrient deficiency). Fortification enhances the nutrients present in salt, rice, wheat, milk and so forth, and millets have higher nutrient levels than cereals.

An independent system for quality checks and outsourcing of activities like midday meals to private companies is also necessary here.

Currently, laboratories designated to execute a quality check on samples from schools every month consistently fail to do so. And stocking food, monitoring cooking, serving and maintaining records compromise the productive time of the faculty.

The broader structural issues are as crucial. Take the complicated issue of funding. India has time and again been criticized for allocating a meagre 1% of GDP (gross domestic product) for health in its annual budget. This does not, however, account for state expenditure in the sector. And health spending should be about more efficient utilization of funds rather than just a higher quantum of funds.

Efficiency measures actual output against standard expected output. WHO has time and again mentioned that it is possible to get better value for money in the health sector. The per capita availability of inputs like the number of primary health centers, doctors, infrastructure like number of hospital beds and institutionalized deliveries are significant variables for enhancing efficiency.

But the lack of comprehensive, state-level localized information—a necessity in a country where human development indicators vary widely across states—is a major obstacle in working out the necessary policy measures for doing so.

NFHS-4 is an extensive, well-timed survey, but phase two of the project, which covers the rest of the states, is yet to be completed. Until then the country is left to derive the estimates of its health demands from a 10-year-old data set.

Hopefully, a joint initiative by the Indian Council of Medical Research and the health ministry, among others, to gather state-specific data with the first set of data estimates to be released this year will help in some measure.

If India has to reap its demographic dividend in an ageing world, it should have its citizens hale and healthy. As the world’s first ever anatomist Herophilus once remarked, “When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied."

What measures can be used to improve the health system? Tell us at views@livemint.com

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