Falling ill, and into poverty

Early this month, Anirudh Krishna, social scientist delivering the inaugural Krishna Raj Memorial Lecture, used a telling phrase to capture the dynamics of poverty. He pointed out that millions of people in India and other poor countries were just one illness away from poverty.

Krishna, whose major work has been on poverty, was not overstating the problem, nor was he making a doomsday prediction. Over the decade anecdotal evidence from health workers in the field and an accumulation of systematic data from empirical studies are pointing to health care as a critical factor that pushes people into poverty.

A single illness, especially and not necessarily requiring hospitalisation, can drive the family over the edge, eating up savings even in cases when the family had not in the past been poor, leave alone households that had just moved out of an existence of scarcity.

Krishna and his colleagues found that in more than 25,000 households in five separate countries, ill health and healthcare expenses have played a principal role in moving households into poverty.

For 59 per cent of households in communities under study in Rajasthan, as many as 74 per cent in Andhra Pradesh and 88 per cent in Gujarat, health and healthcare expenses constituted a primary reason for descent into poverty.

Two other data sets released recently provide other facets of this picture of poverty and illness. The recently released National Family Health Survey data indicate that in state after state, the proportions of people falling ill have not changed.

More interestingly, the data define the growing paradox of health care: a rising awareness of the need for medical care set against a serious paucity of affordable efficient medicare.

This awareness is bringing, for instance, over 60 per cent of children with acute respiratory illness to hospitals even in the poorer states like Orissa.

The proportion of women receiving ante-natal care has sharply risen especially in the poor states. The percentage of women who receive trained assistance at birth has risen, as also have institutional deliveries.

But the increased utilisation of medicare appears to be coming at a grave cost if we were to broadly interpret some of the results. In state after state the proportion of women with BMI below normal has hardly fallen since the last survey.

In fact, the proportion of women in the reproductive age group with anaemia has not shown a significant change. And worse, the proportion of pregnant women with anaemia in that age group has actually risen in many states, especially poorer states of Bihar, Orissa and others.

Even among children there seems to be some indication of poorer access to food. The number of children less than three years recorded as stunted has not fallen rapidly enough and in some states has shown a rise.

While anaemia has many causes, the commonest is poor intake of nutritional iron, especially during the growing years. In situations of scarcity, the conventional gender bias in intra-family food distribution sharply affects women's food intake.

At another level, the Census Commissioner's report on Maternal Mortality 1997-2003, rigorously examining 4,500 maternal deaths from Sample Registration Survey data in this period, estimates that the maternal mortality rate remains 300 deaths per 100,000 live births.

The first cause of death is haemorrhage, which would not lead to death if adequate institutional services were provided. So, either institutional services are inadequate or a significant proportion of high risk pregnancies are not reaching hospitals.

These are telling indicators of a conundrum in health care planning: First, there is a rising demand for medical care; second, in the absence of effective and affordable public health care, people are forced to seek unaffordable high-cost care; and third, this is leading to debt in the worst case, or at least to fractures in the family's welfare supply chain. In turn, this, if not mended, will lead to more ill health.

It is against this that the booming private and corporate hospital industry must be viewed. Had this new escalation lifted off from a strong base of accessible, affordable and efficient services, it would not have made for the dissonance that is already visible and will only get worse.

But as things are, with the neglect of the public systems, corporate hospitals are becoming islands of plenty, mocking populations that cannot afford their services even as they draw the middle class ill into their portals, pushing them into situations of debt.

There has to be an urgent resolution of this paradox. Over the years, far too much discussion has gone into who should invest in health care: the state or the private sector. Debates on the merits and demerits of the growth of private medicare institutions abound. Too little attention has been paid to the delivery of care and the recipients of care.

It has to be admitted that there is little hope that the state alone can provide adequate health coverage to all. It cannot afford any longer to leave out of its purview the burgeoning private sector in health care that is and has been for a long time so many times larger than the public system.

The path clearly lies in evolving public-private partnerships that will require corporate hospitals to submit to some form of regulation on fees and standards of service, and for the state and the health consumer movement to accept, one, that hospitals are businesses that need to show profit and, two, the delivery of services and not ownership is the crucial issue.