Rural Health in Punjab

S OF SIKH STUDIES: JULY-SEPT 2010 / 542 NS 38 better health levels compared to the people living in Southern states like Kerala and Tamil Nadu where one could see much better education and health related indicators than that of Punjab (Brar, 2002). Since the mid-1980s in Punjab, the under-currents of political turmoil, severe state resource crunch and nonresponsive administration in the state on one hand, and the adoption of new economic policy (NEP) of 1991 that insist upon the integration of nation’s economy into world economy (through the forces of l iberal ization, privatization and globalization) on the other hand forced the state to allocate meager public funds to the social sectors, especially to the public health sector. This has brought out a faster deterioration in the public health infrastructure and services, particularly in rural Punjab. The paper makes modest attempt to examine the rural health scenario in Punjab as well as builds a case for radical policy reforms. The paper has been divided into six Parts. Part I analyzes, in brief, the theoretical implications of global forces on the health sector of state. Part II presents the progress in health indicators and emerging health scenario in the state. Part III, examines the growth and pattern of public expenditure on health services in Punjab. Part IV deals with the main features health care infrastructure developed so far in the state. Non-functional and dismal performance of rural health services has been presented in Part V. The summary of main conclusions and emerging issues are set forth in Part VI. GLOBAL FORCES AND HEALTH SECTOR THEORETICAL UNDERSTANDING Global forces are influencing India’s health sector in many ways (Misra, et al., 2003) In its true essence, global forces mean the growing process of economic interdependence of nation-states through the increasing volume and variety of cross-border transactions of goods/services, free movement of capital, people, ideas and knowledge, and more importantly, diffusion of new technology at an astonished speed (Gill, Singh and Brar, 2010). It means that process of globalization has economic, political, 39 RURAL HEALTH IN PUNJAB – NEEDS REFORMS AND INVESTMENTS technological, and cultural dimensions that are interwoven with each other and affecting the main activities of nation-states. But defining the globalization as mere ‘openness of economy’ does not convey and capture the multiple, often contradictory, contours of real forces/mechanism that are at work among the nation-states. This process of integrating a nation’s economy to world economy, indeed, affects the people’s health and health delivery system positively/negatively and directly/indirectly. Its positive impacts may be observed in the range of better health outcomes (more incomes, better living conditions, better access to health technology/medicine, better prevent/control over diseases, high life expectancy, etc.). And, its highly deleterious impacts on human health are high treatment costs, elite oriented policies, high incidence of man-made diseases, ir rational use of drugs/ technology, etc. The global forces directly influence a nation’s health mainly through: (i) enhanced movement of pharmaceutical products, health personnel and patients across the national boundaries; (ii) elite oriented health consumerism and medical tourism via the internet and other means; and (iii) establishment of big corporate hospitals having Five Star facilities. On the other hand, more mobility of people increases more chances of spreading/contracting diseases across the borders. Further, globalization, if accompanied by low public funds to health sector, plays havoc with health of the poor in developing countries (Baum, 2001). On the other side, in an indirect way, global forces affect the people’ health in most of developing countries through the heightened industrial activities, depletion of natural resources, indiscriminate use of insecticides/pesticides, increasing environmental pollution (Air and water pollution), unsafe/untreated disposal of industrial waste, etc. Moreover, high consumption of tobacco/alcoholic products, rising consumption of packed/frozen foods and aerated beverages have also affecting the people’s health negatively. The emergence of high risk diseases like diabetes, cancer, heart disease, and other life style diseases (TB, HIV/AIDS, ABSTRACTS OF SIKH STUDIES: JULY-SEPT 2010 / 542 NS 40S OF SIKH STUDIES: JULY-SEPT 2010 / 542 NS 40 etc.) can be linked to the global economic policies. Moreover, for the resource poor people, falling prey to high risk chronic and life style diseases means less employment, subsequently more poverty and malnourishment of women/children in the family which is also attributed to global forces by some authors (Cornia, 2001 and Chatterjee, 2007). In India, during the early 1990s, with the formal acceptance of structural adjustment programme (SAP), integration of Indian economy to global economy became a reality. In fact, the imposition of SAP has considerably reduced state investment in the social sectors including health sector in India. In public health fields, the role of the state has increasingly been marginalized. Further, health sector reforms piloted by the World Bank in India are actively promoting private sector initiatives, giving more emphasis to non government bodies, contracting out, and suggesting other forms of organization (Public-Private Partnership) in health management. In nutshell, main aspects of IMF-World Bank inspired health reforms in India are: cuts in public health sector investments, opening up of health care to the private sector, levying of users’ charges, contracting out some services of public hospitals and relying upon purely techno-centric public health interventions (Qadeer, 2000). And, due to cutbacks in public health sector funds, primary health care services suffered a major setback in India. For want of more funds, infectious diseases control programmes were disrupted, FW programme began to focus on reproductive health of married women only, children’ health and their nutritional needs were ignored. By handing over the health care to private sector players, without any regulatory mechanism to ensure the quality and standards of treatment, state is withdrawing itself from the constitutional obligations and seriously affecting the equal access of health services to the marginalized section of society (Baru, 1998). All these forces are found to be working more vigorously in the state of Punjab (Gill, Singh and Brar, 2010). II 41 RURAL HEALTH IN PUNJAB – NEEDS REFORMS AND INVESTMENTS The economic theory states that high per capita income often leads to improvements in living standards and health status of people. Rising per capita income in Punjab has a favorable impact on life expectancy at birth for males and females. For instance, life expectancy of males during 2001-06 was 69.8 years, whereas it was 68.4 years during 1996-2001. Similarly, the life expectancy of females was 72.0 years during 2001-06 compared to 71.4 years during 1996-2001 (Table 1). Although the rural areas in Punjab had performed very well in bringing down the birth rate to 18.8 per thousand people and the death rate to 7.4 per thousand people in 2006, yet both these rates can further be improved (Singh, 2005). However, infant mortality rate in rural Punjab is still high (48 per thousand live births). And, total fertility rate (TFR) and maternal mortality rate (MMR) estimated to be very high (2.98 children per woman and. 178 per lakh live births. Besides these, there exists a big gap in proportion of other public facilities such as accessibility of safe drinking water (piped water) and sanitation (toilet facilities, connectivity to drainage, etc) in rural Punjab. About one-fourth of Punjab’s villages (24.04 percent) did not enjoy any drinking water supply scheme. These facilities, in fact, greatly influence the health status/quality of life of people (IIPS, 2001). It clearly shows that, rural people still deprived of basic health related facilities, despite achieving high economic growth in the past. Further, the data on incidence of morbidity in rural Punjab showed that, on the whole, 127 persons per 1000 population were suffering from one or other types of illness during the first half of 2004. Incidence of morbidity was much higher in rural areas (136 persons per 1000 population) compared to that of in urban areas (107 persons per 1000 population). Further, morbidity incidence was significantly higher among females both in rural and urban areas (Table 2). It was very much higher when compared to all India average incidence of morbidity. In fact, Punjab became second highest morbidity state after the Kerala in the country (NSSO, 2006). An analysis of estimated number of persons reporting ailment/s in Punjab over two and half decades (1973-74, 1995-96 ABSTRACTS OF SIKH STUDIES: JULY-SEPT 2010 / 542 NS 42S OF SIKH STUDIES: JULY-SEPT 2010 / 542 NS 42 and 2004) revealed that number of ailing persons in the state grew at the rate 3.8 per annum during 1973-74 to 1995-96. Between 1995-96 and 2004, growth in number of ailing persons rose to 7.1 per cent. The pace of growing morbidity was much higher in rural Punjab, especially during the latter period of 1995-96 to 2004 (8.1 per cent per annum) compared to the earlier period of 197374 to 1995-96 (3.0 per cent per annum). However, in urban Punjab, growth rate in the morbidity was 6.2 per cent per annum between 1973-74 and 1995-96 compared to the growth rate of 4.8 per cent per annum between 1995-96 and 2004. At all-India level, morbidity was also grown during the latter time period (1995-96 to 2004) compared to the previous time period. The data on morbidity by type of diseases/ailments (grouped into 21 categories) state that the respiratory/ENT diseases, fevers of unknown origin, cardiovascular diseases, gastro-intestinal diseases, disorders of joints and bones, and bronchial asthmas emerged as the top six ranking diseases/ ailments in descending order of their prevalence in rural Punjab. Intriguingly, nearly three-fourth of sick persons (58.66 per cent) in rural Punjab suffered from these six diseases/ailments (NSSO, 2006). Besides the prevalence, on an average, every seventh patient suffering from diseases in rural Punjab required hospital ization (indoor treatment) during 2004. In the hospitalization cases, accidents/injuries/burns, gastro-enteritis, fever of unknown origin, kidney/urinary tract infections, gynecological disorders and cardiovascular diseases (in order of importance) emerged as six top ranking diseases/ailments. It means that chronic diseases along with infectious and man-made diseases (accidents, injuries, etc.) were taxing the health of rural people in Punjab. It showed that ruralites in the state were passing through a peculiar health transition phase where the morbidity from chronic, infectious and man-made diseases was rising at an alarming rate, although the mortality data had shown a decline. Hence, low morbidity, low mortality and healthy aging seem to be a distant dream in rural Punjab. 43 RURAL HEALTH IN PUNJAB – NEEDS REFORMS AND INVESTMENTS III For socio-economic welfare of people, developing countries are investing more public funds in the social sector programmes, namely, education, health and fertility control (Walle and Nead, 1995). Further, shifts in pattern of public expenditure in favour of social sectors will certainly improve the living conditions of the poor and, also, the re-distribution of public services towards them (Wulf, 1975). In fact, global forces may affect allocation of public funds not only to the health sector as a whole, but also within the health sector in India (Qadeer, 2000). These forces may distort the priority status of many health care programmes in India as well as in states, mainly due to the cutback in public health sector investments, donor driven priorit ies and emphasis on privatization of health care. Interestingly, all these forces are working more vigorously in Punjab as the state’s health sector plan was found to be largely dependent upon the Union Government’s finances and policy matters. PUBLIC EXPENDITURE ON HEALTH SERVICES An assessment of sector-wise allocation of public expenditure in Punjab is, therefore, necessary and rewarding as the state health sector has to compete with other development and nondevelopment services under the new economic policy of liberalization, privatization and globalization (LPG). In Punjab, the analysis of public expenditure on health including family welfare (FW) services on revenue account (Table 4) reveals that, although the total expenditure on these services (in real terms at 1993-94 prices) has spiraled from Rs. 138.81 crores during the triennium ending 1980-81 to Rs. 371.73 crores during the triennium ending 2004-05, yet, in the relative terms, the share of health sector out of the total budgetary expenditure, development expenditure and state income has shown a decreasing trend. For instance, the share of health sector remained around 9 percent between the triennium ending 1980-81 and the triennium ending 1986-87. And there after, it decreased to 6.97 per cent during the triennium ending 1989-90, 5.46 per cent during the triennium ending 1992-93, and 4.35 per ABSTRACTS OF SIKH STUDIES: JULY-SEPT 2010 / 542 NS 44S OF SIKH STUDIES: JULY-SEPT 2010 / 542 NS 44 cent during the triennium ending 1995-96; again slightly rose to 5.48 per cent during the triennium ending 1998-99 and fell to 4.02 per cent during the triennium ending 2004-05. A similar picture emerged when one viewed the share of health sector as the proportion to total development expenditure and social services in the state. Further, as the percentage of NSDP, the share of health services in Punjab never reached to one percent for the most of years against the India’s normative ratio of 3 per cent of the state/national income. This shows that the pubic expenditure on health sector has experienced a decelerated growth over the time period, especially after the initiation of NEP of 1991 (postreforms period) in India and Punjab also. INTRA-SECTOR PLANNED HEALTH EXPENDITURE Theoretically, allocation of more public funds to health sector is of paramount importance, particularly to improve its accessibility and relevance to the poor sections of society. But, in practice, the intra-sector allocations (expenditure) within health sector are also very important and useful to determine the changing health priorities of the state, if any. However, the programme-wise disaggregated data of total public health expenditure in Punjab are not available, except for the planned expenditure during different plan periods. The data revealed that a very high proportion of total health sector’s planned expenditure incurred on a single programme, i.e., the FW programme. The share of FW programme that was 34.57 percent in the Sixth FY Plan (1980-85) decreased to 28.92 percent in the Seventh FY Plan (1985-90) and rose to 30.84 per cent in the Eighth FY Plan (1992-07). Then it decreased to 21.56 per cent during the Ninth FY Plan (1997-2002). However, planned allocation rose to 33.73 per cent during the Tenth FY Plan (2002-07). Establishment and strengthening of new/old hospitals, PHCs, dispensaries, etc. received second priority status programme, mainly owing to the rural health component of Minimum Needs Programme. Under this head, a little more than one-fourth (25.56 percent) of total health plan expenditure was incurred during the Sixth FY Plan (1980-85), more than one-half (56.33 per cent) during the Ninth FY Plan 45 RURAL HEALTH IN PUNJAB – NEEDS REFORMS AND INVESTMENTS (1997-2002) and a little less than two-fifths (37.46 per cent) during the Tenth FY Plan (2002-07). Control/eradication of communicable diseases is another major component of public health plan expenditure up to the Eighth FY Plan (1992-97). Plan expenditure under this head was 13.46 per cent during the Sixth FY Plan (1980-85) and rose to 27.03 per cent during the Seventh FY Plan (1985-90), but declined to 10.95 per cent during the Eighth FY Plan (1992-97). During the Ninth FY Plan (1997-2002) and Tenth FY Plan (200207), this head has just 0.83 per cent and 2.48 per cent share in the allocation of funds respectively. On the other hand, medical education, research and training consistently decreased its share in relative terms from 14.62 percent during the Sixth FY Plan (1980-85) to 11.27 percent during the Seventh FY Plan (198590), 10.87 percent during the Eighth FY Plan (1992-97) and 5.84 per cent during the Ninth FY Plan (1997-2002). And, during the Tenth FY Plan (2002-07), there is proposal to spend 14.03 per cent of total health plan allocations. This has posed very serious repercussions on the doctors’ training, developing core competencies among them and deterioration in the tertiary health care provided by the hospitals attached with government owned Medical Colleges of the state. Moreover, it is quite interesting that the indigenous systems of medicine (Ayurvedic) and homeopathy are being continuously neglected, at least, in terms of allocation of plan funds in Punjab. Also, the Employees State Insurance Scheme did not find any priority status (Table 5). PLANNED HEALTH EXPENDITURE: CENTRE VS. STATE SHARE The constitutional division of powers between the Centre and the States in India clearly shows that the state governments have exclusive jurisdictional powers to establish and monitor the provision for the ‘public health and sanitation’, ‘hospitals and dispensaries’ and ‘burials and cremations’ in their respective areas. The role of central government is limited largely to regulate the medical standards, formulate health policy, resolve international health issues, issue policy directions and allocate more finances ABSTRACTS OF SIKH STUDIES: JULY-SEPT 2010 / 542 NS 46S OF SIKH STUDIES: JULY-SEPT 2010 / 542 NS 46 for strategic health programmes/schemes (Prakash and Raj, 1972). Thus, in theory, creating provisions for health care are largely the state-subject, but in practice the central government is playing very significant role through financing states’ health sector plans. An analysis of data reveals that the central government financed a greater part of Punjab’s planned health expenditure; 47.62 percent during the Sixth FY Plan (1980-85), 57.83 percent during the Seventh FY Plan (1985-90), 59.57 per cent during the Eighth FY Plan (1992-97) and 39.99 per cent during the Tenth FY Plan (200207). The data also illustrate that all the priority programmes of state health plan l ike the family welfare and control of communicable diseases got more allocation of central funds, mainly due to the policy of central government to promote these programmes. Among these priority programmes, the FW is fully central funded programme and in the case of two other programmes, liberal central grants along with matching contributions by the state are made available. The Punjab government utilized these grants to expand health care and family welfare infrastructure in the state. Establishment of hospitals, PHCs, dispensaries, etc. is another priority programmes in Punjab’s health sector plan. Again, under this head, sufficient central funds were allocated in the past to finance these programmes. Actually, due to this single reason, these programmes have emerged as priority programmes in the state’s health plans. In the case of controlling/eradicating communicable diseases, the central government spent more funds both absolutely and relatively compared to the funds made available by the state government. Further, ‘other programmes’ under the state category, which consists of minimum needs programme, hospitals and dispensaries, medical education, etc., deal with the creation and strengthening of infrastructure facilities in the state. These programmes are crucial health Programmes for the maintenance of health of the people. These are financed partly by the central government and partly by the state from own resources, and state’s share under this head remained around 44 per cent in the Sixth FY Plan (1980-85) and decreased to 30.03 per cent in the Seventh FY Plan (1985-90), but rose to 35.46 percent in the Eighth FY Plan 47 RURAL HEALTH IN PUNJAB – NEEDS REFORMS AND INVESTMENTS (1992-97) and 76.19 per cent in the Ninth FY Plan (1997-2002), and declined to 58.67 per cent in the Tenth FY Plan (2002-07). Thus, state is highly dependent on central government for finances as well as health policy matters. It means that, whenever there is policy shift at the all-India level, it is automatically reflected at the states’ level. Indeed, it is true in the case of health sector of Punjab. IV HEALTH DELIVERY SYSTEM IN PUNJAB Public and private providers dominate the health delivery system of the state. In large urban towns of Punjab, hospitals attached with the Medical Colleges provide tertiary health care facilities. In medium/smaller towns and some larger villages, the state government runs an extensive infrastructure of districts hospitals, tehsil hospitals, community health centres (CHCs) and rural hospitals (RHs). And, a network of CHCs/RHs, PHCs and dispensaries has been serving the rural People. Theoretically, the state health delivery system is operating at three levels: (i) at the primary level, (CHC, PHCs and dispensaries); (ii) at the secondary level, (district and tehsil hospitals); and (iii) at the tertiary level (medical college hospitals and central government hospitals). On the other hand, an overwhelming majority of private health providers dominantly provide clinic/office-based practice of general practitioners, and mostly concentrate on low risk cases. An overwhelming majority of them are based in urban areas. In Punjab, public health facilities have increased up to the mid-1980s mainly due to increased allocation of funds to state health sector and pro-rural policy of state government (Singh, 2005). Thereafter, whatever may be the reasons and factors behind this, public funds to expand state health services declined drastically in the state. The data in Table 1 showed that there was no appreciable increase in health infrastructure in Punjab since the mid1980s. Between the triennium ending 1980-81 and 2004-05, total number of hospitals decreased from 244 to 219, the number of PHCs increased from 129 to 441, the number of dispensaries rose from 1255 to 1479, and of indigenous systems of medicine & homeopathy related ABSTRACTS OF SIKH STUDIES: JULY-SEPT 2010 / 542 NS 48S OF SIKH STUDIES: JULY-SEPT 2010 / 542 NS 48 dispensaries from 454 to 636. Further, the proportion of rural hospitals just increased from 40.98 percent during the triennium ending 1980-81 to 43.77 percent during the triennium ending 198687. And, thereafter the share of rural hospitals decreased consistently to 35.10 percent during the triennium ending 1995-96, and 33.33 per cent during the triennium ending 2004-05. The proportion of rurally located dispensaries also showed a marginal decrease (85.31 per cent during the triennium ending 198081 to 82.56 per cent during the triennium ending 2004-05), despite the allocation of more central funds to rural health under the Minimum Needs Programme that has been implemented in India since the Fifth FY Plan (1974-79). This decrease in proportion of rurally located dispensaries is, perhaps, due to the up-gradation of many rural dispensaries into CHCs/PHCs in the same area during the period of 1984-2000 (Singh, 2005). Further, population served per institution also confirmed that there has been very slow or no increase in the number of medical institutions owned by state compared to increase in population of state. For instance, population served per hospital, which was 0.67 lakh during the triennium ending 1980-81, rose to 1.17 lakh during the triennium ending 2004-05. In the case of PHCs that are exclusively for the rural areas, a different picture has been emerged. Actually, due to the additional of many PHCs over the years, population served per PHC fell from 1.13 lakh persons during the triennium ending 1980-81 to 0.34 lakh during the triennium ending 1989-90, but rose to 0.40 lakh during the triennium ending 2004-05 (Table 1). Consequently, at present, Punjab state again stayed away from the norms set by the Union Government in terms of population served per PHC (i.e. 30,000 populations per PHC). Thus, there was a no increase in the number of PHCs/CHCs in rural Punjab during the 1990s. In economic theory of public health services, it is the number of beds and their utilization that are considered to be the best indicators of the strength of health care facilities prevalent in the state. Since the utilization pattern of public health services has been attempted in the next section, the population served per bed has been attempted 49 RURAL HEALTH IN PUNJAB – NEEDS REFORMS AND INVESTMENTS A ll T yp e s o f In stitu tio n s P o p u la tio n S e ve d P er In stitu tio n A llo p a hic N o n A llo p a th ic