A matter of life and death

By Sandhya Srinivasan

The majority of illnesses Indians suffer are linked to poverty and poor living conditions. Children fall ill because they are not vaccinated. Patients die because the health centre is too far away or because life-saving drugs are not available. Surely it's an injustice that people must accept illness and death because they cannot get even basic treatment?

We read the same news year after year. Tribal children die in a measles epidemic - they fall ill because they were not vaccinated, become severely ill because they're malnourished, and die because the health centre is too far away. Health centres are empty of life-saving drugs. Families are bankrupted as they pay for medicines to save their loved ones. Hospital patients are held hostage till they pay the bill. And hospital staff are attacked by angry patients and relatives.

Such numbing reports need to be put in perspective.

Poverty and ill-health: The majority of illnesses Indians suffer - such as tuberculosis, respiratory infections, malaria and diarrhoeas -- are linked to poverty and poor living conditions. Nearly half of all children under the age of five are undernourished. It is estimated that some 200,000 children die from malnutrition-related causes every year in Maharashtra alone. Nearly half of all Indian women are anaemic. Some 100,000 Indian women die each year from complications of pregnancy, including bleeding to death because they could not get treated. Around 500,000 people die every year from tuberculosis, a curable disease for which free treatment is supposed to be available through the government.

These deaths are preventable through adequate nutrition, clean water and sanitation, effective immunisation and an accessible health service to provide prompt treatment. The right to earn, to eat, to live decently, to healthcare - they're all linked. A government's duty includes enabling its people to exercise these rights. And indeed, governments do this job, in developed countries like the US , the UK and Canada , as also in poor countries like Cuba and Sri Lanka . But in India a government commitment to healthcare, as articulated in various committee reports, has never really been fully asserted , and has become even more limited in recent years. Surely it's an injustice that people must accept illness and death because they cannot get even basic treatment.

This issue of Infochange Agenda contains a collection of articles by researchers, activists and journalists, giving readers an idea of trends in healthcare and the consequences, especially for the poor, and possible ways forward.

The opening articles provide a picture of the situation of most Indians today. A sketch of a shrinking public health system is followed by reports from around the country, and testimonies from public hearings of the Jan Swasthya Abhiyan illustrating the predicament of the poor.

How did we arrive at this state of affairs? An overview of trends in healthcare financing indicates that India 's high healthcare expenditures are borne by individuals, not governments. Should we then be surprised that we also have some of the worst health outcomes in the region? A report on farmers' suicides is a stark illustration of summarised studies on the 'medical poverty trap'. A history of government policy describes the role played by international funding organisations in healthcare in India . A bird's eye view of the international scene suggests that people's health is affected not just by the country's wealth and how much money it spends, but also by how the money is used. Other articles examine the growth of the private sector, access to essential drugs, mental healthcare, and the special problems of women's access to healthcare.

What is the way forward? One thing is clear: healthcare is not distributed equitably when it is treated as a commodity in the marketplace. Competition does not keep prices down. The very poor will just get wiped out in their efforts to obtain healthcare. Various models have demonstrated that communities can be mobilised to provide effective healthcare that is neither expensive nor technologically complex. However, these should not absolve the government of its responsibility. The effort must be to make the government work.

The Jan Swasthya Abhiyan is the Indian circle of the People's Health Movement, a worldwide health movement which directs attention to the social determinants of health, and calls for government provision of comprehensive primary healthcare . Co-convenor Thelma Narayan notes that the JSA is a platform for organisations representing various political as well as non-political perspectives. JSA activities have ranged from public hearings to interventions in policy at the state and national level. One such intervention took place before the recently launched National Rural Health Mission meant to integrate vertical health programmes and reach healthcare services to the village level.

B Ekbal, convenor of the JSA, argues in an interview that the problems are not just about money, but how it is spent. The decentralisation experiment in Kerala looked at whether people's involvement could change the way the healthcare system functioned, without an increase in funds.

While these readings may not provide a complete picture, we hope that they provoke some debate and discussion.

(Sandhya Srinivasan is a freelance health writer and executive editor of The Indian Journal of Medical Ethics. Email : This email address is being protected from spambots. You need JavaScript enabled to view it.)

InfoChange News & Features, June 2005