Ailing System

Punjab's public heath system is in disarray, with falling budget allocations and poor utilisation of available funds writes Annie Zaidi in Frontline

With the state spending less and less on public health, government hospitals and health centres in Punjab suffer from a lack of medical supplies, a shortage of doctors, and possibly, a misplaced emphasis on treatment rather than prevention. Even the funds that are available are not being used fully.
Meet Kulwinder Kaur of Kartarpur village: Her pale skin and hollow eyes belie her smile and matter-of-fact narrative. She gave birth to a stillborn because she could not afford to eat well enough. Standing outside the Boothgarh Primary Health Centre (PHC), where she has been diagnosed with anaemia yet again, the 21-year-old told Frontline: "I miscarried twice. This time, the baby died after the sixth month; the doctors say it's because I had only 5 grams of blood [haemoglobin content]."
She cannot do much to improve her health, she added, "I drink milk-lassi since my husband is in the milk business. But they say I must eat more fruits and vegetables. You know how expensive things can be." Asked whether she had not been checked or registered by a government-appointed female health worker during her pregnancy, Kulwinder said she had never seen one in her village. "It is good that we have this small hospital here because I can walk to it, but we get only a few cheap medicines. We have to buy most medicines from private [stores]."
That seems to be the refrain at most public health institutions, from the bustling civil hospital in Karali, where heart operations are performed, to the tiny Ayurvedic dispensary in Mullan-Gariba. Dr. Harinder Kaur, the Ayurvedic doctor posted here, said that she treated at least 20 patients every day although there was an allopathic mini-PHC just across the road. "But I don't have medicines. I can only write prescriptions. The government needs to do something about medical supplies," she said.
Aswini Kumar Nanda of the Population Research Centre at the Centre for Research in Rural and Industrial Development (CRRID), Chandigarh, explained that health care in Punjab remained mostly tertiary, boosted mainly by the private sector. "Tertiary health care is curative, while primary is preventive. Over the years, primary and secondary health care systems have been crumbling because they don't yield profit. Also, you cannot talk in isolation about health care. It is linked with transport, roads, sanitation and drinking water."
Most health care professionals agree that the first step is to ensure safe water supply, sanitation and nutrition, but the State has been focussing on a technology-intensive model of health that is expensive and time-consuming. Dr. P.L. Garg, who is the State coordinator of the Jan Swasthya Abhiyan, and who works with the Directorate, Research and Medical Education, told Frontline: "In Punjab, 11,849 villages are classified as `water-scarce'. There are commissioned water supply schemes in 8,321 villages. What about the rest? Also, nutritional standards are falling, despite the Green Revolution. There is more calorie intake but protein deficiency is rampant since there are fewer varieties of legumes, which were the primary source. And yet, the government has initiated no research on high-yielding legumes."
The other major issue is that of medical supplies. According to Rajesh Kumar Aggarwal, Senior Research Fellow at the Population Research Centre, most of the budget is spent on salaries. "The percentage of public health spending in the State budget lies between 1.8 and 4.5 per cent. There are only a few diagnostic facilities. Some hospitals don't even have paracetamol. We did an exhaustive survey for the Punjab Development Report, 2002, and found that 70 per cent of the sub-centres, 67 per cent of the SHCs [Subsidiary Health Centres or dispensaries], 62 per cent of the PHCs and 51 per cent of the CHCs [community health centres] do not have proper buildings. At least Rs.32,849 lakhs was needed."
A substantial portion of the State allocation for health and family welfare remains unspent. The ratio of total expenditure to total outlay (for the Ministry of Public Health) has been going down, from 0.83 per cent in the Fourth Plan to 0.66 per cent in the Eighth Plan and 0.74 per cent in the Ninth Plan. Most States, including Punjab, do not even have a health policy. Since most States simply implement the national health programmes and fail to develop targeted ones for its own populations, people have been forced to seek private medical services. Said Aggarwal: "Only 20 per cent of our population uses government health services. In Punjab, only 7 per cent of rural and 6 per cent of urban households use public health care facilities for non-hospitalised illness."
This is borne out by statistics and the experience of medical professionals. In 2005, Punjab had 2,168 institutions, with a network of training facilities. The State's population increased to 2.42 crores (2001 Census). Compare this to the number of people using public health institutions. In 1980, it was 1.32 crores annually, despite the relative lack of health awareness. In 2004, the number of patients was only 1.19 crores. Fewer patients do not mean better health; it means that fewer people visit hospitals owing to a lack of awareness or resources.
Perhaps, some answers may lie in Punjab's spending patterns. Over the past few decades, the State's expenditure on health and family welfare has been falling as a percentage of the annual Budget. In 1980-81, spending on health comprised 5.49 per cent of the State Budget. By way of comparison, the spending on Police and Administration was 8.28 per cent. In 1990-91, the corresponding figures were 4.61 per cent and 20.83 per cent, respectively. In 2003-04, health commanded 3.86 per cent, while Police and Administration claimed 23.18 per cent.
Even during the Tenth Plan (2002-07), state spending on health formed only 2.28 per cent of the Budget. Compare this to the fact that developed nations spend anything between 14 and 20 per cent of their outlay on health. Punjab's priorities do not seem to be so correct, though the State does better than the nation: India spends only 1.5 per cent on health.
What the State has done is to try to recruit more doctors, while moving towards decentralisation. Doctors would be appointed on a three-year contract, and monitored by the Zilla Parishad. The State Mass Media and Education Officer (Department of Health), Jasbeer Bawa, told Frontline that there was a shortage of about 1,300 doctors. "This new scheme, called the `alternative service delivery system', was initiated under the 73rd Amendment to the Constitution devolving powers to panchayati raj institutions. From April onwards, the scheme will be implemented in all 1,200 SHCs," he said.
Under this scheme, a doctor gets recruited on a non-transferable contractual basis for three years on Rs.30,000 a month, which includes salaries for a pharmacist and a class IV worker. He will also be provided Rs.7,500 worth of medicines each month. The State has set down performance benchmarks, like seeing 20-25 patients a day. The registration fee remains Re.1, as with all government hospitals. This goes to the Zilla Parishad, which is responsible for maintaining the building.
However, researchers who approve of the move warn against a half-baked policy. Dr. Pramod Kumar of the Institute for Development and Communication, Chandigarh, points out that a monitoring system is needed. "Panchayats don't have the institutional capacity to regulate educational and health institutions. What procedures and norms have been instituted? There's a danger that feudal values will dominate professional practices. We must first build the panchayat's capacity to implement these procedures."
According to Bawa, the move is aimed at improving public health care since the social audit is a built-in clause. "If the doctor does not perform well, he will not be awarded the contract, after three years." When asked what the State would do if the doctor did not want to renew the contract, she admitted that the department did not have a plan against that possibility since this was a new experiment, which it hoped would be successful. She also admitted that the contracts would cost the State less than employing 1,300 full-time doctors, pharmacists and other workers required.
Medical professionals have been asking for flexible models of public health for many years now. Some, like Dr. Garg, want the State to invest in mobility rather than setting up more dispensaries. The focus ought to be on bigger hospitals with better facilities and more doctors who travel with mobile units, they say.
Others want the focus on public health as a distinct sector and profession. Dr. Satnam Singh, who worked with the World Health Organisation, believes that decentralisation is in keeping with the principles of public health. "Health care must be bottom-up, not top-down. But you have to build public health as a profession - a bridge between doctors and the government. We need schools of public health at the universities. Public health is a communion of social sciences and life sciences. Treatment should come last - when prevention and promotion fails."