INTRODUCTION Key linkages in health Health and health care need to be distinguished from each other for no better

reason than that the former is often incorrectly seen as a direct function of the latter. Heath is clearly not the mere absence of disease. ood Health confers on a !erson or grou!s freedom from illness " and the ability to reali#e one$s !otential. Health is therefore best understood as the indis!ensable basis for defining a !erson$s sense of %ell being. The health of !o!ulations is a distinct key issue in !ublic !olicy discourse in e&ery mature society often determining the de!loyment of huge society. They include its cultural understanding of ill health and %ell"being' e(tent of socio" economic dis!arities' reach of health ser&ices and )uality and costs of care. and current bio"mcdical understanding about health and illness. *hat makes for a +ust health care system e&en as an ideal, -our criteria could be suggested" -irst uni&ersal access' and access to an ade)uate le&el' and access %ithout e(cessi&e burden. .econd fair distribution of financial costs for access and fair distribution of burden in rationing care and ca!acity and a constant search for im!ro&ement to a more +ust system. Third training !ro&iders for com!etence em!athy and accountability' !ursuit of )uality care ad cost effecti&e use of the results of rele&ant research. /ast s!ecial attention to &ulnerable grou!s such a children' %omen' disabled and the aged.

-orecasting in Health .ector 0ll !ro+ections of health care in India must in the end rest on the o&erall changes in its !olitical economy 1 On !rogress made in !o&erty mitigation 2health care to the !oor3 in reduction of ine)ualities 2health ine)ualities affecting access4)uality$3' In generation of em!loyment 4income streams 2to facilitate ca!acity to !ay and to acce!t indi&idual res!onsibility for one$s health 3. In !ublic information and de&elo!ment communication 2to !romote !re&enti&e self care and risk reduction by conduci&e life styles 3 In !ersonal life style changes 2often directly resulting from social changes and global influences3. O Of course it %ill also de!end on !rogress in reducing mortality and the likely disease load' efficient and fair deli&ery and financing systems in !ri&ate and !ublic sectors and attention to &ulnerable sections" family !lanning and nutritional ser&ices and %omen$s em!o%erment and the confirmed interest of me siat"e 56 ensure +ust health care to the /argest e(tent !ossible. To list them is to recall that Indian !lanning had at its best attem!ted to ca!ture this synergistic a!!roach %ithin a democratic structure. It is another matter that it is no% remembered only for its mi(ed success.

-uture of .tate 7ro&ided Health Care

Historically the Indian commitment to health de&elo!ment has been guided by t%o !rinci!les"%ith three conse)uences. The first !rinci!le %as .tate res!onsibility for health care The second 2after inde!endence3 %as free medical care for all 2and not merely to those unable to !ay3' The first set of conse)uences %as inade)uate !riority to !ublic health' !oor in&estment in safe %ater and samtati on and to the neglect of the key role of !ersonal hygiene in good health' culminating in the !ersistence of diseases like Cholera. The second set of conse)uences !ertains to substantially unreali#ed goals of NH7 589: due to funding difficulties from com!ression of !ublic e(!enditures and from organi#ational inade)uacies. The third set of conse)uences a!!ears to be the inability to de&elo! and integrate !lural systems of medicine and the failure to assign !ractical roles to the !ri&ate sector and to assign !ublic duties for !ri&ate !rofessionals. 7ublic !rograms in rural and !oor urban areas engaging indigenous !ractitioners and community &olunteers can !re&ent much seasonal and communicable disease using lo% cost traditional kno%ledge and based on the balance bet%een food' e(ercise medicine and moderate li&ing. .uch an o&erall &ision of the !ublic role of the heterogenous !ri&ate sector must inform the course of future of state led health care in the country.

K;< 0CHI;=;>;NT. IN H;0/TH Our o&erall achie&ement in regard to longe&ity and other key health indicators are im!ressi&e but in many res!ects une&en across .tates' The t%o Data 0nne(ure at the end indicate selected health demogra!hic and economic indicators and highlight the changes bet%een 58?5and @665. In the !ast fi&e decades life e(!ectancy has increased from ?6 years to o&er AB in @666. I>R has come do%n from 5BCA to C. Crude birth rates ha&e dro!!ed to @A.5 and death rates to 9.C. Duality of life re)uires as much e(ternal bio"medical inter&entions as culture based acce!tance of ine&itable decline in faculties %ithout officious start at si(ty but run across life li&ed at alt ages in reduction of mortality among infants through immuni#ation and nutrition inter&entions and reduction of mortality among young and middle aged adults' including adolescents getting inform about se(uality re!roduction and safe motherhood. 0t the same time' some segments %ill remain al%ays more &ulnerable " such as %omen due to !atriarchy and traditions of infra"family denial3' aged 2%hose sur&i&al but not al%ays de&elo!ment %ill increase %ith immuni#ation3 and the disabled 2constituting a tenth of the !o!ulation3. Reduction in child mortality in&ol&es as much attention to !rotecting children from infection as in ensuring nutrition and calls for a holistic &ie% of mother and child health ser&ices. The cluster of ser&ices consisting of antenatal ser&ices' deli&ery care and !ost mortem attention and lo% birth %eight' childhood diarrhoea and 0RI management are linked !riorities.

 7rogramme of immuni#ation and childhood nutrition seen in better !erforming stats indicate sustained attention to routine and com!le( in&estments into gro%ing children as a grou! to make them gro% into !ersons ca!able of li&ing long and %ell Often interest fades in !ursuing the unglamorous routine of su!er&ised immuni#ation and is substituted by !ulse cam!aigns etc. In this conte(t %e may refer to the large ratio"based rural health infrastructure consisting of o&er ? lakh trained doctors %orking under !lural systems of medicine and a &ast frontline force of o&er C lakh 0N>s' >7*. and 0ngan%adi %orkers besides community &olunteers. The creation of such !ublic %ork force should be seen as a ma+or achie&ement in a country short of resources and struggling %ith great dis!arities in health status 0s !art of rural 7rimary health care net%ork lone' a total of 5.A lakh subcenters' 2%ith 5.@C lakh.$ 0N>a in !osition3 and @@8C? 7HCs and @8:? CHCs 2%ith o&er @B666 doctors and o&er :?66 s!ecialists to ser&e in them3 ha&e been set u!. To !romote Indian systems of medicine and homeo!athy there are o&er @@666 dis!ensaries @966 hos!itals Eesides A lakh anga%adis ser&e nutrition needs of nearly @6 million children and B million mothers.

The total effort has cost the bulk of the health de&elo!ment outlay' %hich stood at o&er Rs A@.?664" crores or :"AB F of total !lan s!ending during the last fifty years.

Health .tatus issues The difference bet%een rural and urban indiactors of health status and the %ide interstate dis!arity in health status are %ell kno%n. Clearly the urban rural differentials are substantial and range from childhood and go on increasing the ga! as one gro%s u! to ? years. .heer sur&i&al a!art there is also the %e kno%n under !ro&ision in rural areas in !ractically all social sector ser&ices. -or the children gro%ing u! in rural areas the dis!arities naturally tend to get e&en %orse %hen com!ounded by the %idely !racticed discrimination against %omen' starting %ith foeticide of daughters. H;0/TH IN-R0.TRUCTUR; IN TH; 7UE/IC .;CTOR Issues in regard to !ublic and !ri&ate health infrastructure are different and both of them need attention but in different %ays. Rural !ublic infrastructure must remain in mainstay for %ider access to health care for all %ithout im!osing undue burden on them. .ide by side the e(isting set of !ublic hos!itals at district and sub"district le&els must be su!!orted by good management and %ith ade)uate funding and user fees and out contracting ser&ices' all as !art of a functioning referral net %ork. This demands better routines more accountable staff and attention to !romote )uality. >any re!uted !ublic hos!itals ha&e suffered from lack of autonomy inade)uate budgets for non"%age OG> leading to faltering and !oorly moti&ated care. 0ll these are being tackled in se&eral states are !art health sector reform' and %ill reduce the %aste in&ol&ed in sim!ler cases needlessly reaching tertiary hos!itals direct These' attem!ts must !ersist %ithout any %a&ering or !olicy changes or !eriodic

denigration of their !ast %orking. >ore autonomy to large hos!itals and district !ublic health authorities %ill enable them to !lan and im!lement decentrali#ed and fle(ible and locally controlled ser&ices and remo&e the dichotomy bet%een hos!ital and !rimary care ser&ices. -urther. most !re&enti&e ser&ices can be deli&ered by do%n staging to a !ublic health nurse much of %hat a doctor alone does no%. .uch long term commitment for demystification of medicme and do%n staging of !rofessional hel! has been lost among the !oliticians bureaucracy and technocracy after the decline of the 7HC mo&ement. One conse)uence is the huge regional dis!arities bet%een states %hich are getting stagnated in the transition at different stages and sometimes' !olari#ed in the transition. .ome feasible ste!s in re&itali#ing e(isting infrastructure are e(amined belo% dra%n from successful e(!eriences and therefore feasible else%here' -easible .te!s for better !erformanceH The ado!tion of a ratio based a!!roach tor creating facilities and other m!uls has led /O shortfalls estimated u!to t%enty !ercent. It functions %ell %here e&er there is diligent attention to su!er&ised administrati&e routines such as orderly drugs !rocurement ade)uate OG> budgets and su!!lies and credible !rocedures for redressal of com!laints. Current 7HC CHC budgets may ha&e to be increased by 56F !er year for fi&e years to dra% le&el. The !ro!osal in the Draft NH7 @665 is timely that .tate health e(!enditures be raised to 7% by @65? and to 9F of .tate budgets thereafter. Indeed the target could be ste!!ed u! !rogressi&ely to 56F by @6@?. it also suggests that Central funding should constitute @?F of total !ublic e(!enditure in health against the !resent 5?F. The !eri!heral le&el at the sub center has not been 2and may not no% e&er be3 integrated %ith the rest of the

health system ha&ing become dedicated solely to re!roduction goals. The immediate task %ould be to look dee!ening the range of %ork done at all le&els of e(isting centers and in !articular strengthen the referral links and fuller and fle(ible utili#ation of7HC4CHCs. Tamil Nadu is an instance %here a re&ie% sho%ed that out of 5B66 7HCs 8BF functioned in their o%n buildings and had electricity' 89F of 0N>s and 8?F of !harmacists %ere in !osition. On an a&erage e&ery 7HC treated about 566 !atients @@B out of the @?6 o!en @B hour 7HCs had ambulances. *hat this illustrates is that e&ery .tate must look for imaginati&e uses to %hich e(isting structures can be !ut to fuller use such as making @B hours ser&ices o!en or trauma facilities in 7HCs on high%ay locations etc. The !ersistent under funding of recurring costs had led to the colla!se of !rimary care in many states' some s!ectacular failures occurring in malaria and kala#ar control. This has to do %ith ade)uacy of de&olution of resources and %ith lack of administrati&e %ill !robity and com!etence in ensuring that determined !riorities in !ublic health tasks and routines are carried out timely and in full. Only genuine de&olution or sim!ler tasks and resources to !anchayats' %here there %ill be a third %omen members" can be the ans%er as seen in Kerala or >.7. %here !anchayats are made into fully com!etent local go&ernments %ith assigned resources and control o&er institutions in health care. >any inno&ati&e cost containment initiati&es are also !ossible through focused management " as for instance in the streamlining of drug !urchase stocking distribution arrangements in Tamil Nadu leading to :6F more &alue %ith same budgets. The 7HC a!!roach as im!lemented seems to ha&e strayed a%ay from its key thrust in !re&enti&e and !ublic health action. No system e(ists for !ur!oseful community

focused !ublic information or seasonal alerts or ad&isories or community health information to be circulated among doctors in both !ri&ate !ractice and in !ublic sector. 7HCs %ere meant to be local e!idemiological information centers %hich could de&elo! sim!le community. Tertiary hos!itals had been gi&en concessional land' customs e(em!tion and liberal ta( breaks against a commitment to reser&e beds for !oor !atients for free treatments. No !rocedures e(ist to monitor this and the disclosure systems are far from trans!arent' redressal of !atient grie&ances is !oor and allegations of cuts and commissions to !romote needless !rocedure are common. The bulk of noncor!orate !ri&ate entities such as nursing homes are run by doctors and doctors" entre!reneurs and remain unregulated cither in terms of facility of com!etence standards or )uality and accountability of !ractice and sometimes o!erate %ithout systematic medical records and audits. >edical education has become more e(!ensi&e and %ith ra!id technological ad&ances in medicine' s!eciali#ation has more attracti&e re%ards. Indeed the re%ard e(!ectations of !ri&ate !ractice formerly s!read out o&er career long earnings are s)uee#ed into a fe% years' %hich becomes !ossible only by %orking in hi tech hos!ital some times run as businesses. The res!onsibilities or !ri&ate sector in clinical and !re&enti&e !ublic health ser&ices %ere not s!ecified though under the NH7 589: nor during the last decade of reforms follo%ed u! either by go&ernment of !rofession by any strategy to engage allocate' monitor and regulate such !ri&ate !ro&ision nor assess the costs and benefits or subsidi#ation of !ri&ate hos!itals. There has been talk of !ublic !ri&ate !artnershi!s' but this has yet to take concrete sha!e by im!osing !ubic duties on

!ri&ate !rofessionals' %here&er there is agreement on e(!licitly !ublic health outcomes. In fact it has re)uired the .u!reme Court to lay do%n the !rofessional obligations of !ri&ate doctors in accidents and in+uries %ho used to be refused treatment in case of !otential becoming !art of a criminal offence. The res!ecti&e roles of the !ublic and !ri&ate sectors in health care has been a key issue in debate o&er a long time. *ith the o&erall s%ing to the Right after the 5896s' it is broadly acce!ted that !ri&ate !ro&ision of care should take care of the needs of all but the !oor. hi doing so' risk !ooling arrangements should be made to lighten the financial burden on theirs %ho !ay for health care. 0s regards the !oor %ith !riced ser&ices. Taking into account the si#e of the burden' the clinical and !ublic health ser&ices cannot be shouldered for all by go&ernment alone. To a large e(tent this health sector reform m India at the state le&el confirms this trend. The distribution of the burden' bet%een the t%o sectors %ould de!end on the sha!e and si#e of the social !yramid in each society. There is no ob+ection to introduce user fees' contractual arrangements' risk !ooling' etc. for mobili#ation of resources for health care. Eut' the line should be dra%n not so much bet%een !ublic and !ri&ate roles' but bet%een institutions and health care run as businesses or run in a %ider !ublic interest as a social enter!rise %ith an economic dimensions. In a market economy' health care is sub+ect to three links' none of %hich should become out of balance %ith the other " the link bet%een state and citi#ens$ entitlement for health' the link bet%een the consumer and !ro&ider of health ser&ices and the link bet%een the !hysician and !atient.