I am a doctor, one of 0.88 million who practice in this country. The general elections are here. My vote will not decide who will be our next Prime minister. But the votes of my patients will.
My farmer friend has had his say and now it’s my turn. I haven’t made up my mind yet, not before I see for myself the reality of Gujarat, through the data provided by the United Progressive Alliance. And just like the farmer before me, I will not be swayed by a wave or a clamour. Neither, I hope, will my patients. A man coughing blood or an anaemic woman about to give birth to a baby who will die before it reaches the age of 1, are affected by state apathy not waves. No, instead, I will study the facts just as how a doctor clips the X-Ray on the light box to observe a fracture. Does he hide the bad news from his patient? Does the patient want him to? Health is sacred; it should never be mixed with politics. A patient cannot be stretchered in and out of a CAT scanner without being told what is wrong with him. Relatives, not doctors, hide the prognosis from a patient.
A bitter pill is also a pill. Spit must be gulped and the pill had.
This being the election season, the streets are festooned with state manifestoes exhorting giant strides made in the Health sector – photoshopped images of new hospitals, smiling women advertising a hundred new health schemes, bars and graphs confirming how the state has been lauded by international agencies. The list is long, but the reality is different. All these elevator music manifestoes have a place – the nearest bin. Any other way and one might as well sit at home and wish the infection would go away on its own.
The wonders of Gujarat are hard to miss – in newspaper centrespreads and TV infomercials. It is clear that Narendra Modi wants Indians to see the development in Gujarat before they go out and vote. The economy is flourishing, the per capita income is the second-best among large states, and new jobs are to be found everywhere. Amid all this, what is the state of Gujarat’s Health? In order to find out, we need some valid comparisons. Gujarat’s health indices cannot be compared with those of Bihar, with its crumbling infrastructure and per capita income in the 20,000s. Moreover, Mr Modi wants Indians to elect a Gujarati as their leader, not a Bihari. If Indians have to be impressed by Gujarat’s Health, Gujarat must be compared with states that are as large, as populated, as rich, and as educated. Compete with the best and judge yourself against them – isn’t that what any leader would want?
Let us then narrow down to six states: Kerala, Maharashtra, Andhra Pradesh, Tamil Nadu, Punjab and Karnataka. The choice is apt on many counts. First, the GDP per capita is high across the board as is shown in Table 1.
2012-13 GDP of Indian States at 2004-05 constant prices. The 2012-13 GDP figures for Gujarat and Kerala were not available and were calculated using their latest GDP growth rates (2004-05 constant prices) as follows: Gujarat: 8.53%; Kerala: 9.51%. Population figures are from Census, 2011.
Second, the southern states have always had impressive Health indices – judge yourself against the best or abandon the whole exercise. Third, these states are the powerhouses of Indian economy, as can be seen by their Real GDP growth rates. There is money being made, and correspondingly, there should be money being invested in Health. Fourth, they have a similar private to public Health expenditure ratio, dispelling the notion that Gujarat doesn’t need to spend on Health as much of it is taken care of by private expenditure. Well, barring Karnataka, all the other states have a higher ratio than Gujarat (Table 2). Fifth, all these states have significant rural, tribal and migrant populations as well as substantial slum households, to take care of another caveat that many communities in Gujarat are remote and inaccessible, or that Gujarat’s figures are undone by migrant labour that lives in slums. Maharashtra, as one can see, has more tribals, migrants and slums than Gujarat. Sixth, all these states have been under stable rule, something that affords a deeper understanding of systemic problems and a compassionate stance towards them. A state must take care of its migrant labour, tribals and residents equally. No village is too far, no tribe too remote. The fruits of prosperity must reach every citizen, howsoever poor or inaccessible he or she is. As Narendra Modi said so himself: Sabka Saath, Sabka Vikas.
Data from Census, 2011, Planning Commission, and National Health Profile 2012. PPHE: Private to Public Expenditure on Health, from National Health Accounts Report 2004-05. Rural and tribal population figures are from Census, 2011. Migrant population data is from Census, 2001 as 2011 figures aren’t available. Real GDP growth rate is at constant 2004-05 prices.
To begin with, let us first look at some indicators that have a direct bearing on health, like sanitation and drinking water (Table 3). Gujarat fares badly, especially against Kerala. 42.7% of Gujarati households have no access to toilets – an invitation to disease and epidemic – and only 39.9% Gujarati households get treated tap water. The figure for Maharashtra, despite its slums, is 56.3%.
Date from Census, 2011. 62% of households in Kerala get their water from wells. For Gujarat the figure is 7.1%.
Next, looking at the population to doctor ratio (Table 4), we find that Gujarat lags behind all states except Andhra Pradesh – 1 doctor for 1,179 Gujaratis compared with 1 for 639 Kannadigas. Punjab, an NDA-ruled state, fares twice as well.
The state apathy isn’t limited to just the lack of doctors, as the following 2012 Rural Health Report statistics show (Tables 5, 6, and 7).
SCs: Sub-Centres; PHCs: Primary Health Centres; CHCs: Community Health Centres; MMU: Mobile Medical Units. Specialists: Surgeons, OB&GY, Physicians & Paediatricians; HW: Health worker. Data from Rural Health Statistics Report, 2012. Data for PHCs in Gujarat is of 2011.
SCs: Sub-Centres; PHCs: Primary Health Centres; CHCs: Community Health Centres. Data from Rural Health Statistics Report, 2012.
SCs: Sub-Centres; PHCs: Primary Health Centres; CHCs: Community Health Centres. Data from Rural Health Statistics Report, 2012.
The three components of a state’s response to routine as well as emergency healthcare, especially in rural areas, are Primary Health Centres (PHCs), Community Health Centres (CHCs), and Sub-centres (SCs). As the tables indicate, Gujarat fares appallingly. An unacceptable 31% doctor shortfall in tribal areas; worrying shortfalls in SCs, PHCs, and CHCs – Kerala’s is 0; unimpressive coverage of rural populations; shortage of Health workers and nurses – Karnataka, Andhra Pradesh, Maharashtra, and Punjab have none. Then there is the astounding 94% shortfall in specialist doctors. In fact, this shortfall was highlighted recently in a Times of India article but what it failed to mention was that the figure for Tamil Nadu was an even more astounding 100%. Thankfully, this incongruity was explained a year ago in an article by Sourjya Bhowmick where he cited a Lok Sabha starred Question No.528 which states that, at least for Tamil Nadu, “Specialists are attending CHCs on hiring basis”. It could very well be that Gujarat is doing the same. That said, these figures are certainly disappointing, more so when one realises that lack of infrastructure and human resource translates directly into human suffering. Gujarat, sadly, is no exception as is apparent from the Health and Disease indices, Tables 8, 9, 10, and 11.
Disease cases per million state population. All data for 2012, from National Health Profile 2012.
Data from Planning commission and National Health Profile 2012
Antenatal & Safe delivery data: District Level Household and Facility Survey 2007-08; Anaemic and BMI data: National Family Health Survey-III (2005-06)
Data from National Health Profile 2012, citing District Level Household and Facility Survey 2007-08
Gujarat fails to come out top in any category, be it Acute Diarrhoea – Tamil Nadu and Maharashtra fare better; Malaria – all states fare better; Tuberculosis – Karnataka, Tamil Nadu, and Kerala lead; or Leprosy – Gujarat is second from bottom. Worse, only 52.3% Gujarati pregnant women were provided the first trimester check-up, and only 61.6% had a safe delivery. Look at the figures for Kerala: 99.6 and 99.4% respectively, and a below normal BMI of 18% compared to Gujarat’s 36.3.
The condition of Gujarati children isn’t much better than their mothers. 51.7% are stunted and a horrifying 6.7% have never been immunised. Never been immunised. These are the future of Gujarat; they will carry the burden of her rapid economic progress on their stunted, mangled shoulders.
It gets more grim. Gujarat is the only state among the bunch where, cruelly, the female sex ratio has gotten worse this past decade. One can only gape at the numbers for Kerala and weep, for our girls, for Gujarat, for India.
Sex Ratio is defined as females per 1000 males. Data from Planning commission.
Misery refuses to take a breather when we come to the most gut-wrenching statistic of all – Infant Mortality Rate (Table 12). Nothing can be worse in this world than to see your progeny die before it reaches the age of one. No economic plaudit worth its salt can make up for this crying shame. No balm, monetary or emotional, can lessen the grief. As if the UFMR and MMR figures weren’t bad enough – Gujarat: 56 and 12.8, Kerala: 15 and 4.1 – Gujarat has an IMR of 38. The figure for Kerala is 12. True, the reduction in IMR after Modi took over has been impressive, but more impressive has been the reduction in all other states over the same period – higher than Gujarat without exception.
IMR is defined as the number of deaths of children less than one year of age per 1000 live births. MMR is the ratio of the number of maternal deaths during a given time period per 100,000 live births. UFMR is the probability per 1000 that a new-born baby will die before reaching 5. Data from SRS Report, 2012 and Planning commission.
* Kerala IMR figures in the past decade have remained essentially at the base level of 11 to 12
To summarise, then, Gujarat cuts a sorry figure in the area of Health. In fairness, some of the data (as noted below all tables) was collected as far back as 2005-06, but the majority is from Census 2011 and National Health Profile, 2012. There is no getting away from it – these are the latest statistics policymakers use. Gujarat must therefore answer at least for the 2012 and 2011 indices. To be sure, Gujarat’s indices are better than at least a dozen or more states, UP and Bihar included. The 2012 IMR for the Gandhi dynasty-bastion Raebareli, for example, is 53. But then trailblazers want to be the best, want to compete with the best, and without a shadow of doubt, Kerala is the state to beat, to emulate, to bow before and learn from.
So what explains this conundrum, of a state performing so well on economic parameters while at the same time failing abjectly on Health? Economists mention a two-stage development model being followed currently by Gujarat. They say that in order to spend money on Health, Gujarat had to generate money first. Bibek Debroy talks of little need to study troubling health indicators before 2007 because that is when Gujarat decided to put its focus on the social sector. Jagdish Bhagwati, too, concurs with Debroy. In a recent speech, he said Gujarat’s first phase of development – that of generating revenues – is over. Now to the next stage.
As a doctor, I have two problems with this two-phase theory. First, one can’t just let a whole population suffer interminably because one wants to plan for a glorious future. What about those unimmunised and stunted children – would they benefit from this so-called money surge whenever it comes? In Kerala, the immunised children at least have an option later to emigrate in search of jobs and prosperity if the state fails them.
Second, granted that Gujarat was busy with the first phase and now that it has shown enviable growth for nearly a decade running, the second-phase has kicked in. Well, it has been seven years since 2007. The wealth has been generated. The locomotive whistles and the steam gushes out for all to see and admire. Time then to look at the recent Health and Nutrition expenditure by Gujarat. Surely one would spot the surge, the sudden spurt. Table 13 shows the Revenue expenditure on Medical & Public Health and Nutrition by the chosen states over a decade (state population numbers are in brackets).
If there was a surge somewhere in there, I missed it. Indeed, Andhra Pradesh’s Health spend appears more impressive. To get a clearer picture, one needs to obtain the per capita figures. Table 14 shows the Medical & Public Health and Nutrition expenditure per capita.
Far from a surge, it is quite apparent that Gujarat has been trumped by many states that aren’t as wealthy as Gujarat in the first place – Tamil Nadu, Andhra Pradesh, even Kerala. The trend is reflected when we study the figures for state expenditure on Nutrition (Table 15). Other states are spending much more than Gujarat should or actually is, despite the fact that the first phase was over 7 years ago.
The Nutritional expenditure per child brings this out unambiguously (Table 16). Tamil Nadu is spending much more, and the second-phase surge prize, if one wants to hand it out, must go to Andhra Pradesh not Gujarat.
This, then, is the Gujarat Health story. Not impressive. But is it all doom and gloom? Are Gujarati children and pregnant mothers forever condemned to wait for a surge that might or might not come in the near future? Not quite. What use is a doctor who establishes the symptoms of a disease but finds not its cure?
There is a way out, a way that can bring Gujarat’s health indices to within touching distance of Kerala’s within a year. I have discovered a truly marvellous solution which this margin is too narrow to contain. It shall be elucidated in my next article.