May 9th was celebrated around the world as Mothers Day. A day where the urban population in India took some time to celebrate their mothers and her influence in their lives.
However, in India, Mothers Day has very little meaning to the 254 mothers out of 100,000 who die every year during or after child birth. Even in a so-called advanced state like Karnataka, 213 mothers out of 100,000 die every year due to poor health that complicates their pregnancies and deliveries. In the other Southern States, there has been a more concentrated effort to reduce the maternal mortality rates to below 200. So why was Karnataka slower in achieving this progress? Total fertility rates in Karnataka were reaching 2.1, but in the other states it had fallen below the 2.0 level in 2007 while the target was 1.56. Even the mothers who lived, still did not have a chance of not celebrating the birth of their new born infants as infant mortality in 2008 was around 45 per 100,000 children in the state. In the other southern states, it was below 30. So why then are Karnataka’s health indicators, and its care for its mothers and children still failing to meet the extent of the progress of the other southern States, like Tamil Nadu and Kerala?
An analysis of the state health spending in Karnataka revealed that health expenditure as a percentage of total Gross State Domestic Product (GSDP) remained less than 1% even though in per capita terms, an individual was getting more on health in 2009-10 than in 2000-01. This fact was true even after the expenditure was adjusted for inflation (real expenditure and hence real per capita spending).
A closer analysis of the increases in per capita expenditures revealed that part of this increase could be explained by the stabilizing of population growth within the state. So while per capita expenditures were increasing by around 3% in real terms, a part of this was due to the 1% increase in population. The rest of the increase (4%) was due to the increases in health expenditures (after being adjusted for inflation) made by the government. What was the source of the 4% increase in real expenditures?
Rising administration costs, which grew by around 24%, would best explain this phenomenon. The share of administrative costs in the total health spending rose from 1% to 5% in 2009-10. However, even as the administration costs of the health department increased, people complained about missing doctors in their primary and secondary care hospitals. Doctors who were interviewed complained that there was a shortfall in the number of staff hired for their hospitals. And health workers complained that they were being overworked to make up for the shortage. These service providers form a key link to ensure the health of mothers and children and were either missing in numbers at hospitals where they were key to provide services. Even as the state boasted of new First Referral Units (FRUs) for its women and 24×7 Primary Health Care (PHC) centres for its population, new emergency obstetric care facilities, new ambulances for rushing mothers with complications in deliveries to larger hospitals, these units remained short of doctors, nurses, health workers, ambulance drivers and sometimes medical staff remained missing at the centres.
Another part of the increase could be explained by the disproportionate investment in secondary and tertiary care (increased by 10% CAGR), either in the form of providing insurance for such care or in investing in multi specialty hospitals within the state. It is interesting to note that the amount allocated for this new infrastructure comes at a time when the government is not able to fill in the vacancies for specialists in its own Taluk and District hospitals. Also, the government has been encouraging public private partnerships in managing its hospitals by allowing NGOs and other private medical institutions to take over the running of its primary health centres. The insurance schemes are encouraging the use of the private care systems as an alternative to the failing public health system. Spending on secondary and tertiary care increased from 32% to 38% of the total health expenditures. Still, ensuring reproductive and child health services are more dependent on primary care services and preventative strategies.
Budgetary analysis revealed that spending on primary care has decreased from 19% to 18% of the total during the same time period. Hence we can see that the increases in per capita expenditures are largely due to increases in the administrative and the non primary expenditures, while it is evident that the primary care seems to take a back seat in the State.
The other issue is horizontal co-ordination locally of allied services that can improve overall health outcomes. Access to clean water, sanitation facilities, disease surveillance, ensuring a clean environment, are all examples of investment in preventive health strategies that are required for a coordinated approach to tackle environmental health. Health workers form a key link in providing preventative health services to mothers and children within the state. They regularly have to follow up with mothers and children, identify possible complications and counsel the family involved, ensure that nutritional supplements are adequate, and are responsible for immunizations. However, there is a high level of demotivation within this group, which is neither supported by funds nor by the bureaucracy above them. There is a tendency for the bureaucracy to reprimand mistakes rather than approach the situation with a problem solving attitude to support the staff working on the field. As we sat through a health meeting at the district level, it was surprising to see that the bureaucracy spent around 5 minutes per child who died and an average of 3 minutes per mother who died. The attitude was clear, ‘why did these people die’, not ‘what can we do to prevent this in the future and eliminate it?’
Improvements in the health indicators described above depend on the primary care strategies of the state which need to be supported by adequate financial resources and horizontal coordination with various departments and human resources within the state to become a reality. A budget of less than 1% cannot be sufficient to support any strategy of health.
With the introduction of the NRHM scheme, a lot of funds have been pumped into making up these deficiencies in funds for women and child health services. Money has been offered to mothers if they deliver in hospitals and not at home. There are even schemes that encourage mothers to come to hospitals for check ups and take additional nutritional supplements during their pregnancies. As with most schemes that are sponsored by the central government, the state has initially seen an encouraging increase in its spending on women and child services. Untied money has been allocated to the Panchayats and the health workers to spend on women and child health services. These are positive steps taken by the government to improve the situation of health within the state.
In 2012, when the scheme ends, it will be interesting to see how the innovations of the scheme have reduced the maternal and infant mortality rates of the country’s as well as the state’s. Historically however, it is known that when the central government starts pulling out funds to hand over the responsibility of the service to the state, the state also starts pulling out its schemes. It remains to be seen how Karnataka continues to take this effort forward. Till then Mothers Day will be a reminder about the mothers who die from neglect, poor health and access, if even, to a poor quality public health system.