India’s biggest failings are arguably not in corruption or Maoist areas but in health. Child malnutrition and anaemia rates are among the worst in the world. Infant and maternal mortality rates have fallen but remain tragically high. Illnesses push millions below the poverty line.
Government health spending is below 1% of GDP, among the lowest rate in the world. Its quality is also terrible. A World Bank study by Das and Hammer found that more than half the treatments suggested by government doctors were likely to make patients worse, not better.
The Planning Commission wants to double public spending on health. State governments want it to abandon centrally sponsored schemes like the National Rural Health Mission, criticizing its procedures as cumbersome and one-size-fits all. They claim that getting the money as untied cash will be more flexible and effective. I disagree. The tragic state of Indian health shows that spending by the states has been phenomenally wasteful and corrupt, and more central cash will not solve these ills. Some states in the south and west have done reasonably well, but the record of other states ranges from bad to terrible.
The biggest causes of disease and death are unclean water and indoor air pollution from wood-burning chulhas. Yet water and sanitation typically constitute a separate state ministry, independent of the health ministry. Providing gas connections to reduce firewood usage comes under the ministry of petroleum. Popularising smokeless chulhas comes under the ministry of non-conventional energy. Drainage comes under the irrigation ministry. So, improved health requires not just more money for health ministries but mechanisms cutting across many relevant ministries. The Mission approach is one such, and it helps encourage public-private partnerships.
Allow me illustrate this through a shamelessly self-serving example. The mighty Brahmaputra in Assam has 2,500 islands with 2.5 million people. The vast majority have never seen a doctor. The state government cannot provide decent health services even onshore, let alone in the islands.
So, my friend and fellow journalist Sanjoy Hazarika submitted an entry to the World Bank Development Marketplace, which gives modest cash awards to social entrepreneurs to try out new ideas. Hazarika proposed building a “ship of hope”—a medical boat designed as an OPD (outpatients’ department). This would be run by CNES, his NGO in Assam, serving islands on a regular schedule with enough repeat visits to make improved health sustainable. Country boats would go in advance to inform islanders of the ship schedule.
Hazarika won an award of $10,000 and used this to build his first ship. Inspired by him, i decided as a birthday gift to my wife, Shahnaz, to finance a second ship, named after her. When that too succeeded, we financed four ships more. Initially the state government was partly supportive and partly skeptical. It refused to provide cash for additional ships, but offered to meet operational expenses. Even so the flow of funds was not smooth, and one district collector asked whether we could also provide free diesel.
Then along came the National Rural Health Mission. Its support finally ensured the smooth funding of operational expenses. The fact that we were steadily supplying one ship after another greatly raised our credibility, and state government support became rock-solid. Along with smaller leased vessels, the fleet now has 15 ships. Each ship is 55 to 90 feet long, and carries two doctors, three nurses, one pathologist (for blood testing) and one pharmacist (to dispense medicines). They now cover almost half of the island population across 13 districts, and treat 200,000 to 300,000 cases per year. This vastly exceeds our initial expectations.
Apart from treating patients, the ships screen films, give lectures and distribute pamphlets to villagers on sanitation, clean water and other public health issues. Let’s not exaggerate—coverage of the islands is incomplete, current services are very basic, and patients with serious issues have to be referred to onshore hospitals. We have made no more than a start. Yet this is a small revolution. Two journalists from New Delhi, plus the Mission, have made a breakthrough that defied the state government for six decades.
The National Rural Health Mission’s record is spotty. In many states, health outcomes remain pathetic. Attempts to form village health committees have failed widely. But, as our Assam story shows, where NGOs with integrity exist, astonishingly productive public-private partnerships are possible.
I am, of course, biased. But i think this story illustrates how valuable the national mission approach to development can be. Centrally sponsored schemes may require more flexibility and tailoring to individual states’ needs. But they must not be abolished.