The Pratichi Health Report

by the Pratichi Research Team (Kumar Rana, Subhrangsu Santra, Abdur Rafique, Arindam Mukherjee and Amrita Sengupta) with an Introduction by Amartya Sen; TLM Books in association with Pratichi (India) Trust, 2005; pp 134, Rs 100.

ACHIN CHAKRABORTY

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opular discussions on health and healthcare are usually not cast in quantitative terms. More typical are the impressionistic arguments based on certain cases one happens to know of. To facilitate informed public debate on education and healthcare Pratichi Trust (set up by Amartya Sen in 1999) has been bringing out research reports based on “in-depth” field surveys. Going by the public attention that the Trust’s previous studies on primary education received, it is not hard to imagine that The Pratichi Health Report too will not go unnoticed.

Dumka and Birbhum – two adjacent districts in Jharkhand and West Bengal, respectively – were selected for the present study. Although the two districts are somewhat similar in agro-climatic conditions, they differ in socio-economic characteristics, and not surprisingly they differ in terms of availability and quality of the healthcare services as well. While most of the public health centres (PHCs) in Dumka are non-functioning due to the absence of doctors, medicines and other infrastructural facilities, the situation in Birbhum seems somewhat better. And, the consequences of virtually non-existent public health facilities in Dumka and poorly functioning facilities in Birbhum follow the expected line – proliferation of private providers of poor-quality and high-cost services, and further destitution of lowincome households who are forced to buy these services. The report documents them in detail, in terms of an excessively large number of cross tables and bar diagrams.

System-level Analysis

The sickness incidence, utilisation pattern of different kinds of healthcare services, cost of treatment, etc, for the surveyed population in the two districts have been presented in all conceivable ways – disaggregated by gender, economic categories, social groups and all. The pattern is rather predictable. Fewer women than men seek treatment for their ailments, people belonging to SCs and STs are relatively disadvantaged, a large majority of those who seek treatment on outpatient basis go to private providers, poorer people go to unqualified medical practitioners ((UMPs) or “quacks”), the cost of treatment in a supposedly “free” public facility often exceeds the cost of going to an UMP, the cost of hospitalisation is too high to be afforded by a typical household, and so on. Summary statistics and their analysis contained in this part of the report are roughly similar to what one gets from various other studies based on household surveys on healthcare-seeking behaviour, including the two NSS rounds. Even though the last NSS round on morbidity was conducted in 1995-96, which makes it look somewhat dated now, one might still wonder what new insight one would get from the Pratichi report, on those particular issues which had been covered by the NSS. Not much, perhaps. Besides, largescale surveys like NSS enable us to compare all the states at several time points. However, it would be unfortunate if the reader arrived at her judgment at this point, as the strength of the report lies somewhere else. The detailed description of the variety of providers together with the information on incidence of illnesses and treatment-seeking pattern of different groups of people give a fairly good idea about the organisation of healthcare services at the system level. Until recently, the state ministries of health have hardly appreciated the need for a system-level understanding for policy-making. They confined themselves to the exclusive task of setting up and running the public facilities. With the arrival of funds from the international agencies “to improve health system performance” and the concomitant arrival of ideas like publicprivate partnership, it is now expected that the policy-makers will feel the need for system-level understanding.

Role of ‘Quacks’

Quacks are an integral part of the system. The report gives a vivid description of them. What do they do? They give drips, no matter what the ailment is, as they believe “saline increases blood in the body, gives nutrition and faster relief” (p 51). They also give antibiotics, which they know by the colour of the foil. It’s indeed shocking, for those of us who do not have to go to them for treatment. But our “shock” at their treatment practice should not distract us from understanding the hard logic of the market. Quacks do refer the complicated cases to public hospitals, simply because they cannot afford to do business with potentially fatal cases. They treat mostly what is called “minor illnesses”. The popularity of UMPs for minor illnesses is quite widespread in India, only the degree may vary from Dumka to Delhi. The explanation that the predominance of UMPs is mainly due to the absence of public healthcare facilities or their poor functioning is a plausible one in the context of Dumka, where one clearly sees both in a rather extreme form. But in general, the explanation must be in more complex terms. For more serious illnesses, people do take the trouble of going to the government facility, if they cannot afford qualified private doctors. In other words, the so-called free public facilities have high access-costs, which people want to avoid for minor illnesses and take the risk of going to UMPs. This is, of course, not to suggest that the practices of quacks have less harmful effect on population health than what the report observes. However, health system thinkers are now in favour of recognising a positive role that UMPs can play in the provision of certain services. Too much of moral indignation at the quacks’ “unethical practice” and “exploitation” may mislead us into the naïve

Economic and Political Weekly February 11, 2006 thinking that expansion or reorganisation of public facilities staffed by only qualified doctors is the sure way to get rid of the private healthcare market and the associated “exploitation”. Amartya Sen’s ‘Introduction’, from which a what-is-tobe-done kind of list has been extracted and printed on the back cover, emphasises the need for “a far-reaching reorganisation of public health services”. But this commonplace suggestion, I am afraid, is too general to be seriously taken as a guide to policy. Specific policy interventions would require prior analytical explorations into the complex connection between the micro organisation of government health services and the macro organisation at the health system level (which would include all kinds of stakeholders outside the public system). The Pratichi Report does have useful material for such explorations.

So much effort and good intention have gone into producing the report that one feels a bit diffident about raising uncomfortable questions on the methodology or reporting style. Pages have been filled with sentences of the following kind: “It is 48 per cent in Birbhum, but in Dumka it is still worse – only 27 per cent”. The statements in most cases are “Rupees in words” type – as one sees on a bill – first in figures in the tables and then in words in the text. If one picks up any two districts or states or countries and compare figures pertaining to those entities, one gets plenty of pairs of numbers to compare. But how many pages can one fill with such comparisons? Besides, the reader might find it a bit exhausting to negotiate with them. Amartya Sen once wrote

Any description relies on factual statements. But it also involves a selection from the set of factual statements that can be made pertaining to the phenomenon inquestion: some facts are chosen and othersignored…(A boy I knew in school complained after seeing his first movie, agedten: “What beats me is that they never seemto go to the toilet”).1

The Pratichi Health Report has an abundance of “factual statements”, but an illuminating description would perhaps require a ruthless pruning of these statements and telling the reader in more explicit terms what all those comparative figures really mean.

The report notes that the study “depended heavily upon the perceptions of the villagers – both male and female – in order to get an objective assessment of their health status and the health delivery system in place” (p 14; emphasis added). One should exercise caution in using such words as “objective” in the context of assessing health status. If what is known as “selfreported health status” in the literature is called “objective” then how does one categorise the other kind of health status assessment based on direct measures of haemoglobin, body temperature, blood pressure, weight and height, etc?

In the section titled ‘Prevalence of Ailments’, by “prevalence” the report means the proportion of persons reporting ailment suffered at any time during the reference period (i e, one year). Those who are familiar with the meaning of prevalence following the definition given by the WHO Expert Committee on Health Statistics

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Economic and Political Weekly February 11, 2006

might grumble. Prevalence, strictly speaking, refers to the frequency of illnesses during the reference period. Incidentally, the NSS Report (52nd round) too reported “prevalence” in the same manner as The Pratichi Report has done. But there is an important difference. As the NSS takes a 15-day recall period for non-hospitalised episodes, the frequency of illnesses for a person is most likely to be close to unity, and thus prevalence rate as a distinctly different indicator loses its importance. But in Pratichi’s case a typical person is more likely to report several episodes of illnesses, as the reference period is one year. And therefore, blurring the distinction between incidence and prevalence is likely to be seen as rather problematic in Pratichi’s case.

Notwithstanding the avoidable weaknesses of the kind we have pointed out here, one sincerely hopes that The Pratichi Health Report accomplishes what its authors set out to do – to facilitate public discussion on the appalling condition of the delivery of public health services in India.

EPW

Email: achin@idsk.org