It's not just the corruption

While the World Bank held back around a billion dollars worth of health sector loans to the country on grounds of corruption, this is the least of the problems. Sure, corruption’s an issue, not just with health but in each and every sector. And how important is it? In the current case, there were complaints that some firms were getting most purchase contracts while they were charging more. So, at the worst, this meant the government was shelling out between 20 and 25 per cent more than it should have.

The more important issue here, and especially in projects that the Bank is associated with, such as the Integrated Child Development Scheme (ICDS), is of such poor design and implementation that the impact on the ground is negligible. That is, it’s not the 20-25 per cent of excess payments that is the problem; it’s that the 75-80 per cent balance is hardly having any impact, either.

Nor can it. Between 80 and 90 per cent of health expenditure is on salaries (for Punjab, it was 94 per cent), leaving little for equipment/medicine—in 1998-99, the latest survey available, just 60 per cent of primary health centres had BP instruments and 16 per cent autoclaves/sterilising equipment. Absenteeism is rampant, ranging from a “low” 30 per cent in primary health centres in Maharashtra to as high as 67 per cent in the case of doctors in Bihar. For non-doctors, the figures are lower, but still significant—53 per cent in the case of Gujarat to 30 per cent in Maharashtra. Fix this, and it will more than make up for the corruption in supplies the Bank is so concerned with.

Health expenditure by the central government has risen by over 15 per cent annually since the turn of the century and that on child health has risen 27 per cent; yet even Bangladesh has better macro numbers. China’s infant mortality rates, at 38 per 1,000 live births in 1990, were much better than India’s 80; so it’s hardly surprising that in 2003, China’s infant mortality was 30 as compared to our 63. What’s shocking is that, at 96 in 1990, Bangladesh was a lot worse, but in 2003 its rate was down to 46 as compared to our 63. The same applies to under-five mortality rates.

The number of registered medical practitioners, similarly, remains at just 5.6 per 10,000 people, not much of an improvement over the 4.7 a decade ago. Less than 30 per cent of the population get full antenatal care and even today just a third of all births take place in a hospital/nursing home.

The traditional response of the government to such problems is to throw money at them. Or, when it is at its most responsive, is to go Mission Mode—remember all the missions Sam Pitroda was in charge of when Rajiv Gandhi was the Prime Minister?

Polio eradication has been one such mission we’ve been running for several years now (even Amitabh Bachchan has been roped in to popularise the message), and very successfully—there were just 57 cases reported in the country last year. But, as Laveesh Bhandari of economics research firm Indicus Analytics points out, routine immunisation has declined as a result of the mission-mode approach to polio—while the target for routine immunisation was to reach 85 per cent coverage by 1990, the figure was a mere 52 per cent in 1998-99 and fell to 44.6 per cent in 2002-03. For states like Bihar, the figure is 20.4 per cent in 1998-99 and Rajasthan at 22.5 per cent isn’t much better off—several African countries do better. In other words, don’t be surprised if, in a few years, you have increasing cases of highly preventable diseases like diphtheria or tuberculosis.

A good example of the design problem is the Bank’s analysis in the case of the ICDS. The ICDS, by the way, is run under the ministry of human resources development (who’re more concerned about preventing IIM/IITs from raising fees and now want to hike caste-based reservation there to 50 per cent), but is an integral part of healthcare since malnutrition causes half the child deaths. Iron deficiency in children in the country is 75 per cent as compared to 55 per cent in Bangladesh, while the iodine deficiency is 26 per cent as compared to 18 per cent in Bangladesh. As a result, according to the World Bank, India loses around 3 per cent of GDP each year, apart from the human suffering. While 47 per cent of children were underweight in 1998, around 18 per cent were severely underweight, with the decline over the ’90s just around 1.5 per cent annually as compared to Bangladesh’s 3.5 per cent despite a much lower GDP growth.

According to the Bank, the ICDS programme focuses on supplementing food but not on nutrition and, worse, it focuses on children above three years of age while malnutrition sets in much earlier! A Bank analysis of villages with anganwadi centres finds that children who live here “are not significantly less likely to be underweight or ill than other children” once you adjust for variables like household income and village characteristics. The regional bias is also significant—55 per cent of children in Bihar are underweight, but only 1.5 per cent of them are covered under the ICDS.

The finance ministry is trying to persuade the Bank to go slow on the corruption issue. It may just succeed, given how the Bank has such few credible borrowers nowadays, but how will it get the health ministry to get its act together?