HEALTH SITUATION IN INDIA: AN OVERVIEW. Shabir Ahmad Padder 1

Transcription

1 Journal of Regional Development and Planning, Vol. 2, No. 1, HEALTH SITUATION IN INDIA: AN OVERVIEW Shabir Ahmad Padder 1 Health is an essential input for development of human resources and quality of life and in turn the social and economic development of nation.a positive health status is defined as a state of complete physical, mental and social well-being and not only the absence of disease or infirmity (WHO, 1946).Health is a regardless priority for sustained development interventions both at the individual community and national levels. Improved health is a part of total socio-economic development and is regarded as an index of social development. A provision of basic health care services to rural community is the primary objective of the government as well non-government organizations in the context of rural development.rural health services, safe drinking water,sanitation,nutrition, etc., have therefore, been brought together in the form of an integral package to improve the social, economic and health conditions of the people. Therefore, the primary goal of any health care delivery system is to organize the health services in such a manner as to optimally utilize the available resources, knowledge and technology, with a view to preventing and alleviating diseases, disability and sufferings of the people. INTRODUCTION We stand at the threshold of a new era in striving for the goal of Health for All as a public health professions looking at the 20thcentury picture of our health, or lack of it, the view is primarily filled with the images of our struggles against the old diseases that have plagued our ancestors for centuries. But as we look towards the 21stcentury, The view is markedly different. We see ourselves confronting new diseases in a world where borders and geographic distances are increasingly irrelevant to the pattern of disease in our globe village yet we also perceive ourselves continuing to fight many of those old diseases that are learning new tricks to foil our attempts to combat them. Our challenge, at the threshold of the new millennium is not only to address the assault of the disease producing microbes around us, but also to recognize that many of the causes of our ill health are increasingly related to our life styles and man made changes in our environment. Health, life styles and environments will ultimately return greater increments in longevity than any additions scientific advantages. More importantly, improvement in life styles and the environment will help to ensure that these extra years of life are of high quality. We need to add life to year rather than simple adding years to life developing countries such as India, face three major problems ignorance, poverty and disease. The link between these is so strong that it is difficult to identify which leads to what! Consequently, setting priorities for any of the above three has become a problem. However, efforts are underway in the developing countries through various development programmes to eradicate ignorance, poverty and ill health prevalent among the major portion of the population. India is essentially a rural country with 80 per cent of the population living in about villages with unsatisfactory sanitary conditions, poor economics and educations standards. The 1 Assistant Professor, Department of Economics, Govt. Degree College Shopian, Kashmir (J&K) , shabirpadder_college@rediff mail.com

2 66 JOURNAL OF REGIONAL DEVELOPMENT AND PLANNING central and state Governments have realized the importance of health, family planning and welfare, nutrition and sanitation in the whole process of development. For attaining the goal of Health for All, India requires not only thorough over hauling of existing Strategies in education and training of medical services and health personal, but also a radical restructuring of health services infrastructure. Methods have to be evolved within a fully integrated planning frame which should seek to provide universal comprehensive primary health care services, relevant to actual needs and priorities of the community at a cost which the people can afford ensuring that planning and implementation of the various health programmes is through organized involvement and participation of the community, adequately utilizing the services rendered by private voluntary organizations active in health the sector. Presently, despite the constraints of resources, there is disproportionate emphasis on the establishment of curative centres, hospitals and institutions for special treatment. The large majority is concentrated in the urban areas in unplanned fashion which result s in the under utilization of some services and over utilization of the other services. The vast majority of those seeking medical relief have to travel long distance to nearest curative centre, seeking relief ailment which should have been readily and effectively handled at the community level. Also for want of well established referral systems those seeking curative care have a tendency to visit specialist centres, thus further contributing to congestion, duplication of efforts and constantly waste of resources. The objective of the paper is to assess the Health status of India in Global and National perspective. Further issues of inequity in health services and financing of health care will also be addressed. Suitable suggestions/ policy implications for making health care services / programmes more relevant to the people will be given in this paper. SOME COMPONENTS OF HEALTH IN GLOBAL PERSPECTIVE The WHO highlights three specific dimensions of health the physical, the mental and the social. Health is multifactor as well. There are numerous factors influencing health like hereditary factors, environmental factors, life style, adequate housing, basic sanitation and socio economic conditions including income, education, availability and quality of health infrastructure and per capita health expenditure. Safe drinking water and proper sanitation has a significant role in health sector. water borne diseases like diarrhoea, malaria, cholera and hepatitis are basically targeted to infants, children and old people. Every year there are four billion cases of diarrhoea in the world causing two billion deaths among children under five and 15 per cent of deaths in developing courtiers (WHO and 2000). Contaminated water is one of the most important causes of diarrhoea among children. There is other water pollutant such as long term exposure to arsenic in drinking water, which can causes cancer of skin, lungs, urinary bladder and kidney (Haq, 2004). The beginning of the new millennium one sixth of the world population was without improved water source and two fifths were without improved sanitation facilities (UNICEF 2000). Sanitation facilities still fail to meet the requirements of all population groups, especially in India where access to sanitation needs much progress. Nutrition is an aspect of health where income matters hungry people who have more money are likely to spend it on food and as famously illustrated by Amartya Sen. s ground breaking work on famines, hungry often reflects the lack of means to acquire food rather than general food scarcity

3 Journal of Regional Development and Planning, Vol. 2, No. 1, (OECD, 2010)..However, more income does not always guarantee proper nutrition, and people who are not poor can still go hungry. Inadequate nutrition also affects the people particularly children acquire knowledge and participate in society. It hampers the ability to work and be productive and thus limits the ability to earn the income needed to lead a decent life. And the irreversibility of some health consequences of malnutrition blindness from Vitamin A deficiency, physical stunting from protein shortages reinforces the urgency of eradicating hunger (Neumayer, 2010). Jean Dreze and Amartya Sen wrote that Hunger is a many- headed monster highlighting the many ways a lack of food can affect people's freedoms (Southgate, 1990).Hunger is also a behemoth and a stubborn one. Hunger persists despite the remarkable boost in food production brought about by the green revolution between the early 1960s and the early 1980s. by 2000 further gain in food production had contributed to lower prices for most staples. The share of undernourished people in developing countries fell from 25 percent in 1980 to 16 percent in 2005(HDR, 2010). While many millions of people have too little to eat, millions eat too much. The recent rise in obesity, especially in children, jeopardizes advances in the care of cardiovascular disease, stroke and diabetes. Severe obesity can reduce life by 5 20 years, leading some specialists to conclude that life expectancy in United States is likely to level off and may even fall by 2050 (Barro, 1991). These risks are the result not just of higher income but also of cultural influences that can be transmitted across borders. Mexico were peoples incomes average only a fifth those of the United States, has shares of obeyed and overweight people similar to those in the United States(Ibrahim and Alkire, 2007). HEALTH STATUS OF INDIA INTERNATIONAL COMPARISON Health is a vital indicator of human development. Health stands in India have improved considerably since independence. The concerted efforts to the government and other agencies engaged in expanding the health infrastructure have paid off, as evidenced by the improvement in some of our health indicators. Longevity has more than doubled since independence, infant Mortality Rate has fallen, malaria has been contained, small pox and guinea worm have been completely eradicated and leprosy and polio are nearing elimination. We have made deeper inroads into rural areas with focused schemes like the National Rural Health Mission and have even started a scheme for health insurance for the poor population. Despite these achievements, the health services that India provides to her people continues to be far from adequate and compares rather poorly with even Asia n neighbours like Sri Lanka and China. One fifth of the world s share of diseases is in India, there are huge regional disparities in health standards in the country and huge gaps in health care infrastructure, in rural areas. The reasons for this can be many, with centralize planning and low government spending on health being some of the major among them. India spends only 1.1% of GDP on health against the 7.5 % by United States, 7.1% by Norway as is shown in Table. 1. It is evident from the table that still 12% of the population in India do not have access to safe drinking water and 69% do not have access to proper sanitation facility. India has lowest sanitation coverage among the neighbouring countries. In developed courtiers 100% of the people have access to safe drinking water and proper sanitation facility.

4 68 Country JOURNAL OF REGIONAL DEVELOPMENT AND PLANNING Table 1 Economic and Health Indicators of India and Few Selected Countries GDP per Expenditu Public % of % of Prevalence capita re on expenditure people people of under US$ health per on health as a without without nourishme (2008) capita % of GDP access to access to nt (% of (PPP$) ( ) Safe Proper total (2007) drinking sanitation population water (2008) ) (2008) ( ) Intensity of food deprivation (average % short fall in minimum dietary energy requirements ( ) Norway 94,759 47, <5 - US 46,350 7, <5 - Japan 38, <5 - UK 43,541 2, <5 - China 3,267 2, Sri Lanka 2, India 1, Pakistan 9, Bangladesh Source: UNDP, Human Development Report 2010 Percentage of malnourished population is quite high in all developing countries China has lower percentage of malnourished population than that of India 10% population suffer from malnutrition and 13% face food deprivation in India. Figure is little bit satisfactory when compared with Pakistan and Bangladesh. Table 2.shows health indicators / outcomes of India vis a vis other developed and developing countries. Table reveals that Number of physicians available per ten thousand of population is more than 20 in case of developed countries while as it is lower than 15 in developing countries. Similarly number of Hospital beds available per 10 thousand of the population varies from 39 to 139 in developed countries while as it varies from 4 to 31 in developing countries. Life Expectancy in developed countries is more than 80 years while as it is comparatively low in developing countries. India has lowest life Expectancy 64 years when compared other neighbouring countries like Bangladesh, Pakistan, Sri Lanka and China. Infant Mortality rate per thousand live births is 3 to 7 in DC s, it is much higher in south Asian Countries ranging from 18 to 72. Maternal Mortality Rate is less than ten in developed countries while as it is 450 in India and 570 in Bangladesh. It is only 45 China and 58 in Sri Lanka. Further Total Fertility Rate is quite high in developing countries India (2.5), Pakistan (3.6) compared to developed countries which are less than 2. Similarly 34% infants lack immunization facility in India against DTP and 2% against measles. Health outcomes are influenced more by the share public expenditure in health expenditure rather than the share of health expenditure in GDP. Per capita income of developed countries vary from more than 50 to 80 times that of India among the neighbouring countries China and Sri Lanka as a higher per capita income. Health expenditure as a percentage of GDP is significantly higher in developed countries as compared to India and the neighbouring developing countries.

5 Journal of Regional Development and Planning, Vol. 2, No. 1, Country Table 2 Health Indicators of India and Few Selected Countries Hospital beds Life Expectancy (per 10 (2010 ) thousand people ) Physicians (per 10 thousand people ) Norway US Japan UK China Sri Lanka India Pakistan Bangladesh Maternal Mortality Rate ( ) Total Fertility Rate ( ) Infants lacking Immunization against DTP (2008) Norway US Japan UK China Sri Lanka India Pakistan Bangladesh Source: UNDP, Human Development Report 2010 Infant Mortality Rate (per thousand live births 2008) Infants lacking Immunization against (% of one year s olds) Measles 2008 HEALTH EXPENDITURES AND FINANCING AGENTS In India over 80% of the health expenditure is private. As against this, in most developed countries, more than 80 per cent of health expenditure is borne by the public exchequer. The NHS (National Health Service) of the UK is an especially stark example of a state run and publicity funded health care system. Along with the Scandinavian countries, the UK uses tax finances to pay for 80 per cent of the health care spending. Elsewhere in Europe, social insurance schemes shoulder most of the financial burden for health care. The United States (US) has its own system of financing health care relying on private insurance paid, mostly, by the employers, almost half of the super sized health spending of the US (16 per cent of the GDP) is still financed by tax money for the care of the old and the very poor (Kurain, 2010). Due to very minor rule of insurance in Indian Health Sector, almost three fourth of the total health expenditure is borne by the households as out of pocket expenditure and it is estimated that one quarter of all Indians slip below the poverty line in the event of hospitalization and more than 40% of the individuals who are hospitalized in India in a year barrow money or sell assets to cover the cost of health care. Rising health care costs are major cause of indebtedness and

6 70 JOURNAL OF REGIONAL DEVELOPMENT AND PLANNING impoverishment especially in the context of the poor and marginalized as is evident from the Table 3 NSSO surveys have established that the proportion of households which are unable to seek any health care in the event of illness on account of cost considerations is on the increase (GoI 2007, NCAER 2001). These are matters of serious concern for a nation which is emerging a major force in the world arena. Table 3 Measured levels of Expenditure on Health in India (latest) Selected national health accounts indicators Total expenditure on health as % GDP General government expenditure on health as % of total expenditure on health Private expenditure on health as % of total expenditure on health General government expenditure on health as % of total government expenditure External resources for health as % of total expenditure on health Social security expenditure on health as % of general govt. expenditure on health Out of pocket expenditure as % of private expenditure on health Private prepaid plans as % of private expenditure on health Source: - World Health Statistics 2010 (latest) Note: Data are harmonized by WHO for international comparability. They are not necessarily t he official of member states, which may use alternative methods. Several mechanisms of financing have been considered such as user charges of government services community financing and insurance. Health insurance to meet the cost of hospitalization for major illness may ensure that health care costs do not come as a major financial, burden to the patients or their families, particularly of the low and middle income group of population. Thus, there is a great scope for extending health services of private sector hospitals and nursing homes. Further, if the health services are to be delivered at affordable cost, it is imperative that the pattern of the public health expenditure s be charged and private health sector needs regulated and a constructive public private sector partnership nurtured.

7 Journal of Regional Development and Planning, Vol. 2, No. 1, HEALTH STATUS IN INDIA INTERSTATE COMPARISON Table 4 presents state wise data on major economic indicators and achievements of important health outcomes per capita income of Major States for at constant prices ( ) is given in column 2. The figure varies from lowest level of Rs 6610 in Bihar to highest figure of in Haryana, Bihar, Orissa, Uttar Pradesh have low level of perfect income while Haryana and Maharashtra have highest level of income. Health expenditure as a percentage of total state expenditure is represented in column third the figure varies from 4.65% in Kerala to 2.88% in Maharashtra. Maternal Mortality Ratio varies from low figure of 95 in Kerala to high of 480 in Assam. Light Expectancy at Birth during 2002 to 2006 for males, females and total is given in column 4,5,and 6 male expectancy varies from 71.4 in Kerala to 58.1 in Madhya Pradesh While Female life expectancy varies from 76.3 in Kerala to 57.9 in MP. Total life expectancy varies from 74 in Kerala to 58 in Madhya Pradesh. Male infant mortality rate for 2007 varies from 12 in Kerala to 72 in MP. Female infant mortality rate varies from 13 in Kerala to 72 in Orissa and MP. Total infant mortality rate varies from 13 in Kerala to 15 in MP. The ranking of major states on the basis of economic and health indicators is presented in Table 5. It appears that there is not strong relationship between the level of health indicators and income across Indian States. Given the size, diversity, and stratified nature of Indian society, the health outcomes can be described as mirroring the multiple axes of socio-economic inequalities, such as rural-urban; inter and intra state; caste; income; and gender. Several studies have tried to capture these inequalities by using the association between variables like level of education, type of housing, income, and social groups with health outcomes like Infant Mortality Rate and Under-5Mortality Rate. The National Family Health Survey (NFHS)-2 reveals sharp regional and socio-economic divides in health outcomes with the lower caste, the poor, and less developed states bearing a disproportionate burden of mortality. The scheduled castes and scheduled tribes are clearly at disadvantage and studies show that improvement has been slow in case of these groups as compared to others. It is well known that IMR is a sensitive indicator for socio-economic and health services development. This can be discerned when the IMR is disaggregated across socioeconomic groups and the association between the two is obvious. As Deogankar s (2009) analysis shows: The Infant Mortality Rate in the poorest 20% of the population is 2.5 times higher than that in the richest 20% of the population. In other words, an infant born in a poor family is two and half times more likely to die in infancy, than an infant in abettor off family. A child in the Low standard of living economic group is almost four times more likely to die in childhood than a child in the High standard of living group. A child born in the tribal belt is one and half times more likely to die before the fifth birthday than children of other groups. A female child is 1.5 times more likely to die before reaching her fifth birthday as compared to a male child Based on the analysis of two rounds of NFHS, Subramanian et al.(2006) show the existence of gender and caste differentials. The gender differentials are not marked for IMR but the divide becomes apparent for the Under-5 Mortality Rates, indicating that social discrimination against girl children begins early and contributes to their progressive neglect throughout their life. The risk of mortality before the age of 5 is higher for girls than for boys on one hand, and for schedule caste, schedule tribe, other backward classes, and the rural areas of one of the poorest states than for all India on the other. While the all-india average for U-5MR came down from 95 to 74 between 1998 and

8 72 JOURNAL OF REGIONAL DEVELOPMENT AND PLANNING 2006, it shows an increase in inequality in U-5MR for the scheduled caste and scheduled tribe communities when compared to the all India average. The socio-economic inequalities get further compounded by inter-state and intra-state inequalities in IMR and the Under-5 Mortality Rates. States Table 4 Economic Growth and Health Status in Major States PCI # Health LEB IMR MMR 2006 Exp (%) Male Female Total Male Female Andhra Pradesh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradesh Maharashtra Orissa 13329* Punjab Rajasthan Tamil Nadu Uttar Pradesh Total West Bengal Source: - Statistical Digest Directorate of Economics and Statistics, Planning and Development Department Government of J&K ; Economic Survey , GOI. National Health Accounts Report of MOHFW, GOI; Note: # PCNSDP at constant prices; Health Expenditure as percentage of Gross State Expenditure The sharp inter-state inequality in health outcomes can be illustrated by contrasting Kerala and Tamil Nadu, which represent the better developed states, with Uttar Pradesh and Bihar, which are ranked as less developed. While socio-economic factors are important determinants of health outcomes, health services play an important role in averting deaths by providing both preventive and curative services. Therefore, it can be argued that differences in availability, accessibility, and quality of health services are an important determinant of variations in health outcomes. Available evidence from India shows that there are variations in the financing and provisioning of public and private health services (Baru, 1999; Krishnan, 1999). The better developed states have a functional public sector as well as a large private sector, while less developed ones like Bihar, UP, MP, and Rajasthan have a weak public and private sector. NSS data on utilization shows that there is high reliance across states on the private sector for outpatient treatment, which is dominated by informal practitioners. Given the federal nature of the State, the major responsibility for financing, provisioning, and administration of health rests with the respective states that influence availability, accessibility, and acceptability of services. Rao (2007) in his analysis of financial variations shows that while per capita spending on heal this Rs for Kerala and Rs42 for Tamil Nadu, it is abysmally low for UP at Rs18.10p during This is just to illustrate the

9 Journal of Regional Development and Planning, Vol. 2, No. 1, extent of variation in health spending while fully acknowledging that per capita figures are mere averages which, in themselves, mask inequities. The pattern of health spending influences the structure of provisioning of health services. Table 5 Major States Ranked on the basis of Economic Growth and Health Status States PCI # Health LEB IMR MMR 2006 Exp (%) Male Female Total Male Female Total Andhra Pradesh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Source: Same as Table 4 Note: Same as Table 4 Further there is no discernable relation between per capita income and share of government expenditure on health care. Haryana, Maharashtra, Punjab rank high in per capita income while Kerala, Orissa, West Bengal are top raking states in State expenditure on health care. Maharashtra spend low share on health care Bihar, UP having low per capita income spend high share on health care. In terms of health outcomes Kerala ranks 1 in all health indicators it ranks high in health expenditure while it ranks fit in per capita income. Maharashtra which ranks two in per capita income and health expenditure share rank of 15, has been second best ranking State in terms of health outcomes followed by Punjab, Tamil Nadu. Public and private expenditure on Health Care in Major States for on the basis of National Health Accounts Statistics are presented in Table6. Per capita public expenditure on health care varies from high figure of Rs. 630 in HP to a very low figure of Rs. 128 in UP. Private expenditure across major Indian States is presented in column 3 where figure varies from Rs in Kerala to a lower figure of Rs. 420 in Bihar. Assam ranks one in per capita public expenditure while as Kerala stands on the lowest ebb in per capita public spending. High per capita income states like Haryana, Maharashtra, and Punjab have relatively low level of per capita public spending. Kerala, HP, Assam for top ranking states in terms of total expenditure while as Bihar Rajasthan MP are bottom ranking states in total expenditure on health care.

10 74 JOURNAL OF REGIONAL DEVELOPMENT AND PLANNING Table 6 Public and Private Expenditure on Health in Major States Per capita Health Expense Public Ranks per annum (Rs) Exp as % to Pub Pub Pvt States Public Pvt Total total % Exp Exp Andhra Pradesh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Jammu & Kashmir Himachal Pr Source: National Health Accounts; (Ranks computed) However, there is close relation between the income and expense indicators and the health status indicators as evident from Table 7. Higher income and expense leads to lower infant and maternal mortality and higher life expectancy. Table 7 Association between Health Indicators and Select Variables Per Capita Income Per Capita Health Expense MMR IMR LEB Source: Author s calculation RURAL URBAN INEQUITY IN HEALTH SERVICES Although health indicators have continued to improve over time, villagers are far behind the towns and cities in case of healthcare facilities and their outcomes. This difference can be observed both qualitatively and quantitatively. The major part of the healthcare facilities in rural areas are provided by the unqualified and untrained medical professionals. Most of the public hospitals and dispensaries are located in urban areas and almost all private clinics and nursing homes are in the urban areas. If we look at the rural urban difference in the level of healthcare infrastructure, we find that villages are far behind the cities. For instance in 2001, there were 0.54 hospitals, 1.49 Tot Exp

11 Journal of Regional Development and Planning, Vol. 2, No. 1, dispensaries and hospital beds per lakh population in rural India. While the corresponding figures in Urban India were 0.80, and 3.60 respectively. Table 8 Rural Urban Inequity in Health Status Total fertility rate Births assisted by health professions % Birth delivered in medical institution Two does or of TT vaccination during pregnancy (%) Mothers who had at least 3 antenatal care visits for their last birth (%) Total unmet need for family planning (%) Women whose body mass index is below normal (%) Ever married age who are anaemic (%) Children months fully immunized (BCG, measles and 3 doses each of polio / DPT) % Children months who have received BCG % Children months who have received 3 doses of polio vaccine (%) Children months who have received 3 doses of DPT Vaccine (%) Children with Diarrhoea in the last 2 weeks who received ORS (%) Children with Diarrhoea in the last 2 weeks taken to a health facility (%) Children with acute respiratory infect ion or f ever in the last 2 weeks taken to a health facility (%) Children age 6 35 months who are anaemic (%) underweight children below 3 years age (%) infant death (per 1000 of live children) under five mortality (per 1000) CDR (pr 1000) Source: National Family Health Survey III Table 8 provides information on some of the health indicators for the last survey of National Family Health Survey. Table reveals that Urban India has better outcome in case of almost all health indicators. Fertility rate. Infant death rate, under 5 mortality rate, and CDR are much higher in rural areas than the urban areas. Percentage of total unmet need for family planning was also higher in the rural area when compared to the urban areas. It is evident from Table 8 that overall health status of women and children in the rural India is much poorer than their urban counterparts. For example, the results of NFHS III ( ) reveal that percentage of rural women with body mass index (BMI) below normal was 38.8 while the corresponding percentage in urban women was only There were more anaemic women and children in rural areas than in urban areas, as is evident from the data given in the Table.

12 76 JOURNAL OF REGIONAL DEVELOPMENT AND PLANNING Percentage of fully immunized children age months were only 38.6 percent in rural areas, while the corresponding percentage in urban areas was 57.5 percentages of children with acute respiratory infection (ARI) in the last 2 weeks, who were taken to a health facility, were 59.9 in rural areas and 78.1 in urban areas. These figures clearly indicate that there exists wide inequality in the distribution of healthcare infrastructure among rural and urban locations. Due to the deficiency of proper medical aid, the death rate, infant mortality rate and fertility rate all are higher in the villages than the cities. Although these rates have been declining over the years, these are still high especially in the rural India. Provision of public health services, such as, access to basic and preventive healthcare sanitation, clean water and raising awareness about the causes of illness and their treatment are necessary for improving human development in rural India. POLICY IMPLICATIONS The problems of health care are enormous. Access to primary health care is inadequate to the majority of the people because of low availability of basic preventive and promotive health care packages, clinics, doctors, drugs and paramedical persons in rural areas. Greater stress on preventive health care medicine and health education should be laid. Health literacy efforts should be made integral to preventive, promotive curative and rehabilitative health care.a meaningful involvement of private sector and NGOs is critical in all these endeavours for promoting a people oriented and sustain able health care system. A vast network of health institutions has been developed.rapid expansion has however, resulted in a considerable drop in the quality of functioning of health institutions.for several reasons the quality of services and work done by various health institutions and by different categories of health personal are poor, resulting I n low credibility among rural community.moreover, for want of quality, the efficiency and effectiveness of the programmes and services has been limited and the objectives not fully realized. This is one of the causes of non utilization or underutilization of health services and facilities by the people especially the rural communities. Organisation of health services has become complex, centralized and insensitive to the varying health felt-needs of the rural community. It is suggested that organizational setup of health services needs organization.while the health organization has grown tremendously, functionally the structure has changed with the dynamic and divergent demands of effective health management. The middle level management is weak because of low status accorded to training in public health, inadequate decentralization of authority and resources allocation. The most important problem is the mal-distribution of health manpower, both geographically and category wise. Both technical knowledge and motivation to serve rural people fall short of requirement and expectations. Communicable diseases such as malaria, tuberculosis, leprosy are likely to continue to pose challenges to the country in the coming years. Non-communicable diseases will become a major health problem in the country due to the changing lifestyles, increasing stress and tensions and cultural systems in the society. With increase in the number of aged people, there will be higher incidence and prevalence of diseases like hypertension, diabetes, cancer in the whole range of genetic problems.

13 Journal of Regional Development and Planning, Vol. 2, No. 1, Equitable distribution of rural health care should be ensured by the government. Location of health services and facilities should be such that these are easily accessible and available to rural community. The most pervasive inadequacy and critical deficiency of our primary health care system is the non availability of medical staff and other supporting personnel in primary Health care system sis the non availability of medical staff and other supporting personal in rural areas. An ineffective supervisory and monitoring system compounded by corrupt practices, helps to sustain this situation. This virtually renders the public health units in rural areas non functional. As a result of the non availability of doctors the implementation of many public health programmes has been adversely affected. The lack of effective initiative in regulating the private health sector is another area where the soft character of the state is evident. The incidents of unethical practices reported from private sector health providers are mounting, and these, are also reported by the media from time to time. These practices range from exorbitant charges, unnecessary and superfluous investigations, lack of quality care, negligence and total lack of accountability (Nandraj 1994) private sector hospitals suffer from inadequate and unqualified medical and Para Medical Personnel, unclean environment, improper location of facility, negligence and unethical behaviour. State Governments have failed to take adequate steps by enacting tough laws and introducing strict regulations followed by rigorous inspections to check unethical practices and to protect consumer interests as well as health standards. The location of facility and allocation of resources to specific health units / schemes/ programmed that are, quite often, governed by political considerations ( Jeffery, 1988). Ideally, the available funds should be distributed to units, areas and programmes as per norms based on objective consideration. In respect of health units, for example, these considerations should include the population and the physical areas to be served, the level of disease burden, status of existing facilities, inefficiencies in the infrastructure and the priorities in gaps to be bridged, etc. however, these objective norms are rarely followed in taking such decisions. The skewness in the distribution of resources based on these influences leads to several distortions. One of them is the vide gap in the quality of Health Care between Rural and urban areas. The latter, in any case, consume larger resources because of the location of hospitals. Thus the rural urban inequity gets accentuated. The other consequence is the increase in the regional imbalance between backward areas and more developed/ prosperous areas. In view of experiences and difficulties faced in the provision of rural health services, it has been realized that acceleration of the pace of implementation of rural health programmes is urgent and concerted efforts need to be made for rapidly improving the health profile of the country. For making rural health care services more meaningful to the rural community, it needed to bring about fundamental changes in the approach to the entire health care delivery system in general and rural health care in particular. Reference

14 78 JOURNAL OF REGIONAL DEVELOPMENT AND PLANNING Baru, Rama V. (1889)- Private Sector in Medical Care, Radical Journal of Health, March (1995), Mixed Economy in Health Care: Some Issues, IASSI Quarterly, Vol.14 No s 1 and 2. Baru, Rama V. (1999)- The Structure and Utilization of Health Services: An Inter-state Analysis in M. Rao (ed.) Disinvesting in health: the World Bank's prescriptions for health, Sage, New Delhi Barro, R.J Economic Growth in a Cross Section of Countries Quarterly Journal of Economics 106 (2) : Comin, D, B Hobijn, and E. Rovito (2008)- Technology Us age Lags Journal of Economic Growth 13 (4) : Deodhar,N.S (1999) Rural India-Policy and Management Perspective in Basic Rural Infrastructure and Services for Improved Quality of life (ed.)r.c Choudhury and P. D. Durgaprasad, NIRD, Hyderabad Deogaonkar, Milind (2010)- Socio-economic Inequality and its Effect on Healthcare Delivery in India, available athttp:// site accessed on 4 th March, Government of India HEALTH, BULLETIN Ministry of Health and Family welfare, New Delhi Government of India, Economic Survey , Ministry of Finance, Department Economic Affairs, Government of India National Health Policy, Ministry of Health and Family welfare, New Delhi. Gupta, M.C (2002) Health and Law. Government of Jammu & Kashmir -Statistical Digest , Directorate of Economics and Statistics, Planning and Development Department J&K. Government of India Selected Health Parameters : a Comparative Analysis across National Sample Survey organization (NSSO) 422 nd, 52 nd and 60 th Rounds, Ministry of Health and Family Welfare in collaboration with WHO Country Office for India. ICSSR and ICMR (1981)- Health For All: An Alternative Strategy, Indian Council for Social Science Research and Indian Council for Medical Research. Ibrahim, S and S. Alkire, (2007)- Agency and Empowerment A Proposal for internationally comparable Indicators Oxford Development Studies 35 (4) : ICRIER (1999)-, Report on trade Potential in Health Sector Indian Council for Research on International Economic Relations. Indian Express (2003)- Apollo defends Itself on free Treatment for poor May 20. Indian Economic Association (2006) 89 th Annual Conference Volume. December Jeffery, Roger (1988)- the Politics of Health in India (1996)- Towards Political Economy of Health Care: Comparison of India and Pakistan in Dasgupta M, Chen, Lincoin C and Krishna, T.N (1996) Health, Poverty and Development in India. Kurian, N.J Issues of Health and Equity in India India Social Development Report, Council for Social Development, Oxford University Press, NCAER(National Council of Applied Economic Research) Concurrent National Evaluation of Integrated Child Development Services. National Family Health Survey National Family Health Survey II Mumbai, International Institute of Population Sciences National Family Health Survey III Mumbai. International Institute of Population Sciences. National Commission on Macroeconomics and Health (2005)- Background Papers, Ministry of Health and Family Welfare, Government of India, New Delhi Neumayer, E( 2010)-. Human Development and Sustainability Human Development Research paper 5. UNDP HDR New York. OECD ( Organization for Economic Co operation and Development) Survey on Monitoring the Paris Declaration Making Aid More Effective by 2010 Paris. Park (1994), Preventive and Social Medicine, Banarasi Das Publishers, Jabalpur. Rao, M.(2007), Health in India in the Age of Globalised Governance in Kameshwar Choudhary (ed.) Globalisation, Governance Reforms and Development in India, Sage, New Delhi, pp Saxena, K.B( 2006)- Governance and Health Sector, Securing Health for All Dimensions and Challenges (eds). Sujata Prasad and C. Sathyamala, Institute of Human Development, New Delhi.

15 Journal of Regional Development and Planning, Vol. 2, No. 1, Southgate, D (1990)- The Causes of Land Degradation along Spontaneously Expanding Agricultural Frontiers in the Third World land Economics 66 (1) : Singh, S. P (2007)-, Growing Rural Urban Disparities in India, Kurukshetra Vol. 56, No. 1., November Subramanian, S.V., S. Nandy, M. Irving, D. Gordon, H. Lambert, and G.D. Smith (2006)-, The Mortality Divide in India: The Differential Contributions of Gender, Caste and Standard of Living Across the Life Course, American Journal of Public Health, Vol.96,No 5, p UNDP(2010)- Human Development Report 2010, Palgrave Macmillan, New York. UNICEF (1998)- The State of the worlds Children 2001 New York Oxford University Press. UNICEF (2000)- The State of the Worlds Children. 1999, New York, Oxford University Press. UNDP (2004) - Human Development Report 2004 Cultural Liberty in Todays Diverse World, New York: Oxford University Press. Voluntary Health Association of India,1995-;Health Status of India, VHA, New Delhi. WHO (2000) World Health Organization Global and Sanitation Report World Bank (1996)- World Development report 1996, from Plan to market Oxford University Press, New York. World Bank (2003)- World Development Report 2004: Making Services Work for Poor People, New York: Oxford University Press.