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Do We Care?
India is one of the fastest-growing economies in the world. Yet health is not a part of our ambitious development story. In fact, India’s disproportionately stingy healthcare budget makes some of the poorer nations look better in comparison. Statistics, however, speak louder than critics: we have one of the highest numbers of women dying in childbirth and under-five mortality rates. Every year nearly sixty million people get pushed below the poverty line due to the health expenditures that they incur. But there are a few bright spots too: India has eradicated polio and reversed the incidence of HIV/AIDS by an impressive margin.
Drawing on her experience as the former union health secretary, K. Sujatha Rao gives us an unsparingly candid insider’s view of India’s health system. This richly detailed book favours increasing the health budget, greater use of technology, and providing leadership and good governance. Rao argues that unless good health is prioritized as a national goal, India’s growth story will remain largely self-congratulatory.
Drawing on her experience as the former union health secretary, K. Sujatha Rao gives us an unsparingly candid insider’s view of India’s health system. This richly detailed book favours increasing the health budget, greater use of technology, and providing leadership and good governance. Rao argues that unless good health is prioritized as a national goal, India’s growth story will remain largely self-congratulatory.
478 pages, Hardcover
Published January 3, 2017
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Displaying 1 - 7 of 7 reviews
August 9, 2020
On reading _Do We Care?_ by K Sujatha Rao, you would first wonder at how bold, direct and evidence-based her writing is. As a former Union Health Secretary of MoHFW and former Director General of the National AIDS Control Organization (NACO), we get an in-depth view of how the distinct approaches across NACO and the NRHM and what worked and what still remains to be done.
Some of the recurrent themes on what can be improved are:
1. *Making local communities and civil society participants and not only advisors*. This can be achieved by giving them a voice at the policy table and ensuring regular reviews to get feedback on the program, on the difficulties key implementation functionaries have in understanding the scheme and central guidelines and on highlighting challenges in execution. Program budgets should be allocated to NGO's, collectives and training of Village Panchayats and Hospital Committees to ensure community participation.
E.g. Community based systems such as the ASHA (Accredited Social Health Activists), VHSNC (Village Health, Sanitation, Nutrition Councils) and RKS are essential to mobilize change at the village level. It is imperative to define the role of the ASHA as more than just top-down contract agent working for a remuneration for services rendered of a host of government health priorities (ANC, immunization, PNC etc.) and define her role as a health activist and as a key stakeholder to raise community awareness, improve utilisation of services and provide upward feedback from the community to functionaries to make the system more accountable and responsive to the needs of the community ("rights-based approach"). This made her only "another supply-side functionary rather than a demand-side protagonist" (Banerji). The recent protests against over-burdening during COVID-19, lack of PPE and limited budgets also indicates areas of improvement.
VHSNC's were also just advisory without the power of oversight on ASHA appointments (ASHA's were selected and paid for by ANM's/Auxiliary Nurse Midwives), did not have direct access to financial resources to take up work it considered as a priority (funds are controlled by the Panchayat and ANM) and not given any training for the functions they were expected to discharge.
The participation of sex workers and People Living with HIV/AIDS (PLHIV) was institutionalized, alongside donors, state governments and civil society, in the finalization of intervention design and implementation processes via Technical Resource Groups (TRG's) under National AIDS Control Program (NACP). Other successful examples include CEHAT (Maharashtra) and PFI (Bihar).
This concept of community monitoring and social audit is the most powerful means to enhance accountability and transparency in the implementation of public policy. Human behaviour change is as important as the focus on data and the techno-managerial approach
2. *Solve for supply-side*: if you'd want to increase institutional births, it's not enough to incentivise mothers to visit health facilities for childbirth through the _Janani Suraksha Yojana_ if you don't have adequate hospitals to treat them! (India has only 5.3 beds per 10,000 population in 2017, WHO). Additionally, there should have been differential incentives for high-risk pregnancies to prioritise their treatment in public health facilities.
3. *Focus on primary healthcare*: while Universal Health Care is desirable, it should not come at the cost of improving public primary health centres by encouraging people to use more expensive and commercial private sector hospitals (75% of total healthcare expenses are due to the 1% population that can access expensive private tertiary care in metros). Substituting prevention with treatment is more costly and unsustainable, especially given that such financing has strengthened private hospitals without putting in adequate regulations to monitor them for price and quality. Thus, as per the 71st NSSO, despite the expansion of insurance coverage, there has been no appreciaable reduction in Out-of-Pocket Expenditure (OOPE) especially for the last 2 quintiles. This is the danger that UHC will only not ensure equitable access to the ones who really need it: the rural poor with limited functioning health facilities.
4. *Account for the costs when you make policies*: while defining the HR and infrastructural standards for public health facilities under IPHS norms, the total expenditure on revamping existing facilities should be considered to determine if the standards are uniformly feasible. *Decentralising and cooperative federalism* could be used to let states define the standards as a local re-assessment can be made due to the substantial development in road and transport communication (telemedicine), technological advances and mapping facilities to rationalize infrastructure needs (ANM's can be rationally re-deployed)
Some of the recurrent themes on what can be improved are:
1. *Making local communities and civil society participants and not only advisors*. This can be achieved by giving them a voice at the policy table and ensuring regular reviews to get feedback on the program, on the difficulties key implementation functionaries have in understanding the scheme and central guidelines and on highlighting challenges in execution. Program budgets should be allocated to NGO's, collectives and training of Village Panchayats and Hospital Committees to ensure community participation.
E.g. Community based systems such as the ASHA (Accredited Social Health Activists), VHSNC (Village Health, Sanitation, Nutrition Councils) and RKS are essential to mobilize change at the village level. It is imperative to define the role of the ASHA as more than just top-down contract agent working for a remuneration for services rendered of a host of government health priorities (ANC, immunization, PNC etc.) and define her role as a health activist and as a key stakeholder to raise community awareness, improve utilisation of services and provide upward feedback from the community to functionaries to make the system more accountable and responsive to the needs of the community ("rights-based approach"). This made her only "another supply-side functionary rather than a demand-side protagonist" (Banerji). The recent protests against over-burdening during COVID-19, lack of PPE and limited budgets also indicates areas of improvement.
VHSNC's were also just advisory without the power of oversight on ASHA appointments (ASHA's were selected and paid for by ANM's/Auxiliary Nurse Midwives), did not have direct access to financial resources to take up work it considered as a priority (funds are controlled by the Panchayat and ANM) and not given any training for the functions they were expected to discharge.
The participation of sex workers and People Living with HIV/AIDS (PLHIV) was institutionalized, alongside donors, state governments and civil society, in the finalization of intervention design and implementation processes via Technical Resource Groups (TRG's) under National AIDS Control Program (NACP). Other successful examples include CEHAT (Maharashtra) and PFI (Bihar).
This concept of community monitoring and social audit is the most powerful means to enhance accountability and transparency in the implementation of public policy. Human behaviour change is as important as the focus on data and the techno-managerial approach
2. *Solve for supply-side*: if you'd want to increase institutional births, it's not enough to incentivise mothers to visit health facilities for childbirth through the _Janani Suraksha Yojana_ if you don't have adequate hospitals to treat them! (India has only 5.3 beds per 10,000 population in 2017, WHO). Additionally, there should have been differential incentives for high-risk pregnancies to prioritise their treatment in public health facilities.
3. *Focus on primary healthcare*: while Universal Health Care is desirable, it should not come at the cost of improving public primary health centres by encouraging people to use more expensive and commercial private sector hospitals (75% of total healthcare expenses are due to the 1% population that can access expensive private tertiary care in metros). Substituting prevention with treatment is more costly and unsustainable, especially given that such financing has strengthened private hospitals without putting in adequate regulations to monitor them for price and quality. Thus, as per the 71st NSSO, despite the expansion of insurance coverage, there has been no appreciaable reduction in Out-of-Pocket Expenditure (OOPE) especially for the last 2 quintiles. This is the danger that UHC will only not ensure equitable access to the ones who really need it: the rural poor with limited functioning health facilities.
4. *Account for the costs when you make policies*: while defining the HR and infrastructural standards for public health facilities under IPHS norms, the total expenditure on revamping existing facilities should be considered to determine if the standards are uniformly feasible. *Decentralising and cooperative federalism* could be used to let states define the standards as a local re-assessment can be made due to the substantial development in road and transport communication (telemedicine), technological advances and mapping facilities to rationalize infrastructure needs (ANM's can be rationally re-deployed)
This entire review has been hidden because of spoilers.
August 8, 2019
Incisive, informed, balanced read about health systems in India. The author is almost encyclopedic in her knowledge and diligently tells us not just an incredible appraisal of public health in India but also the politics of public health in India. She is an insider and former civil servant and it's always a treat to hear a bureaucrat speaking about policy, planning and implementation. She brings nuance, balance and value to her discourse. Especially reading about the fight against hiv / aids was a treat because it came from a place of absolute objectivity. Without being unfairly critical or patronising about any of the elements in the vast galaxy of public health actors, she works hard to put forth sharp arguments. I'm professionally and personally very infested in public health in this country and learnt very complex concepts and viewpoints from this book.
August 18, 2019
Took me over two months to complete. Detailed and with the sort of insight very few can provide about public health in India. The author is objective, rigorous and has put together the perfect textbook for anyone looking to break into public health in India.
November 24, 2019
Eponymously, the book describes the grey spaces in the health stack of our country. The case studies of NACO and NRHM offer a peek into the labyrinthic procedures needed to drive change gradually. The book was saporific in between, but the ennui can be tackled with a set agenda of the reader.
May 24, 2025
Good book on Public Health
The author wass an Indian Bureacrat and shares her experience within the sytem. She specifically delves into why India succeeded againsr AIDS and why we are struggling with NRHM. The writing could have been better.
The author wass an Indian Bureacrat and shares her experience within the sytem. She specifically delves into why India succeeded againsr AIDS and why we are struggling with NRHM. The writing could have been better.
February 12, 2018
a must read for anyone who wants to learn about the india's healthcare system
February 22, 2020
A comprehensive guide to the Indian Health System.
After spearheading a successful health program of NACP(preventing the incidence of AIDS cases in India), the author has ably penned the success, failures, and challenges facing the Indian Health Sector. The issues ranging from under-funding, poor planning, weak infrastructures, private practices, privatization, and misplaced priorities were brought to the fore through the finding of different committees, reports, and close encounters.
Having managed NACP program through evidence-based planning, professional management, project monitoring, and communitization, she has charted out the course that the leadership should take for achieving access to universal and affordable healthcare.
If one can navigate through all the abbreviations used in the book, it'll be an interesting read.
After spearheading a successful health program of NACP(preventing the incidence of AIDS cases in India), the author has ably penned the success, failures, and challenges facing the Indian Health Sector. The issues ranging from under-funding, poor planning, weak infrastructures, private practices, privatization, and misplaced priorities were brought to the fore through the finding of different committees, reports, and close encounters.
Having managed NACP program through evidence-based planning, professional management, project monitoring, and communitization, she has charted out the course that the leadership should take for achieving access to universal and affordable healthcare.
If one can navigate through all the abbreviations used in the book, it'll be an interesting read.
Displaying 1 - 7 of 7 reviews