South India #1: Healthcare

In a recent blog, I had mentioned infant mortality rate (IMR) as a good proxy for the quality of life in a country. But, as Nilakantan RS says in South vs North:

“Describing India with one metric is as accurate as describing the planet with one metric.”

 

Which is why in his chapter on health, he uses several other metrics to compare the southern states with the rest of India. Life expectancy is not one of them. Why not? Because it is a lagging metric, i.e., it takes a very long time for any improvement to show up (a person has to die for it to show up in the data!). Nilakantan uses IMR (Infant Mortality Rate), U5MR (Under 5 Mortality Rate), and MMR (Maternal Mortality Rate). On all of these parameters, the south does far better than the north. It speaks about the kind of governance over time:

“(The strategies to improve these metrics) call for time, effort, long-term commitment and budgetary support from state governments.”

 

A lot of child and mother deaths are preventable deaths – by having adequate functional hospitals and primary health centers (PHC’s). The books shows stats on how well equipped or staffed these PHC’s are – on that front too, the southern states are way better. As expected, the higher the institutional deliveries, the lower the mortality rates. (If you are wondering, there are indirect ways to detect institutional deliveries – the time to register a birth is one such item. A baby born in a PHC gets registered almost immediately; while the others take longer to show (if at all). So how does one get to know of the ones that didn’t show up? The census would throw up the difference in headcount).

 

Prevention is always better than cure. Better nutrition leads to better outcomes. The proportion of kids with stunted growth in the north is much higher than the south. On that axis too, the south does much better. And immunization rates too are higher in the southern states.

 

Another interesting point is the impact of lower fertility rates in the south:

“South India produces fewer babies and takes better care of them without stretching the limits of its delivery system.”

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All of which brings us to the next question: Why has south India done so much better on the mortality rates? Different states have done different things; some schemes worked, others failed, while some leaked (aka corruption). Tamil Nadu rewarded healthcare workers and districts that did better. Ambulance services were improved in Andhra. Karnataka has pickup and drop services for pregnant women. Broadly speaking:

“The state governments addressed each contributing factor to high child mortality rate using a government service… The slow march towards better outcomes was a constant... (southern) state governments transcend the electoral cycle (at least, on this matter).”

 

While there is no clear cause and effect relation between economic prosperity and good health (there are exceptions to any pattern in India), he says:

“Having resources is a basic requirement for health, but the resolve to prioritize health matters too.”

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Since southern states have done better due to state government policies, the south is unhappy with the center imposing its healthcare policies. Even the targets make no sense, he points out. They are set based on national averages, so in effect, the south is being told to do worse than it currently does!

 

Second, center driven policies result in misallocation of funds e.g. it allocates money to schemes that produce less return in the south (since they are already in good shape) and prevents them from allocating funds to the next set of priorities.

 

He cites NEET (common, national entrance exam for medical posts) as a dangerous idea because it risks derailing a well-functioning health system in the south. Why tweak state level systems, even if they have their faults, when they work better than the national average? Don’t “fix” what’s not broken.

 

And lastly, as the south’s population growth rate dips, and their life expectancy rises, they will face different challenges than the rest of India over the next couple of decades – yes, the challenges of taking care of an ageing population. And relative prosperity brings new problems – the south needs to decrease its calories consumption even as parts of the north don’t enough calories. One size fit all solutions don’t make any sense, he concludes.