India, with its population of 1.2 billion, is planning to build 150 new medical schools in the next five years and at least 250 more in the following five years. “India,” as Venkat Narayan, a lean, lively and vocal Indian academic who had flown in that morning from Emory School of Public Health in Atlanta to Delhi, put it, “is a place of magnificent chaos, where poverty and wealth co-exist, almost with no self-consciousness, a place where it is very difficult to get things done because of stifling bureaucracy but a place where you can get things done because of the permissive chaos!” No-one minds a cow slowly crossing the road or minicab drivers lining up and having a pee on the verge even in prosperous neighbourhoods.
“When I was a medical student at Bangalore in 1980, there were two medical colleges and two colleges of engineering. Now there are nine medical schools and 86 schools of engineering!” Venkat told me, with an energetic laugh. He admits that equity gets rough treatment in India.
I was visiting Delhi as a member of a review panel that has visited India eleven times in the past decade and reports to the prime minister, the minister for health and the ministry to offer informed comment on progress with the National Rural Health Program. The panel is headed by Jeffrey Sachs, an economist who leads the Earth Institute at Columbia University. He is a valiant warrior for global awareness of poverty. He has ‘skin in the game’ as his Institute has auspiced the formation of over 40 experimental development villages in Africa where education, health and agriculture capacity building is under way but self-limited to a sustainable budget.
Sachs has strongly supported a rural health initiative in India to enlist social health workers, respected women in the villages who, with only days of training and no salary, assist young pregnant women to access facilities for safe delivery and neonatal care. There are now 800,000 of these women working effectively in rural India. Mobile phones and bicycles are their basic equipment. Maternal mortality rates have continued to fall. Infant mortality rates have been declining in India as a whole (more so in the cities, less so in rural areas) at 6% per annum.
The rural health program is achieving other goals: there have been no reported cases of polio in India for two years. Five years ago I recall learning how the polio vaccination team, concentrated around Kolkata, numbered an astonishing 400,000.
And now India, as we have done in Australia, is actively pursuing a program of managed decentralisation of health services. Expenditure is slowly, slowly rising from 1% to 2% GDP. Health districts, generally much larger than ours and working on budgets of about $40 per capita per annum, are forming. It is interesting to see the complex tensions between federal, state and district, so familiar to us in Australia, played out at a mind boggling scale and stupendous complexity. India gives democracy as a conversation among all citizens powerful and astonishing meaning.
Health statistics are sparse and hard to interpret. What stats there are point upwards. As I drove through urban slum areas all my thoughts about chronic disease prevention and primary health care were pounded by rough surf of the social realities of that vast country. But India is moving and progress is occurring. No shortage of work for doctors there!
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