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Monday, 27 January 2014

Health inequality in West Bengal provinces in India


 Author 
 Professor (Dr. ) Pranab kumar Bhattacharyya- Professor and Head, Department of Pathology , School of Tropical  Medicine, Kolkata-700073

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity by definition of WHO. Before common &medically untrained people define health by its absence and so seek intervention when they are not in that state1What is a right to health in West Bengal provinces of India for the low socioeconomic class & poor people? How many people of disadvantaged class are aware here for his/her key rights? How many people in Kolkata  and its suburban areas are aware of their health status and right for health ? The rights to health are broad demands that go beyond legislating good health care of a state or a country2 (important as that is). They needs  mostly political, governmental ,social, economic, scientific, and cultural actions2. Can health be a right here(?) ,as there is  till days no binding legislation in West Bengal? We doctors are demanding and just that? According  me Right to health means  coverage of equal  but quality health cure & care and providing quality of life  for all people of any state [including those pavement dwellers, beggars, unemployed, low socioeconomic class people, students child, schizophrenic &mental patients, old people,] at free of cost or with minimum user fees by government. Every patients must have sufficient accesses to safest and / high / or highest quality of health care regardless how much they earn, where they live and how seek they are!- Question  till  2014 remains how much is it feasible in West Bengal state or  even in India?:  Can a state  of India ensure of  it’s population that everyone will have a good Quality health?  Nay ! The lands of West Bengal is today turned a land of extreme level of disparity & inequity between haves middle class and haves not proletariat class.   I think, we first consider a minimum equity in health care system, as a  basic human right, since the health care system in West Bengal province is mostly under the control of policy making by state government. Of course Health care system does never reflect the actual state of health of the people.  What a good dignified society should have? The acceptance of health Education &employment as a right for all citizen - a justified demand to take into action and to promote that goal, such as we have the right to vote in election process with a voter card 1   . Health human rights, and development of  state economy are complementary and synergistic, so are human rights and social justice. But does good health and quality of life depend only on health care &cure only?. It also depends on employment, nutrition, purchase capacity, lifestyle, education level, and the extent of inequality and un freedom in a society. The basic problems in West Bengal state is poverty, hunger, political unwillingness to have a pro poor quality health care delivery system and corruption at every level. The Economic growth of a state or of a country is usually measured by economists in increase of GDP and GDP per capita. GDP per capita per year is also a very important key point of human development index used by UNDP. Health care expenditure of a country is also measured by percentage of GDP spent for it & GDP spent by Indian government for health care is<3% ,despite gross domestic product growth rate of India was 9% in2007( and in 2013 it is  reduced around 4%). But a very big question often strikes me does GDP per capita in a real sense reflects the poverty status of any state or of any country? It appears before me to imagine or to calculate a decline in poverty unaccompanied by a simultaneous improvement in aggregate economic performance- my  thenlate 82 years old father late Mr. Bholanath Bhattacharya commented me 6 yearsback in 2007.  The determinant of economic growth of a state, we people use the denominators like Life expectation at birth[ 68 years in male and 70 years in female now], Infant mortality rate [37 per1000 live birth in India in 2007], Crude birth rate( in West Bengal 12.7), Crude death rate( 7.5 in India and 17.6 in West Bengal in 2000], Maternal mortality rate [301 per 1 lack live birth in India in 2007] etc does really reflect the economic progress of poverty laden families of the state or of a country? I myself don’t belief that ever. I see daily so large rushes in public tertiary medical colleges hospitals [in the year-2006 Total OPD 1,42,51,407 cases, Total indoor admissions 1,88,8121 cases Total1,61,39,528 of 8.5 cores population (19.69%) of the state]  & most of them belongs to so poor and bellow poverty line families( 70% of population in West Bengal seeks public health care system till today]. But our  central government still says economic growth of India is 5-6%. Rather state level growth of real Net state Domestic product (NSDP) may be a good determinant factor. In west Bengal, PCNSDP in 2000-2001 is Rs9778/= per year, per person which means per person capacity to purchase essential goods or calorie for living is Rs 814/= only at poverty level when central govt. definition bellow poverty line is Rs1500/= and people still at BPL level in West Bengal is 27.09% & when  poverty line considered Rs 1500/=Pm per person. If PCNSDP criteria is considered to define poverty line then people at poverty level in 2008, at West Bengal will be more then 62%.Over last 3-4 decades , there had been tremendous out break of unemployment in West Bengal  amongst the educated younger generation of age range 21-45 yrs the productive age group. This picture of unemployment is not only in West Bengal but through out India. Why? Because government is reluctant to establish small and medium scale industries and doing memorandum of Understanding(MOU) for heavy big industries that did never solve large section unemployment’s in state. The system provides jobs to highly skilled young in technological  education and not in general streams and in Open market economy education is so costly and mostly unbearable for most population without debt from bank loans to acquire the skills for large industries. The number of registered unemployed in India through employment exchange is about 10 corers, whereas in West Bengal the figure is about 2.5 corers.  Though LEB during the period of 1970s to 2008 period raised from 49.7 to 61.7 years  & Bihar state which is one of the lowest NSDP  of Rs 4123/= in 2007 is in better position then MP,UP as per these conventional health indicators. But the fact also says that LEB Per capita GDP & per ca pita expenditure for health shows better growth. In India Poverty line is decreasing & so in West Bengal!
Then what should be the denominators of an economic growth of a family of a state of a local society of a country? Growth of physical labor! Stock of physical capacity!  Increase of laborers in paddy fields. Technological labor class advancement! Advancement of science, information and technology  in area of intellectual property Right, Copy Right amendments laws as per IPR acts/laws( every one is today conscious of his/her copy right Intellectual property right of his/her knowledge and nothing is free but payable and India needs to develop its own science, knowledge, technology in health care also] to grow more food & crops and for a better health care and cure in arena of IPR,  Quality and quantity [skilled and unskilled ratio] of human resources and human resources as capital! Their living standard, their nutrition, their education and their mental health- physical labors are  always related to economic growth of a province or of a country. As for example, physical labors are related to production in any small ,medium scale industries, or in paddy fields, or in agriculture or in roads or other civil sectors, in construction works or in surface, Rails, in water transport works, in home guards industries and in electricity sectors , Foundry Industry sectors Automobile industries.  These  are not/were not done metropolis or urban or semi urban so called educated “Babus” we  may call them with university degrees, post graduate degrees or phDs or DSc or DLitt. The development of a state, in a country is thus dependent on mostly on” lower socioeconomic class and poor class peoplemy old father replied me. My father through out his life led his life in extreme poverty and was a Marxist by his heart and action. He worked in fields for economic uplift & fought for settlement of refugees of Bangladesh war-1970s settled at a colony areas of my native village sodepur, 24 parganas(north) W.B, India.  And his name is  Wikipedia  at “ Sodepur” article  in the history section  provided by Panihati Municipality  North 24 parganas  West Bengal, India section and  was published in in News Papers  like “Bangla darpan ‘ and “Gana SAkti” after his journey in heaven  in year 2009.  MY youngest brother “Rupak Bhattacharya” is today following his  views and Idea  for Pro-poor health care development  in Sodepur area through myself.  How much was he true? If his views are correct then two elements come in questions in my mind. 1) the economic growth of a family and thus of a state in larger sense depends on i) that how much labor forces are present in a family and how much they are educated at high school level or at university level ii )  the health of these labor class forces as a big capital- Both these elementary determinant level ha been neglected and is being today also neglected since freedom, in West Bengal provinces of India. The role of human health in influencing the economic outcome of a state is well understood at macroeconomic level. But health deals with microeconomics at the same time._ healthier workers are likely to able to work for longer period, becomes more productive then their relatively less healthy counterparts and are able to work for longer periods, able to secure higher earnings then the later. Illness and diseases shorter the working level of people. Health has thus a positive significance effect on the rate of growth of GDP per capita. Higher income permits individuals to achieve better nutrition and better health care improvement of them results probably improvement of net domestic products(NSDP) of state , thus increase of national income and can thus decline poverty level. So it is very important to give priority that towards which the health care should be directed! Rich or poor or upper middle class people,  to establish health industry or scientific community based health care & cure institutions?
 India is in conglomeration of states with diverse level of socioeconomic status, governance political parties, health systems and situation. In West Bengal provinces has shortage and mal distribution within its health work force that have contributed to inequities in health and its outcomes. In West Bengal  health workforce is  combination of both registered, formal health care providers and informal medical Practioners(Quacks) those are in contact with large nos of populations in cities, urban semi urban and Rural villages  India as well as West Bengal because an expanding of Private for only profit making center is Juxtaposed which compete for a net work of Public health facilities and they compete for common pool  for health human resources. India has also emerged as important for health human resources in the Global Health market.
 In Indian open health market, in today’s health tourism market, in West Bengal provinces improvement of health care delivery is till days mainly directed towards whom? Obviously not a pro poor health care delivery system it is what was in 1977s-1990s! What should be focus in health care in 21st century? It must be patients cure and care both. Every patients must have sufficient accesses to safest and  higher / or highest quality of health care regardless how much they earn,  how much poor they are , where they live and how seek they are!- A patient, a citizen must be the first priority and not the health industry and profitable health financing. Then why to step for privatization of health  care and cure in west Bengal? Why opening accesses for so many & mushrooming Private health care institutions, hospitals  including private Medical colleges in not only India but in West Bengal When there is dearth of qualified teachers for undergraduate  post graduate  or post doctoral level courses to be recognized by Medical council of India? Whom they  will serve? whom they do serve? Why to patronize those private care hospitals from government level? As they deals with few hundred billion dollars in health care and cure market without spending a few to generate for their own health care providers
 Improvement of health care through public health care delivery when directed at poor, it contributes more directly to poverty reduction and serve as pro-poor growth strategy. In west Bengal Provinces of India out of 9.5 cores population 27.09% population is till bellow poverty line( Rs 1500/= pm I.e. < $1-1.5 per day per person) and 62% population is at poverty line (Rs 1500/=)even after 67 years of Independence!  What  a shame!. In India, tuberculosis kills 364,000 people and diarrheal disease and other infections kills 3 million people every years .600 million people in India lives with daily income<us$1-1.5( 2007 figure). These poor bears disproportionate burdens of illness, psychiatric illness, suicides and various under nourishment,  Helminth infestations ,infectious diseases including Leprosy T. B( even XDR and TDR!), HIV,, HIV in Children of Low socioeconomic class[ HIV in children an estimated 4,30,000 children younger then 15 years are infected with HIV and almost all the infections are in South East Asian countries and through parent to child transmission during pregnancy, child birth or breast feeding so meeting needs of HIV Positive people and their off springs is critical to Indian political and financial commitment for universal access  to HIV prevention, treatment, care, rehabilitation & support ] sanitation & sewage disposal problems related diseases, water borne infections, mosquito borne diseases  Mal nutrition related  DM ( insulin Dependent Type II DM as Per ADA), Chronic Bronchities,COPD, Smoking related diseases GI problems like gastritis, worm infestations, Deodinal Ulcer, G I Cancer  then upper middle class, middle class and rich people. The poor suffers from ill heath due to mainly of causes of poor nutrition that reduces their ability to perform works due to weakness, due to threaten Tuberculosis, their defective immunity and resistance for diseases, frequent treatment expenditure, frequent doctors fee, nursing home charges and loss of economic forces. Poor families thus exhaust their earnings, their savings, their assets and take re curse of borrowing leading to more poverty, poor health status & drop in school & colleges. They can not even adhere to a costly prescriptions in brand name or when suffer from chronic diseases[ India is turning home for Chronic diseases among Poor’s -26%] and old age problems.
There always remained inequalities between rich and poor population within a state within a country or between rich and poor counties.  In case of state of West Bengal, in India, the same is also true & over expressed presently. No doubt there happened a systemic (in hands of few percentage -<20% population) economic growth and number of middle class economic families or people increased in the state. In last decade there has been total transformation of middle class population life style. Material benefits appear to lower the basic human values. The ever increasing gap between haves not and haves had been drastically increased at all level of urban, semi urban rural areas of India and West Bengal escalating youth violances, rape, murders, due to widening socioeconomically disparities now posses a major threat and challenges to all those involved in providing basic human needs at low to moderate cost. It is fact that 62% of our people living in250 major cities with population of 1 lack and above live in pathetic, unhappy life of the less privileged millions factually the rural services has undergone a remarkable transformation as far as basic amenities are concerned. The problem has escalated with ever increasing rural-urbun migration in search of openings for their dependents survival. The rural environment are improving no doubt due to implementation of various central government of India’s socially beneficial measures when the urban Sub urban and metro cities scenario has worsened for last decade[3]  In India, now 350 millions people may be classed in middle class economy. Their physical or labor contribution for economic growth of the state is  so negligible and their life style is really most unhealthy one, that they are eating too much of calories , fat, eggs, milk products, cheese, packed dry foods,  fast foods in food plazas ,meat, chicken perperations, consume much  cooking oil, proteins & carbohydrates salt intake(40%), but they are reluctant to burn their calorie by physical labor. They lost all their physical activities including daily one hour walking. City middle class and upper middle class population mostly drive their cars every where they go even to malls and Ion ox as  their status symbol.  The numbers of  self owned cars in every roads of metro cities increased   at so high level, that these  self owned cars are one of main causes of air pollution in cities and towns with various poisonous chemicals  and heavy metals  that acts as carcinogens and are the  most important causes of various lung diseases like COPD, asthma, cancer lungs even those who are not using it. As a result, I think, they suffer from obesity over weight, high BMI, increased abnormal waist circumference(42%) metabolic syndrome, diabetes mellitus type-2[ India and China share approx 1/3rd  of diabetes population of world. The International  Diabetes Federation in 2008 estimated projected India as diabetes capital of the World. The Figure in 2011 is 61.3 million and 77 million pre-diabetics  waiting to add co-existing and by 2030 my prediction is it will be 101 million], high blood pressure(27%) and its all sequels,  Chronic renal failure, NASH, atherosclerosis , cardiovascular diseases and CVA and they try to occupy most beds in a hospital , ITU or ICU be in public or private hospital. If one looks at nos of Bed distributions in Critical care units the bed strengths are triple then in public state hospitals as because these critical care units in private sectors are  one of good  means of their profitable business  and generations of incentive for their health care providers, pharmaceuticals.  Are not these people themselves responsible for their own  diseases and early death if occurs? Why then state health services policies pays priority for these people’s health care and cure, opening marketing  accesses for business houses like mushrooming private  health institutions/hospitals[  These hospitals  or institutions never show any human faces] in healthcare system, neglecting the real needs of poor and low middle class?. We so need a renaissaue in health care driving force towards an effective and strong primary health care in state of west Bengal particularly targeting poor people, low middle class people, unemployed people  students, employed middle class, child  in regard immunization, proper food care, nutrition, safe water, sanitation, maternal and child care, prevention and quality treatment of local diseases, provision of essential drugs, medical instruments, gadgets through  fare price shops in every hospitals including in PHCs level, A National level policies for access to medicine of appropriate quality efficacy and safe drugs through Fair price shops,  laboratories diagnostic facilities extending from secondary health care tire to primary health center level. In 1983 the India’s national health policy adopted the alma- atta definition of primary health care to mean the provision of curative, preventive and rehabilitative health services and accesses of health services to rural areas. A large three tire health care system  thus developed in all provinces including in state west Bengal. Primary health centers are units that provide integrated health care in rural villages [30,000 populations] and provide referral to secondary and tertiary care in an almost non effective referral system now. Where is the problem? Is not infrastructure enough for an appendectomy or cholecsytectomy or cesarean section operations in State general or subdivisional level hospital or is not infrastructure adequate to treat Diabetes mellitus, simple Thyroid diseases, or pneumonia  or a ischemic stroke  or  a  gastric dyspepsia  for treatment? Or Physician/ surgeon/ Gynecologists/  anesthetists/ pathologists/ technicians/ nurses/ GDAs/ Sweeper posted  in those public hospitals  are too insufficient  or many such posts remained vacant after retirement to give  24  hours care . The real fact is human resources are to day so less and what ever  negligible I are there  they are busy to do private business in their private chambers or nursing homes and they are turned qualified doctors to refer those patients in the tertiary care hospitals or state medical colleges. Why the good quality MD/MS or Post Doctoral DM/Mch are reluctant  to join in government run hospitals or in medical Education services but prefer  to join private care hospitals for lucrative salaries and job facilities with incentives and rewards  But problem of PHCs remained, are unavailability of human resources [doctors, nurses], essential medicines and forcing poor people to get treatment in private chambers and often before quack doctors, on whom villagers depends on much
  The fact is that for last 2, decades, in the state, there was dominance of profit making health insurances industries, a new wave of investor-owned specialty or super specialty hospitals, and profit-maximizing behavior in west Bengal provinces including in India .The involvement of private companies any where always generates some controversy. Some health policy maker people believe that only commercial interests can bring health innovation and efficiency and can modernize the health system. –the idea is not a default .I rather assume that the profit motive is incompatible with the pursuit of excellence in health care system. The government of west Bengal so planned to  establishing at least 60 primary health centers, diagnostic laboratories services in secondary and tertiary level health care including in medical colleges of the state  to be run by private companies in the name of public Private Partnership in Health care system. Health care is the responsibility of a state government. It must be free and must not afford profit at expense of poor and what I feel. The Health inequality can be reduced by 1) reducing the poverty level 2) Improving the health 3) taking health as a Right as it is a right to Vote by a legislation 4) increasing the mental health 5) increasing the palliative care of health 6) Affordable Health care Act(ACA) which will  require all employers to offer lower and lowest income group workers health insurances coverage in affordable financial terms by government instead of private health insurances and purchasing coverage directly. ACA Should  reimburse from fee for services towards rewarding of improved quality outcomes and efficiency. Payment and delivery system models  such as patients- centered medical homes accountable to Govt.run care organizations. Audit of prescriptions and control of Private care & cure Health system,  7) Prescription of generic medicine 8) Fair Price shops opening to poor class and low socioeconomic and middle class population of the state and through out all states of India selling quality medicine, gadazets, instruments for interventions 9) Increasing quality of Undergraduate and Post Graduate examinations system to level of excellence 10) Electronic Prescribing system can result better data sources and real time maintaining of medicines required and sold, best ways of counseling to patients, target massaging  and quality improvement
 At heart of Problem lie essential questions about political motivation, human consciousness about his/her Right to his/her health and physician’s mood, responsibility and willingness to help people and reduce in equity in health care system of West Bengal.

 References:-
1) Response by David Brookman  on 12 th December 2008 to BMJ group Blogs “A global conversation on defining health” by Alex Jadad and Laura O’Grady on10 Dec, 08 | by BMJ Group
2) Amartya Sen “Why and how is health a human right?” The Lancet, Volume 372, Issue 9655, Page 2010, 13 December 2008 doi:10.1016/S0140-6736(08)61784-5
3) TG Krisnamurthi “ Value based Education: role in empowerment” Editorial article JIMA vol11;N-09;sept;P586; 2013
 Acknowledgements-:
The author acknowledges his diseased  parents late  Bholanath Bhattacharya( 1926-2009) and  late Mrs Bani Bhattacharya , his daughter Miss Upasna Bhattacharya and his youngest brothers Mr Rupak Bhattacharya and RitwikBhattacharya, his sister Dalia Mukherjee whose some suggestions had been reflected  in this article which was originally written in 2008 for BMJ group journals QHSC and BMJ Group Blogs by the author and was submitted

 Copy Right Statement-:
 The opinions expressed in this article is of author’s only. Copy Right of the article belongs to Prof.Pranab kumar Bhattacharya-the author and only to  his first degree blood relatives under Copy Right Rules 3D/ 107/1201 (a) (b)/ RDF of Intellectual Property Right Act and SPARC Copy Right rules-2006 and PIP Copy Right Rules-2012 of USA. For Permission for reproducing, citation, references , further research work,  for self use and  for implementation of more than three words or any meaning full sentences in any health care system either in  any state of India or in any other countries or in any  pvt  care & cure Institute /hospital or  translating in other languages  please mail to profpkb@ yahoo.co.in to avoid infringement and plagiarism from your end to avoid copy right damage suit in million US dollar for injury to author.  

  Sd/  Professor Pranab Kumar Bhattacharya  MD(Calcutta Univ) - Professor and Head, Department of Pathology , School of Tropical  Medicine, Kolkata-700073