Dr Monika Choudhary, Associate Professor, IIHMR University, Jaipur, gives an insight on how interconnectedness of health, poverty and livelihoods, will help India achieve SDG goals
Being the second most populous country, India and the efforts it makes would be important for the achievement of overall sustainable development goals (SDG) targets which the world adopted a couple of years ago to end poverty, protect the planet and ensure prosperity for all. The strategies that India adopts to frame and achieve SDG goals and targets would be of relevance for the rest of the world, as best practices, models, and paradigms.
However, India’s journey towards sustainable, equitable development would be one of the most complicated and unique, given the level of socio-economic diversities in the country. While there are states like Kerala, which are already far ahead and at par with the world on some of the SDG goals and targets, there are states like Bihar, UP, Rajasthan, Chhattisgarh, and Jharkhand, which are far behind. India has fared badly on SDG goals and particularly on goals related to health and poverty.
Interconnection of goals
SDG goals are interconnected to each other. Universal Health Coverage, becomes a very difficult goal to achieve when about 276 million people (or about 23 per cent of the population) live below poverty line. According to Census 2011, the workers (consisting of main workers and marginal workers) formed 39.79 per cent (481.7 million people) of the total population as against 39.10 per cent in 2001 census. Only a small percentage of the total workforce of the country is employed in the organised sector. Organised sector employment as on March 31, 2011 was 29.00 million of which 60.52 per cent or 17.55 million was in public sector.
The population that lives below poverty line falls short on the aspects of accessibility and affordability of healthcare because they are forced to make huge out of pocket expenditures. They work for unorganised sector and cannot resort to health insurance largely. They fall into a vicious cycle of poverty – which results from inadequate source of livelihood, low productivity due to bad health.
Micro level data and planning must
Structuring an optimal ‘big push’ is the most critical link to chasing SDG goals. The efforts made at the macro level by government should be supported by efforts made at the micro level by households. Creating infrastructure and systems should be balanced by creating skills, education and awareness. When there are resource constraints, optimal solutions are reached at by permutations, combinations and an interplay of variables, which would be too many in case of health, poverty, and livelihoods. There are zero sum situations, and a negotiation between various outcomes is hard to make.
One of the factors which accounts for an interplay of variables with-in resource constraining situation is an imperative out of pocket expenditures to be made by those belonging to the lowest quintile in terms of disposable income. According to National Health Accounts statistics (2014), all households’ out of pocket expenditures is 69.1 per cent of the total health expenditure. Households must resort to their own financing resources to seek healthcare. Many studies have indicated that households belonging to lower quintiles of disposable income are pushed back to below poverty line status because of imperative health expenditures. One of the main source of financing is assets and debt, for households. Healthcare expenditures thus account for dissavings for households having lower disposable incomes.
Savings as a percentage of disposable incomes rise when incomes increases. Households that must make healthcare expenditures are not able to save enough to do capital formation, which leads to subsistence existence. Health-Wealth nexus, cannot be broken unless a push in terms of public health and livelihoods is provided.
At the district level, a primary effort should be made to identify these households. District level data related to poverty, unemployment, seasonal and disguised unemployment, nutrition, disease surveillance, health indicators, water and sanitation should be disaggregated at the panchayat and block level. Research related to epidemiology of the district should be collected by district health officer.
Health expenditure details are of paramount importance
Health expenditure on preventive care is a very small percentage of curative care expenditure in India. As per National Health Accounts estimates general inpatient curative care accounts for 20.5 per cent of the total expenditure while outpatient care accounts for 29.5 per cent of total expenditure, while preventive care is a mere 9.6 per cent of expenditures.
The underserved population with regards to health in India is huge and it is difficult to achieve the goal of universal health coverage or healthy India through curative way. It will require huge funds, and will cut into other essential developmental expenditure on education, infrastructure, and energy. That is where the interconnectedness of health-poverty-livelihoods variables and the dynamic of interplay of these variables becomes extremely important tounderstand.
Increasing public expenditure on preventive care is one such ‘big push’ that could be provided. Government budgets for all the preventive health programmes mentioned above should be increased at the centre and the state level. District level public health management cadre of officials, and larger investment in primary health has been mentioned as essential steps to be taken by the government in Health Policy 2017. Department of Statistics and Planning are working in close co-ordination with public health officials, to generate data, and design localised solutions for health problems in the district would bring results. The district public health office will prepare regular reports on epidemiological surveillance studies conducted in the district and combine it with poverty and unemployment data collected by department of statistics and planning to identify vulnerable population groups.
Employment generation schemes
Linking MNREGA, and other employment generation schemes with health insurance, nutritional programmes, awareness programmes, disease surveillance and developmental works like infrastructure development, and water conservation would bring about bigger outcomes with cost effective investment. District level planning of comprehensive development schemes for a household which requires assistance in all the three areas of health, employment and poverty is the key to achieving SDG goals in India.