Chasing SDG goals
India must tap into the interconnected dynamic of health, poverty, and livelihood to ensure holistic progress matching global standards
Being the second most populous country, India's efforts in achieving the 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, would be crucial. The strategies that India adopts would be of relevance to the rest of the world, as best practices, models, and paradigms.
However, India's journey towards sustainable, equitable development would be complicated and unique, given the extent 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, particularly on the goals related to health and poverty.
SDG Goals are interconnected. 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 the poverty line. According to Census 2011, the workers formed 39.79 per cent (481.7 million people) of the total population as against 39.10 per cent in Census 2001. 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 the public sector.
The population that lives below the poverty line falls short on the aspects of accessibility and affordability of healthcare because they are forced to make massive out of pocket expenditures. They work for the unorganised sector and cannot resort to private health insurance. They fall into a vicious cycle of poverty –which results from an inadequate source of livelihood and low productivity due to bad health.
Microdata and planning
Structuring an optimal 'big push' is the most critical link to chasing SDG goals. The efforts made at the macro level by the government should be supported 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 the case of health, poverty, and livelihoods. There are zero-sum situations, and a negotiation between the various outcomes is hard to make.
One of the factors which account for an interplay of variables within a 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 the National Health Accounts statistics (2014), the out of pocket expenditures across household 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 sources of financing is assets and debt, for households.
Savings as a percentage of the disposable incomes rises when incomes increase. Households that must make healthcare expenditures are not able to save enough for capital formation, which leads to a subsistence existence. The Health-Wealth nexus cannot be broken unless a push in public health and livelihood 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 the epidemiology of the district should be collected by the district health officer.
Detailing health expenditure
Health expenditure on preventive care is a very small percentage of curative care expenditure in India. As per the 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 in India is huge and it is difficult to achieve the goal of universal health coverage or Healthy India only in a 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 and dynamic interplay of the health-poverty-livelihood variable become extremely important to understand.
Increasing public expenditure on preventive care is one such 'big push' that could be provided. Government budgets for all the preventive health programs mentioned above should be increased at the Central and the state level. District level Public Health Management cadre of officials and larger investment in primary health has been mentioned as an essential government intervention in the Health Policy 2017. The Department of Statistics and Planning working in close coordination with Public Health officials, to generate data, and design localised solutions for health problems in the district would bring in the desired 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 the department of statistics and planning to identify vulnerable population groups.
Employment generation schemes
Linking MNREGA and other employment generation schemes with health insurance, nutritional programs, awareness programs, 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.
(Dr. Monika Choudhary is Associate Professor, IIHMR University, Jaipur. The views expressed are strictly personal)