While it might be dismissed as a ‘throw-away line’, the budget speech includes a 16% increase in the National Rural Health Mission, addressing one complaint heard frequently that too little is allocated to health. The complaint may be justified but almost certainly not by examining allocations to items in the budget labelled ‘health’. Public policy can make an enormous contribution to the health of India’s citizens but much of that help has virtually nothing to do with the public provision of medical care. Once again, an opportunity to use money that could make an improvement in the lives of poor people is almost certainly going to feed people’s scepticism of government’s abilities to accomplish much in the way of social well-being.
The complication is that budgets for health go disproportionately to medical care—a dramatic understatement. But people’s health is determined by a vast array of factors of which medical care is a minor part. In fact, it is often very hard to find any connection at all between publicly provided medical care and standard measures of health status. In two rounds of the National Family Health Survey, it is impossible to detect any correlation at all of having a public medical facility in your village and having lower infant (or child, or maternal) mortality once other factors are considered. Lots of other things are correlated: income, education (probably mothers’ but that’s debatable), water supply, sanitation habits and even roads but not publicly provided medical care. The most recent round of the NFHS, unfortunately, can’t be used for this purpose since it doesn’t even ask about the presence of public clinics.
How can that be? How can public medical care not be correlated with the simplest measures of health status when so many other things that don’t appear to have anything to do with health are? The answer involves both inadequacies of the public delivery of healthcare (particularly primary healthcare) and the complexity of the determinants of health.
Take roads for example. Students of mine examined data from a recent NCAER survey among other surveys done in Himachal Pradesh. They found that the great majority of people bypassed their local, small, public facility to go to a larger public facility or to a town with a competent private doctor. With a reliable road system, it was preferable for people to travel to where they were sure of receiving good