PERSPECTIVES Economic & Political Weekly EPW october 23, 2010 vol xlv no 43 41 The views expressed in this paper are not necessarily shared by the employers of the authors. Meeta (meeta29@hotmail.com) is with the Indian Administrative Service. Rajivlochan (mrajivlochan@gmail.com) is with the Panjab University, Chandigarh. Inequities in Health, Agrarian Distress and a Policy of Avoidance Meeta, Rajivlochan The absence of irst level healthcare facilities and the high cost of treating even routine illnesses are the immediate problems in the existing healthcare system as also the fact that high costs do not necessarily imply reliability of treatment. No insurance scheme or altruistic healthcare providers can address these problems. The solution lies in strengthening the public healthcare system. I t is a matter of contemporary fact that health facilities in India have col- lapsed. Public health facilities are close to non-existent and private health services far too few, far too exploitative and focused mainly on the urban areas. This makes for a signiicant contribution to agrarian distress that is currently visit- ing the countryside. In fact, a closer look at health-related information with respect to the problems of farmers suggests that health issues might even be more impor- tant than the farm-related ones. 1 Scale of Health Problem Most reports on farm distress, whether academic or journalistic in nature, do highlight a number of cases where illness was the starting point for the family in trouble; yet practically, none looked at health systems in general as an important explanatory factor for farmers’ distress. Perhaps, we have become so inured to the absence of responsible and reliable health- care facilities that their shaky presence is taken for granted and it is assumed that no further note need be taken of the mat- ter. Other than in the context of agrarian distress, there are many writings on the lack of healthcare services in India, and especially in rural areas, but they all focus on hospitalisation expenditure and the inancial distress that hospitalisation causes. Concomitantly, they discuss the need for a comprehensive system of health insurance. However, all these writings tend to pre- sume the existence of a well-developed pri- vate health sector which is also considera- bly altruistic and not exorbitantly costly. They take for granted the willingness of the private sector to cooperate in the work- ing of a health insurance system and on the availability of public funds for the same (Duggal 2007; Joglekar 2008). We submit that, while all these sugges- tions are laudable, they are also depend- ent on variables which are extremely uncertain, and to that extent, it is dificult to achieve the target. Perhaps, a more practical and people-friendly approach would be to take the irst step, the step of strengthening the public health system by investing in health providers as the irst line of care. The absence of irst level healthcare facilities and the high cost of treatment even for routine illnesses are the more important problems. Moreover, even the high costs incurred in healthcare do not necessarily imply reliability of treatment. Reliability is substantially dependent upon the presence of accredited health providers and the ease of obtaining reliable diagnoses and counselling for cur- ative care at the initial stage of treatment. No insurance scheme can address this problem. Only a large number of trained physicians, available at the irst line of healthcare, can make a difference here. The disturbing fact is that according to information derived from the Central Bureau of Health Intelligence ( CBHI ), Gov- ernment of India, over the past 20 years, the ratio of the rural population to govern- ment doctors in rural areas has deterio- rated, from being one doctor to 17,000 population for the country in 1986 to one doctor to 34,000 population in 2006 (CBHI 1986-2006). If you simply do not have the doctors in place, how do you expect anyone to get any medicare? Despite such abysmal numbers and the poor experience with com- munity health volunteers since the 1970s, the government does not seem to plan any increase in the number of service providers in the public sector. Instead, the National Rural Health Mission (NRHM), a lagship scheme for rural healthcare of the government of India, continues to depend heavily on voluntary workers, whose main job seems to be to concentrate on preventive healthcare and on assisting people to reach the healthcare facilities at the primary health centre (PHC) and community health centre (CHC) level. Generating demand for health services is a laudable idea, but it needs to be accompa- nied by some plans to meet the increased demand; of the latter, unfortunately, there