Most South Asian countries continue to perform poorly on most social indicators, something that is reflected in their human development indices. With the onset of structural adjustment reforms, even the policy commitment to free, universal healthcare has quietly slipped into the wings. The shifting emphasis on fiscal management and structural adjustment has restricted the public sector's role to 'regulation' and little more. Evidently, healthcare provision is no longer the business of the state, as against universal and equitable provision of healthcare, which is not only a basic human right, but also the prerequisite of a dynamic human resource. Without an elaborate healthcare system and effective population planning, focusing on women and children's healthcare, South Asia cannot join the ranks of civilised nations.
In the case of India, Pakistan, and Bangladesh, the Government of India had affirmed its policy commitment to providing universal and, more importantly free, healthcare even before Partition in 1947. But policies and budget allocations within and outside the health sector are not always made on the basis of need, but on what is politically expedient and on the 'consumer's' ability to pay. Relegated as South Asia's poor are to this euphemism, healthcare continues to be something the poor simply cannot afford.
Meanwhile, acute inefficiencies in healthcare, inadequate and inefficient resource allocation, and correspondingly poor service delivery have all triggered the growth of private sector healthcare providers available only at a higher price, leaving the poor and much of the lower-middle class - women and children in particular - at the mercy of disease and ill health. In many cases, it has only encouraged 'over-diagnosis' and 'over-medication' with the aim of profiteering.
The blue-ribbon Commission on Social Determinants of Health (CSDH), convened in 2005 by the World Health Organization (WHO) maintains that longevity and susceptibility to disease often have less to do with infections and genetics than with the social determinants of health - factors such as income, education, occupation, access to services such as sanitation, good medical treatment, and decent housing. In South Asia, we have yet to come to terms with the interlocking relationships between economic achievements, social investments, and health outcomes. Not only does a country's state of health boost economic output, economics can and should promote better health as well.
The urban and elitist biases inherent in health facilities in most South Asian countries, and the neglect of primary and tertiary healthcare, mean that such facilities over-care for the rich and neglect the poor. With the exception of Sri Lanka, these countries' health sectors have tended to evolve in line with the broader dynamics of 'free' market forces, the inherent class contradictions of which have led to the development of a largely curative-care model. Medical education at local institutions in the region often replicates what is found in developed countries, resulting in a demand for the 'latest' (which does not necessarily mean the most appropriate) medical care.
This bleak picture aside, there are nonetheless instances that show that it is possible to challenge the hegemony of laissez-faire economics under which health, and indeed other social services, become profiteering ventures. Sri Lanka's success in developing a highly dispersed rural health infrastructure and policies rooted in preventative healthcare; and the success of Pakistan's community-embedded Lady Health Workers Programme, show that health outcomes need be achieved even at the cost of economic gains. As Nobel laureate Amartya Sen has often candidly pointed out, people can hardly be expected to generate income when they are not healthy enough to hold a job.
Improving the state of health in the region requires a creative and more far-reaching approach to how the health and well-being of the region's people can be improved. Sri Lanka, for instance, has been able to use efficiency gains to keep government health spending limited to less than two percent of its GDP. By giving curative and preventative healthcare priority in public health budgets, and allowing access to precede quality, the country's public healthcare providers have not allowed themselves to be dislodged by the private sector.
