#India- The Doctor Only Knows Economics #Sundayreading


Lucknow In a daze, a poor couple bring their sick child to a government hospital, holding up a drip bottle. For many like them, private hospitals are out of reach. Care at government hospitals is poor.
HEALTH: SICK & SOLDOUT
This could be the UPA’s worst cut to its beloved aam admi. Healthcare has virtually been handed over to privateers.

Not For Those Who Need It Most
Govt seems to have abandoned healthcare to the private sector

Diagnosing An Ailing Republic

  • 70 per cent of India still lives in the villages, where only two per cent of qualified allopathic doctors are available
  • Due to lack of access to medical care, rural India relies on homoeopathy, Ayurveda, nature cure, and village doctors
  • While the world trend is to move towards public health systems, India is moving in the opposite direction: 80 per cent of healthcare is now in private sector
  • India faces a shortage of 65 lakh allied health workers. This is apart from the nurse-doctor shortage.
  • According to World Health Statistics,  2011, the density of doctors in India is 6 for a population of 10,000, while that of nurses and midwives is 13 per 10,000
  • India has a doctor: population ratio of 0.5: 1000 in comparison to 0.3 in Thailand, 0.4 in Sri Lanka, 1.6 in China, 5.4 in the UK, and 5.5 in the United States of America
  • Fifty-six per cent of all newborn deaths occur in five states: UP, Rajasthan, Orissa, MP and Andhra Pradesh
  • Forty-nine per cent of pregnant women still do not have three ante-natal visits to a doctor during pregnancy
  • An estimated 60,000 to 100,000 child deaths occur annually due to measles, a treatable disease
  • Uttar Pradesh, the most populated state in the country, does not have a single speciality hospital for cancer
  • The top three causes of death in India are malaria, tuberculosis and diarrhea, all treatable
  • The WHO ranked India’s public healthcare system 112th on a roster of 190 countries
  • Post-independence India’s most noteworthy achievement in the public health arena has been the eradication of polio and smallpox

Affair of the states

***

India is taking firm steps to a certain health disaster. All of 80 per cent of healthcare is now privatised and caters to a minuscule, privileged section. The metros are better off: they have at least a few excellent public health facilities,  crowded though they might be. Tier II and III towns mostly have no public healthcare to speak of. As the government sector retreats, the private booms. In villages, if you are poor and sick, no one really cares, even if the government pretends to. You go to the untrained village “doctor”; you pray, you get better perhaps; all too often, you die of something curable. “India is the only country in the world that’s trying to have a health transition on the basis of a private healthcare that does not exist,” Amartya Sen said recently in Calcutta. “It doesn’t happen anywhere else in the world. We have an out-of-the-pocket system, occasionally supplemented by government hospitals, but the whole trend in the world is towards public health systems. Even the US has come partly under the so-called Obamacare.”

Sadly, even the few initiatives the Indian state takes are badly implemented. Hear the story of Suresh, 45, who lost his younger sister to cancer, eight months ago. He’s a guard at the guesthouse of a pharmaceutical company in Mumbai and could not afford her treatment, so he sold some ancestral farmland in Gujarat. That money covered but a few months of bills from a private hospital. He then turned to a government hospital, but it didn’t have cancer care. It didn’t help in any way for Suresh that he worked for a pharmaceutical company: his job didn’t come with medical benefits. “We brought her back home, hoping that if we saved on the hospital bills, we would be able to buy her medication. Finally, the money I had was too little to provide her basic help. Maybe if I had been able to buy her medicines, she would have been alive today.”

But the state could have ensured that Suresh’s sister lived had he been able to utilise the ambitious health insurance scheme announced in Maharashtra in 1997. The Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) is on paper supposed to provide for 972 surgeries, therapies or procedures, along with 121 follow-up packages in 30 specialised categories. It provides each family coverage of up to Rs 1.5 lakh in hospitalisation charges at empanelled hospitals. It even allows for treatment at private hospitals. But poor implementation has ensured Suresh and hundreds of families like his do not know of such a scheme. This is true of other schemes across the country too.


Photograph by Vivek Pateria
Bhopal At the Sultaniya Hospital, as at many hospitals in the Hindi belt, there just isn’t enough space for the patients who turn up. Those who attend on patients routinely brave the open.

Meanwhile, health statistics are terrifying. More than 40,000 people die every year of mosquito-borne diseases, which are easily preventable; a maternity death takes place every 10 minutes; every year, 1.8 million children (below 5 years of age) die of preventable diseases. “We are the only country in the world with such a huge percentage of privatised healthcare. Recent estimates suggest that approximately 39 million people are being pushed into poverty because of high out-of-pocket expenses on healthcare. In 1993-94, the figure was 26 million people,” says Dr Shakhtivel Selvaraj, a health economist.

So the state’s pretence of reaching out to the poor is really quite a farce. Consider what’s been happening between the Planning Commission and health ministry. In November, the battle between then health minister Ghulam Nabi Azad and the Planning Commission came to light: Azad had pressed for increased spending on the public sector while the commission was intent on increasing private participation. This was a telling comment on the priorities of the UPA government. But with the 2014 elections in view, the government would like to present “health reforms” as a political tool. A framework for “universal health for all” is expected by April this year.

 

While talking always of the aam admi’s needs, the UPA has been handing healthcare over to the private sector.

According to the draft of the 12th Plan, the government will increase spending on health from 1.2 per cent of the GDP to 1.9 per cent, with greater emphasis on public-private partnership. While the expert group asked for scaling up public funding from the current 1.2 per cent of GDP to roughly 2.5 per cent by the 12th Plan-end (2017-18) and to roughly 3 per cent by the 13th Plan-end (2023-24), the government only relented a bit—enough to give it room to announce more populous aam admi schemes. D. Raja of the CPI believes that “through PPP (public-private-partnership), floated in the 12th Plan, the government is working as facilitator for private sector”, something that goes against the constitutional mandate of a welfare state. Former health secretary Sujata Rao says the state “cannot co-opt the private sector to provide healthcare for which government is paying money without framing stringent rules and norms.” More than 70 per cent of expenditure on health in the past five years has come from households. In its nine years in power, the UPA has overseen the shrinking of the public sector and the boom in the private. All the while, it has paid lip service to aam admi causes—even as it pushes people from the margins into the wilderness. In those five years, the well-to-do have obtained better healthcare than ever before. Both the Congress and the BJP have said in their party manifestos that they want to make India a “health tourism” destination. That has already happened. Would the UPA, champion of the aam admi’s interests, pat itself on the back for that? Meanwhile, most private facilities ignore a Supreme Court directive to reserve a certain percentage of their beds and treatment for the poor because they were given land at concessional rates. 

Barely 100 km from the national capital, the Kosi Kalan district of Uttar Pradesh, near Mathura, presents a pathetic picture of community health care. Four months ago, the primary health centre, which caters to more than 50,000 patients with two trained nurses and two doctors, was upgraded into a community health centre with a new building. However, doctors haven’t been posted at the new centre. Says Rajkumar, a doctor at the primary health centre, “We got the new building about four months ago. We are waiting for administrative sanctions”


Photograph by Tribhuvan Tiwari
Gurgaon Subedar Gupta (right) has spent about Rs 30,000 at private hospitals for his wife’s treatment in one month. He feels the hospitals have made her undergo unnecessary tests.

It’s a familiar tale of rural India. But what is also significant is that in the post-liberalisation era, the government health sector has virtually vanished from Tier II and III urban centres. Subedar Gupta, 32-year-old commercial vehicle driver from Gurgaon, has discovered that the government sector is an empty shell. It’s the private sector that has fleeced him. His wife Chanda Devi has been complaining of severe bodyache, itching and weakness for the last five years and no one knows why. Gupta spent about Rs 30,000 last month at private hospitals. He is now broke. “They ask us for same tests—blood test, X-rays and ecg. She is continuously on medicines. They are sucking all the money out of us.”

 

In Tier II and Tier III towns, the public healthcare system is non-existent. Even the private hospitals here are inadequate.

Millions of Indians living in small towns go through the same agony–not knowing where to turn to in the absence of a good health system. Because of that, thousands travel to Delhi’s overburdened AIIMS and Safdarjung Hospital, which are staffed with excellent doctors. The rest just pay for a private system designed to extract the maximum from each patient. “Public health is a big question in small cities. They have government hospitals, which are not well-equipped—in terms of infrastructure or adequate numbers of doctors and other staff.  There is also a shortage of woman doctors,” says Dr Rajesh Shukla, a consultant who has evaluated icds programmes in rural areas and studied medical care in small towns. 

A large number of swanky hospitals and clinics have come up in urban India. But that does not ensure good care. There is also the issue of all this being loaded in favour of a profit-seeking system. Take the Rashtriya Swastha Bima Yojna, a government-supported health insurance scheme that rides on the private sector to provide medical care and surgical procedures at predetermined rates. Experts point to the dangers of induced demand and the prescription of unnecessary procedures to claim insurance benefits. Besides, the technology at private centres is often used to fleece patients rather than help them.

Dr Subhash Salunke, former director-general of health services, Goa, and currently director of the Public Health Federation of India, says the private sector is very scattered and unregulated, leading to lot of malpractices. This could have been checked to some extent had rules of the Clinical Establishment Act, 2010, been framed and implemented. Two years after the legislation was passed by Parliament, it hasn’t been implemented. The problem lies with the “stiff resistance from the private sector to the laying down of guidelines”.


Photograph by Sandipan Chatterjee
Calcutta Nomita Pramanik, a domestic help, has asthma. She earns Rs 2,800. A hospital visit costs Rs 250-300. She calls free treatment at government hospitals a “curse even enemies shouldn’t suffer”.

The health sector is also crippled by a shortage of doctors and nurses (see graphic). So when the government says it is serious about training more doctors and nurses, by setting up six new AIIMSes, it makes for sound planning. But politics quickly shows up: one of the AIIMSes is planned in Sonia Gandhi’s constituency, Rae Bareli. Many doctors trained in excellent government medical colleges swiftly move to the private sector; they are even reluctant to take up rural jobs or postings. “Of the 1,400 doctors appointed after a proper selection process, only 900 joined the service,” disclosed a spokesman of the Uttar Pradesh health directorate. Because of the shortage of doctors in government hospitals, the National Rural Health Mission (NRHM) had started to recruit those trained in the Ayurvedic, Unani, Siddha and homoeopathic streams, but the process was stalled by a Rs 5,000 crore scam.

So the poor continue to suffer. In a general ward of Krishnanagar Hospital in Nandia District, West Bengal, members of a patient’s family say that not a single doctor checked their ward for 24 hours after he was admitted with a cerebral condition. The doctor assigned to the hospital, who was in his chambers some 10 km away, had this to say when tracked down by Outlook, “I’m the only doctor for close to 500 patients. Is it possible for me to visit each and every patient? You have to understand my constraints. There is very little monetary incentive for doctors working in the rural areas. These are punishment postings. No one wants to come here. They want to work with rich patients and earn big money.”

As he spoke, there were close to 100 patients waiting in the visiting room to see him. They were all from the villages and small towns in Nandia district. Krishnanagar Hospital is the main district hospital and patients from all over Nadia are referred to this hospital. In Uttar Pradesh, modern private health services have yet to reach beyond a dozen key cities. The rest of the state has to depend on these 12 cities, a handful of which have facilities for tertiary care. Some facilities are available only in Lucknow, where the government has concentrated all the healthcare while the rest of the sprawling state—75 districts—goes without even secondary care. According to the NRHM’s fourth common review mission report, of the 515 community health centres in Uttar Pradesh, 308 were below norms laid down in the Indian Public Health Standards.

 

Andhra’s Rajiv Aarogyasri scheme, a brainchild of YSR, sounds perfect on paper. Only, the rich end up misusing it.

Even in states that are economically better off, such as Andhra Pradesh, it is an abject tale. Right from Seetampeta in north Srikakulam district to Utnoor in Adilabad, the public healthcare system is in a shambles. Adivasis simply have no access to potable drinking water and succumb easily to totally preventable diseases. If it’s gastroenteritis in Adilabad, it’s malaria in Paderu Agency of Visakhapatnam district. Anti-larval spraying operations are late and haphazard. Community health workers are badly trained. Human rights teams which visit these areas say the medicines provided are sometimes past the expiry date. “Deaths due to malaria are sought to be passed off as due to other diseases like cancer, heart stroke, old age or TB,” says V.S. Krishna of the Human Rights Foundation. Once touted as a model state for implementation of health insurance, Andhra Pradesh today faces a problem where the scheme is being misused by the rich. A qualified doctor himself, the late YSR, former chief minister of Andhra Pradesh, launched the Rajiv Aarogyasri Scheme in 2006, providing medical cover of up to Rs 2 lakh for bpl families. Since corporate hospitals handle a bulk of the procedures, the scheme is misused. Says a cardiac surgeon at a leading Hyderabad hospital, “The rich come and seek heart procedures under Aarogyasri, casually whipping out white cards meant for bpl families. There are no checks.” 

The ailments of the poor often have nothing to do with the agendas of rich and powerful pharma companies. Are there lessons India can learn from the world? Experts say that the US has one of the worst public healthcare systems in the developed world. But in most countries, in Latin America or Europe, universal healthcare been achieved through governments. In Asia, Sri Lanka and Thailand can teach India some lessons on the health front. So India may be a powerful nation simply by dint of its size and market. But it is also a ‘sick’ nation, where there’s no help for the poor when they fall sick. It’s a country where a poor man can die on the pavement outside a gleaming state-of-the-art hospital with the best medical technology in the world.


By Amba Batra Bakshi & Lola Nayar with Sharat Pradhan, Madhavi Tata, Dola Mitra, Panini Anand, Chandrani Banerjee, Prarthna Gahilote and Prachi Pinglay-Plumber

 

Jan Swasthya Abhiyan (JSA) campaigns against outsourcing of diagnostic centres #Chhattisgarh


TNN | Feb 1, 2013, 03.04 AM IST

RAIPUR: Jan Swasthya Abhiyan,  today started a campaign against the proposed move of the government to outsource diagnostic centres at 379 public health facilities in the state. A public meeting was also held to show discontent with the decision.Talking to TOI, Sulakshna, member of JSA, said that instead of improving and expanding services in the existing system, the government is replacing it with private service providers. “What is disheartening is that the Raman Singh government has taken no lessons from other states where privatisation in this sector flopped,” she added.

Some senior officials in the state also agree that the government seems to be in a haste to privatise the service. They admit that flaws do exist in the system, the biggest being that privatisation would not solve the problem of understaffing. “How will the private sector get qualified staff in Bastar when the government cannot get it on their own,” one of them said.Experts say that unless and until checks and balances are put in place and they are implemented in letter and spirit, the move is bound to backfire. Moreover quality and not the quantity of the tests conducted should be the criteria and the same has to be monitored on day to day basis, a difficult proposition in the present scenario.A senior official commented that merely putting tough conditions on the contract paper will not resolve the problem. “What is required is monitoring, which is a difficult task”, he said.

 

HIV and the Law-Risks, Rights & Health


Thursday, 25 October 2012, IFHHRO

Earlier this year, the Global Commission on HIV and the Law published a report presenting the available evidence on human rights and legal issues relating to HIV: HIV and the Law: Risks, Rights & Health.

The Global Commission on HIV and the Law consisted of fourteen individuals who advocate on issues of HIV, public health, law and development. Some of the Commission’s findings include:

  • 123 countries have legislation to outlaw discrimination based on HIV, and 112 legally protect at least some populations based on their vulnerability to HIV. However, these laws are often ignored or badly enforced.
  • In over 60 countries it is a crime to expose another person to HIV or to transmit it, especially through sex. At least 600 individuals living with HIV in 24 countries have been convicted under HIV-specific or general criminal laws.
  • In many countries, the law dehumanises many of those at highest risk for HIV: sex workers, transgender people, men who have sex with men (MSM), people who use drugs, prisoners and migrants. Rather than providing protection, the law renders these “key populations” all the more vulnerable to HIV. The criminalisation of sex work, drug use and harm reduction measures create climates in which civilian and police violence is rife and legal redress for victims impossible.
  • 78 countries make same-sex activity a criminal offence, with penalties ranging from whipping to execution.
  • A growing body of international trade law and the over-reach of intellectual property (IP) protections are impeding the production and distribution of low-cost generic drugs. IP protection is supposed to provide an incentive for innovation but experience has shown that the current laws are failing to promote innovation that serves the medical needs of the poor. The fallout from these regulations—in particular the TRIPS framework—has exposed the central role of excessive IP protections in exacerbating the lack of access to HIV treatment and other essential medicines.

Reason for hope

Notwithstanding these problems, the Commission has found reason for hope: “There are instances where legal and justice systems have played constructive roles in responding to HIV, by respecting, protecting and fulfi lling human rights. To some such an approach may seem a paradox—the AIDS paradox. But compelling evidence shows that it is the way to reduce the toll of HIV.” Examples given are police cooperation with community workers who assist sex workers; the promotion of harm reduction programmes for injecting drug users; effective legal aid for people living with HIV; and court actions and legislative initiatives promoting the rights of sexual minorities, women and young people. Despite international pressures to prioritise trade over public health, some governments
and civil society groups are using the law to ensure access to affordable medicines, while exploring new incentives for medical research and development.

The report is available in English, Spanish,French and Russian.

Download HIV and the Law: Risks, Rights & Health

 

Evidence, Consensus and Policy: curious case of changes proposed in India’s public health policy


English: National Rural Health Mission of India

English: National Rural Health Mission of India (Photo credit: Wikipedia)

SEPTEMBER 27, 2012

Guest post by KAVERI GILL, at  kafila.org

The world of development is as prone to fashions as any other. In recent times, ‘evidence-based policy’ has become the new gold standard, following hot on the heels of participation and ownership of policy processes and outcomes by academics, activists and civil society groups. This applies within nation states, especially of the global South. India today epitomises such objective and bottom-up democratic largesse in favour of the ‘aam admi’- for largesse it is, make no mistake – with a near constant refrain of the avowed aim of ‘inclusive growth’. And yet, does it really?

Or is politically correct discourse and seemingly open decision-making processes in the social sector sphere merely dangerous fig leaves for seismic and opaque shifts in policy, which have very little to do with evidence and even less to do with broad-based consensus? Rather, they are an outcome of fixed ex-ante views – which may be termed as a distinct partiality to the Chicago School of Economics – about the path to a fictitious endpoint of a mainstream development paradigm, which itself is faith-based. It is not justified by theory or a heterodox reading of the empirical experiences of presently developed countries, let alone latecomer developing nations which are, for various exogenous and endogenous reasons, likely to have different trajectories altogether. I refer here to the hackneyed line about faster growth being pursued as a necessary, if not sufficient, condition for eventual trickle down, no matter that the ‘dur khaima’ of an equitable society is never arrived at!

In his address to the nation last Friday, the Hon. Prime Minister mentioned ‘the common man’ twice in the opening lines, as a straw man in whose name and interests all ‘difficult’ second-stage reforms are being undertaken. On p.1 of the Planning Commission of India’s Approach Paper to the XIIth Plan [1], it is argued that high growth during the XIth Plan was seen as instrumental to achieving two ends: to create income and employment opportunities for better living standards for the majority, and to generate resources in order to finance social sector programmes, aimed at “enabling inclusiveness”. It goes on to define the latter: “…inclusiveness is a multidimensional concept. Inclusive growth should result in lower incidence of poverty, broad-based and significant improvement in health outcomes…” (ibid., p.2). A wish list of the Left liberal’s ideal social contract follows, in the Rawlsian sense of justice, and quite far from Nozick’s Libertarian minimal nightwatchmen role of the state. The discourse could not be better.

But let us unpack the ‘inclusive growth’ jargon – with particular reference to public health care – as an illustrative exercise of evidence, and its selective and biased use to derive unwarranted policy prescriptions in the social sector sphere in recent times. Quickly, to recap a refresher undergraduate course in economics, health care is not a routine commodity, rather more of a public good [2], exhibiting externalities and marked information asymmetries of moral hazard and adverse selection. In layman’s terms, because of these and other characteristics, the state remains heavily involved in this sector even in advanced countries, through public financing, and provision or regulation or both, for the market is bound to fail. When returns to large investments accrue over the time horizon of many generations – and admittedly many governments – then it is only a progressive state that has the gumption to invest in such sectors.

Judging by its expansive discourse and promises, one could be forgiven for thinking this is precisely what the present government in India means to do. For structurally, the ‘demographic dividend’ advantage of a relatively young population, that it  also constantly waxes eloquent about, can only be realised if we have achieved decent health (and education) outcomes for the majority. It is the briefest window of time which, given the present dire state of malnutrition amongst children, and the fact that India is far from attaining any of the numerous health-related goals of the MDGs [3], lead many to suggest it is closed off already. Even discounting this view as needlessly grim, the Approach Paper to the XIIth plan itself concedes that health outcome indicators, such as infant mortality rates and maternal mortality rates, are weaker than they should be at this level of development (cf. Footnote 1).  So what does it propose to actually do, in its Health Chapter of the Approach Paper to the XIIth Plan [4]?

India has averaged 8% p.a. GDP growth rates over the XIth Plan period. And yet, its public spending on (core) health – combined Centre and State, plan and non-plan– has hovered around an abysmal 1-1.2% of GDP [5], one of the lowest in the world [6]. Where the XIth Plan still ostensibly aimed to increase this (core) amount to 2-3% by the end of plan period, the Approach Paper to the XIIth Plan settles for an avowed increase to only 1.58% by the end of the plan period. Why should this be the case, given that higher growth rates for the country are justified time and again as being necessary for fiscal room to spend more on social sector programmes?

And how is this possible, given the government has recently vocalised a desire to move towards universal health care for all, in which connection the Planning Commission of India constituted a High Level Expert Group (HLEG) of respected academics and practitioners, to deliberate and come up with the best way forward [7]. The logistical ‘how’ is threefold in the Health Chapter (August draft).

First, the Centre expects individual States to contribute increasingly to the funding of public health, which over the XIth Plan was roughly in the ratio of 1:2. The previous sharing formula for Centrally Sponsored Schemes, such as the National Rural Health Mission (NRHM), was largely in the form of a self-regulated MOU, which States progressively lived up to over the course of a plan period, depending on their fiscal capacities and levels of development. Such contributions would now be mandatory, in that a large part of the Central funding is conditional on higher investments by States.

The proposed new formula to determine the quantum of the flexible ‘incentive fund’ to each State still takes into account its health lag versus that of the national average. In so doing, it gives some weight to its developmental and poverty levels. But linking this amount to its own contribution, and to “agreed parameters of performance and reform in previous year’s sector wide MOU with the MoHFW” (p. 32, Health Chapter (August draft)) – whatever the latter refers to – penalises the worse off States, which are most likely to be cash-strapped and  have less room for manoeuvre for additional fiscal spend. In a federal system, States are in any case reluctant to own Centrally Sponsored Schemes, such as NRHM, because they are conceived of elsewhere and the political credit for them accrues to the government in power at the Centre.

In recognition of externality and equity issues in the provision of basic health care services at the national level, HLEG recommends “a substantial proportion of financing of these services can and should come from the Central government, even though such services have to be provided at sub-national levels” (p.11, HLEG 2011). Yes, States should not use Central contributions as a substitute for their own spending, as many have done so in the recent past, rather to complement it. But this peculiar form of forced ‘incentivisation’ coming out of a misplaced desire to straighten negotiation between Centres and States on the distribution of funding is likely to result in a poverty trap for poorer and less well governed States, and their hapless populations.

More confounding, given the evidence, is the proposal to follow the ‘managed-care’ model of health care provision, the beacon for it being the USA model. The latter is universally derided for being highly inequitable in provision, extremely expensive, and leading to relatively poor health outcomes, compared to other advanced countries. This despite the fact that the private sector is regulated to a far higher degree in that country and patients have recourse to expensive law suits in case of transgressions in delivery by them. What this model would mean in India is that large corporate networks would compete with public health institutions for public funds, to deliver packages of services (most outpatient care and hospital services) at cost to patients. If they cannot compete, as hitherto poorly funded and supported public sector health institutions are unlikely to be able to do so, they do not survive the Darwinian game. The public sector’s role in delivery of health care will be restricted to a minimal essential package, made up of basic child and reproductive care, as well as prevention and promotion roles. In short, the spectre of the private sector is to be unleashed on the public health delivery system.

Strong critiques of the proposed structural ‘privatisation by stealth’, including indisputable international evidence to show how such managed care models work over time to reduce choice in the range of (free) services on offer, and quality of care, have emerged from committed researchers and practitioners working in the public health sphere, so I will not repeat what they have said far better [8]. Indeed, the Health Chapter (August draft) itself admits the following: “…the system creates strong incentives for whoever is managing the network to minimise total cost… there is limited patient choice, and as such the quality of medical care provided has to be carefully regulated” (p.29, ibid.). I would like to focus instead, in conjecturing what could be the objective intellectual motivations for such a shift in policy, and in so doing, make some observations about public sector performance, quality, regulation and finally, rights and justice, in the Indian social sector context, and health care sphere in particular.

Is the shift driven by an argument about poor public sector performance in delivery in health care? If a researcher is objective and without ideological bias, they cannot deny that it has been lacking, which reflects in the dismal health outcomes in the country (noted previously), as well as the flight of those who can and who cannot afford it from the public delivery systems in health (and education). At 67%, the proportion or private out-of-pocket spending on health is sky high, and research has established that health expenses is one of the primary reasons for pushing households below the poverty line. But how can we best read this voting with one’s feet – or in this case – wallet?

Cross-country data on health expenditures show that a higher level of government spending on health is frequently associated with lower levels of reliance of a country’s health system on private out-of-pocket expenditures [9]. So if the quest is eliciting better performance, isn’t the answer to strengthen the public health care system after decades of below-minimal (forget-optimal) spending by the government on this sector? To completely emasculate and demolish it, on the logic that the private sector will force it to perform better or die out, reeks of rather strong ideological proclivities (of the Chicago School of Economics variety).

Is the idea that frontline providers in the public health care system, be they doctors or paramedical staff, are completely unaccountable and therefore, need the stick of private sector discipline to get in line? Again, any open-minded researcher and practitioner would be foolish to dispute widespread doctor absenteeism in public health care centres, especially in rural India, the system’s de facto privatisation through corrupt medical functionaries diverting patients to their ‘private clinics’ in the same compound, charging a fee for consultation and medicines etc. Indeed, I myself found that to be the case in 2008-09, when working on an evaluation of NRHM, as an independent researcher for the Planning Commission of India [10])!

But in the public health system’s defense, what do we expect from a huge cadre of contract and not regular employees, such as are currently employed in NRHM.  I refer here to doctors and paramedics, not even the accredited social health activists (ASHAs), itself a large cadre of underpaid and overworked ‘voluntary’ women workers, on whom the system exploitatively and cheaply depends [11]. The next question to ask is whether private sector employees would be more accountable? Specialist and super-specialist services in public health centres in rural Bihar are already contracted out to the private sector, and their employees behave as badly, if not worse, than their public sector counterparts. We come to the vexed question of asymmetrical geographical power and monetary incentives in a fully corporatised medical sector, because of course highly well-paid doctors in urban centres have to perform, in terms of showing up and working long hours, to the tune of profit-maximising payroll masters (and broke patients!)

If the idea behind this shift in policy really is to guarantee good performance and high quality in public delivery, a far better idea is to tie powerful people to the public health system in the country, and ensure they have a stake in its doing well, as we have all read and absorbed Hirschman’s classic 1970 treatise on ‘Exit, Voice and Loyalty’. A good beginning would be to somehow link CGHS benefits for all public sector employees – from the most junior to the most senior, as they are all relatively powerful in their own tiers and domains – to the public health care system alone. It will be remarkable how quickly we see an improvement in performance and quality of provision, were such a move undertaken. Additionally, legislation ought to be passed that the private costs of health care, as well as foreign costs of health care, for government and political functionaries, is not underwritten by the Government of India. This will countervail, to a significant extent, the argument that there is no fiscal room for additional social sector spending in these recessionary times, since the amount saved will add to the ability to do so (cross-subsidisation of sorts, always a decent redistribution tool).

Further, is the government willing and able to rein in and regulate the private sector in general? For as the Health Chapter (August draft) itself acknowledges, any kind of privatisation in the provision of health care, such as the managed-care model, has to be carefully and heavily regulated by the government. So far, it is unable to stem empanelled doctors and hospitals from gaming the system and performing unnecessary hysterectomies, in rural and small-town India, the costs of which are reclaimed through the Rashtriya Swasthya Bima Yojana insurance scheme (which we will come to shortly). In subaltern India, it will also find it hard to enforce necessary emergency caesareans be performed, in a managed-care model whose financial imperative act to cut free services over time, especially those of a more expensive nature. Moral hazard and adverse selection are going to be rife in this system, as is the complexity of information and understanding needed sidestep them. Such information asymmetry problems are known to be much worse for poorer and illiterate women, and other subordinate groups, so it will be the government’s duty to safeguard their rights if it is the one foisting this market on them.

What about the argument that the public delivery of health care is irrevocably interwoven with large-scale corruption, such as recently publicised about NRHM in Uttar Pradesh, and therefore, what is the harm in trying the private sector alternative? First, this is not universally true across states of India, as anyone with a passing knowledge of Tamil Nadu and other well performing states’ social sector programmes will counteract. Second, a sophisticated understanding of corruption as also including unilateral power to behave with impunity, especially in today’s India, suggest the  private sector will be allowed to get away with ‘corruption’ on an equally, if not larger, scale than the public sector. In Delhi itself, the post-Imperial capital, the government is unwilling or unable to ensure that powerful private hospitals, who have obtained government land on the condition that they admit a certain percentage of patients from economically weaker sections (EWS), actually do so. It is also turning a blind eye to the hidden but increasing private medical trials industry that is mushrooming in the country.

Privatisation of an entire system is not something that can be easily – or at all – rolled back, in our Age of Capitalism. How hard it is to stuff the genie back in the bottle, in the face of greedy corporates and powerful lobby groups, is something the NHS is set to find out soon in the United Kingdom, just as numerous Presidents of the USA did when trying to reform its deeply flawed system, and ironically, as Obama has fought hard to do in recent times. So before this massive step is taken, let us think very carefully as a nation, especially as our levels of development and health achievements are far worse than that of these countries.

Finally, if privatisation and PPPs are something the government needs for faster growth, as signals to attract FDI and keep the stock market bullish, why not fully privatise numerous other sectors, such as large-scale infrastructure, construction, airlines operations etc.? Let these be riven with ‘efficient corruption’, in the Shleifer and Vishny sense, or not, in which case they can keep rooking on cost, quality and timing, with need for repeat delivery at short intervals etc. (it will keep the aggregate demand high, in any event!) Let the opportunity to earn supra-normal profits, via monopolies and even natural monopolies, be with the private sector alone (not even PPPs). For they matter – relatively – little to the social contract of the state, with its citizens, other than cutting the government’s revenues in earnings.  If something has to be ceded from the public sector portfolio in the India of 2012, to keep it on the conveyor belt of growth, let it be these areas. In lieu, ring fence public spending and the public provision of basic needs, such as health care (and education), for not only are these instrumentally important to achieve ‘inclusive growth’, if we really mean to, but they are constitutively important, to ensure the majority of citizens in a democracy have capabilities to lead a flourishing life.

The less said about the third ‘how’ of financing universal health care, via insurance, in the Health Chapter (August Draft), the better. International evidence is overwhelmingly of the view that this is not possible, and numerous early academic and evaluation studies of the Rashtriya Swasthya Bima Yojana (RSBY) insurance scheme show its many flaws. These are acknowledged by the Planning Commission: “They [HLEG] have also noted the problems with reliance on a market oriented, “fee for service model”, based on insurance in which the premium is paid by the government. This creates incentives for unnecessary curative care and a consequent spiraling of costs (p. 29, Health Chapter (August draft)). And still, it proposes to expand it across the entire BPL population of the country, to numerous other unorganised sector worker groups and so on.

If all these suggestions and the associated policy push are not coming from theory or empirical evidence, then where are they coming from? Unless one were party to inner policy formulation deliberations, it is hard to say. The Health Chapter (August draft) places the full onus on the origin of the managed-care model recommendations with the HLEG. The HLEG 2011 does suggest a networked system at the district level, leaving itself wittingly or unwittingly open to such misinterpretation, as activists feared. If news reportage is correct, there is an on-going debate and disagreement between the Ministry of Health and Family Welfare, and the Planning Commission of India, on the proposed changes. As an outsider, it is again hard to keep track of the exact nature of the differences, and how they are being negotiated, day by day. Therefore, the broader political economy ‘how’, of the eventual form of the Health Chapter (August Draft) in the final approved Approach Paper to the XIIth Plan, is still an open-ended one.

As Buchanan and Tullock (1962) famously noted, government and the bureaucracy is not a monolithic, uniform black-box of an actor, and is rather made up of individuals, their idiosyncracies, their failures, their incentives, their propensities to act in certain ways. So we are yet to see where the chips eventually fall on the policy front, as regards proposed changes to the public health care system. But I will appeal to the higher selves of those determining the final version of the Health Chapter, in the Approach Paper to the XIIth Plan, whomsoever they be, to rather act to strengthen its many good ideas, some drawn from bright  people working within the government and others from HLEG 2011, on the expansion of regional AIIMS-like institutions across the country, medical education in the public sector, the provision of free essential generic medicines, the regulation of private sector quacks through accreditation and so on. This is your and our moment, this country’s moment, if it really aspires to being just, fair and ‘inclusive’.

To remind public sector naysayers, within and outside the government, health care is not a normal commodity in many respects (neither is education). Both are linked to fundamental needs and aspirations of the people, what it means to be human, in essence, and as a social animal, a community. A catastrophic illness in the poorest family will compel them to spend all their money, even money they do not have, on the slim chance of survival for one of its members. The desperation of the poor to better their situation and become upwardly mobile – though that is semantically a misleading gradient, too opulent at that standard of living – is what compels families to enroll their children in schools, as they are doing in droves at present in India, against every socio-economic odd and every geographical constraint of vast distances between remote hamlets and providers. Such aspiration is only going to grow in our country today, because of what the media and every single sensory source in our Age of Information Overload is consciously projecting as our country’s shining future.

If the judiciary is increasingly recognising and legislating on rights in the social sector sphere, surely the government ignores them at its own peril in a democracy? And if it is going to do so, let us forget all this humbug about faster growth being pursued to better the lot of ‘the common man’. Let us openly acknowledge that evidence-base and ownership by academics, activist and civil society groups matters not a whit to eventual policy formulation. Let us not attempt to co-opt all dissenting voices, by soliciting their views in endless committees and platforms, while proceeding exactly or even worse than before (such as a supposed desire to move towards universal health care, disguising all sorts of sins of omission and commission), for it is more cynical an act than never having consulted them at all. And let us be prepared politically for the consequences of systematically and knowingly ruling out the possibility of the majority ever being able to participate in a democracy’s so-called ‘success story’, of growth alone. Pursued for its own sake, it is to be a private celebration for an exclusive few.

(Kaveri Gill is an independent academic and researcher based in Delhi. The views expressed in this piece are the author’s own and are independent of any professional institutional affiliation she holds, past or present).


[2] So is education, especially elementary education.

[3] On the primary education side, too, there has been an increase in enrollment and fall in drop-out rates in recent years, but grave questions remain about the actual learning levels and quality of education.

[4] I allude in this piece to an August draft of the proposed Health Chapter of the Approach Paper to the XIIth Plan, which is at present being finalised by the Planning Commission of India. It shall forthwith be referred to as the Health Chapter (August draft). Since there are many drafts and it is a work in progress, figures may differ slightly in citations of different versions by various authors.

[5] These figures vary by source, but the range remains as stated. Public spending increases marginally, if spending on co-determinants of health, such as water, sanitation etcetera, is included.

[6] At 19%, public spending on health as a percentage of total health expenditure is also lower in India (WHO 2007 & 2008) than all South Asian countries, except Pakistan (Sri Lanka: 46.2%; Bangladesh: 29.1%; Nepal: 28.1%; Pakistan: 17.5%), let alone China (38.8%) and Brazil (44.1%). Interestingly, Europe (Germany: 76.9%; France: 79.9%; UK: 87.1%) – with its tradition of welfare states – far outshines the USA (45.1%) in this respect.

[7] It produced, “High Level Expert Group Report on Universal Health Coverage for India” (November 2011), forthwith referred to as HLEG 2011.

[8] Inter alia, “Dangerous Drift in Health Policy – Jan Swasthya Abhiyan Action Alert” (August-September 2012) maybe be accessed at: http://www.scribd.com/doc/103888531/Jan-Swasthya-Abhiyan-Action-Alert; “Setting up Universal Health Care Pvt. Ltd.”, Rakhal Gaitonde and Abhay Shukla, op-ed in The Hindu, 13 September 2012).

[9] Much also “depends upon the specific way the additional public spending is pooled and spent. Prepayment from compulsory sources (i.e. some form of taxation) and the pooling of these revenues for the purpose of purchasing healthcare services on behalf of the entire population is the cornerstone of the proposed universal healthcare…[it] is essential for ensuring that the system is able to redistribute resources and thus services to those in greatest need…both theory and evidence [shows] that no country that can be said to have attained universal coverage relies predominantly on voluntary funding sources (p. 9, HLEG 2011).

[10] “A Primary Evaluation of Service Delivery under the National Rural Health Mission (NRHM): Findings from a Study in Andhra Pradesh, Uttar Pradesh, Bihar and Rajasthan”, Gill 2009, Working Paper 1/2009 – PEO, Planning Commission of India.

[11] This trend for contractual employment to do the same job, in the public and private sector in India (the distribution of regular to contractual workers in Maruti Suzuki’s factory in Manesar is a good example of the latter), can also be traced to the many labour market perils of unfettered globalisation and capitalism.

27th Ramanadham Memorial Meeting: Public Health, Inequality and Democratic Rights


The late sixties marked the first major crisis of independent India at all levels of its
economy and polity. This crisis gave birth to radical movements. Among these
were the tribal and peasant struggles led by Marxist Leninist parties. Brutal state
repression was launched on these movements. Regional civil rights
organisations arose as a response to the various illegal modes of repression. Thus in
1974 Andhra Pradesh Civil Liberties Committee [APCLC] was founded in
Andhra Pradesh.

Those were the times when A. Ramanadham, a medical doctor by profession,
founded one of the district units of APCLC in Warangal town.
Born in Mustikuntla, a small village in Khamman district in 1933, he started his
career as a government doctor. Dissatisfied with the unethical medical practices, he
left his job and set up his own Children’s Clinic in 1968 in Warangal. That year
marked the beginning of his involvement in various social issues. The clinic was to
become, perhaps, the only democratic centre in the entire town.
In June 1975, Emergency was imposed institutionalising the ongoing repression. Dr.
Ramanadham, along with other activists, were arrested. After lifting of
Emergency APCLC was able to function again. Dr. Ramanadham became its
Vice President.
Civil rights organisations that had earlier been confined to their own regions and
histories, began to share information and experiences. Joint investigations into
repression on worker and peasant struggles and joint campaigns on repressive
laws. In this process of building fraternal relations PUDR came to know the work of
Dr. Ramanadham. And to appreciate his gentle friendliness and modesty

Dr. Ramanadham’s involvement with civil liberties was inseparable from his
professional role as a doctor. In fact, his professional role helped the civil rights
movement which, in turn, made him a better doctor. It helped him to understand
the social origins of the diseases of his patients He did not confine himself to
giving medicines but tried to spread a scientific outlook. Out of this came his
famous book in Telugu, Medical Guide which was addressed to the people and not
to health workers.
Dr. Ramanadham tried to create a space for democratic values wherever he went
and in whatever he did. Struggling against corrupt medical practices in a health
centre in Husnabad, helping friends to bring out a revolutionary literary journal in
Warangal, helping a young girl and conducting her marriage against the will of her
influential parents, organising a people’s clinic with the help of doctors on strike in
front of Warangal -Government Hospital, are examples of Dr. Ramanadliam’s
involvement and initiative in democratic concerns

In the late seventies peasant struggles for higher agricultural wages and against
landlord repression spread in Warangal and other districts Police was given extensive illegal powersto repress these struggles. Governments kept changing  but state violence continued. With APCLC, Dr. Ramanadham was actively involved in investigating fake encounters, custodial torture and deaths. This earned  them the wrath of the police

On 2nd September 1985, at Kazipet railway station, SI Yadagiri Reddy was shot
dead by unidentified assailants, believed to be naxalites. Next morning his body
was carried in a funeral procession in which a number of armed policemen
participated. The procession was led by the district Superintendent and the Deputy
General of Police. When it neared the Children’s Clinic, a group of policemen
broke into the clinic. They ransacked the clinic and assaulted the compounder and
waiting patients. Then they went into the neighbouring shop, Kalpana Opticals,
where they found Dr. Ramanadham and shot him at point blank range.
Immediately after, a neighbouring doctor took him to Mahatama Gandhi Memorial
Hospital, about two kilometres away. Soon after he was declared dead. With his
death the Warangal unit of APCLC” ceased to function
Four days after his death, police filed a second FIR in the Yadagiri Reddy murder
case, the first murder case to be registered under TADA in Warangal. Dr
Ramanadham was named as accused. However, in the case of the murder of Dr.
Ramanadham, no accused were named. Police maintained that naxalites were
responsible and they had used snatched police revolvers. Two policemen were
suspended for dereliction of duty as their revolvers had been snatched
Barely a year later J. Laxmareddy, President of the Karmmagar unit of APCLC
was killed by police on 7 November 1986. The Warangal unit was revived with
the efforts of N. Prabhakar Reddy who became its convenor. A lawyer by
profession, he was instrumental in obtaining bail for hundreds of rural youth
charged under TADA. On 7 December 1991, police came to his house and shot
him dead.
The murders of civil rights activists are not random acts of violence by a few
deviant policemen. These are part of a larger political policy of the government
against the people. Perhaps the only meaningful way of remembering Dr
Ramanadham is by committing oneself to the movement for democratic rights
and affirming our faith in people’s struggles to implement and extend these
rights.

People’s Union for Democratic Rights (PUDR), Delhi

Invites you to attend

27th Ramanadham Memorial Meeting

Public Health, Inequality and

Democratic Rights

Speakers:

Dr. Yogesh Jain

Jan Swasthya Sahyog

Topic: Social Inequality and Public Health

Dr. Jacob Puliyal

St. Stephens Hospital, Delhi

Topic: Immunization Programmes and Public Health

Dr. Amit Sen Gupta

People’s Health Movement

Topic: Drug Policy, Pricing and Public Health

Chair

Dr. Ritu Priya Mehrotra

Centre for Social Medicine & Community Health, JNU

8th September, 2012

5 pm – 8pm

Conference Hall

Indian Law Institute

Opp Supreme Court

Bhagwan Das Road

New Delhi

Film on how a dalit women’s collective rose up against the failing public health system #Mustwatch


 

Directed by-Vijaya Kumar

Produced by : Jagruti (http://www.jagruti.org )

Duration :23 mins

Language:Kannada with English subtitles.

Synopsis of Guna Mukhi 

GUNA MUKHI, reconstructs the narrative of how a dalit women’s collective in a small village in Belgaum district.Karnataka, defied class, caste and gender barriers and rose up against the failing public health system.

The film draws from the rich and first hand experiences of the village women who, with the support of various village level peoples’ organizations and activists, stake claim to their health entitlements.

The film concludes by asserting the importance of people’s struggles in creating a functional, responsive, people-centric health care systems and in the larger context of holding the State accountable for its duties and responsibilities towards its citizens.

This film was one of the outcomes of the efforts to address the issue of health as a human right and taking forward the issue of revitalizing the public health system by various state and national level networks and activists.

Karnataka state unit of the People’s Health Movement(JAA-K) screened this film extensively to intensify their Health as a Human Right campaign. It was used in various training programs for health activists who found the film inspiring and drew ideas from it to carry out similar actions to get their local government health centers functioning.

 

Free Online Harvard School of Public Health Course on Clinical Research


This year  Swati Piramal was elected to the Harvard Board
of Overseers, a 350 year old governing board of Harvard University
for a term of 6 years. She has been frequently asked how that would
benefit her own country. She wanted to bring the best of Harvard to
India and as a first step has ensured the initiation of a Free Online
Course on Clinical Research.

 

One of the big shortages we have in Indian science is the lack of
research curriculum in our medical training. India has over 900,000
doctors but few are trained to be physician scientists. This is a
glaring gap in our country. Medical doctors trained in the science of
quantitative methods can become top professionals in clinical research
and become investigators for trials. Some months ago, Swati mooted the
idea of training for doctors in research methods to the Harvard School
of Public Health and was pleased that they responded with the first
ever Edx course in Clinical research  which is online training in
Quantitative Methods in Clinical and Public Health Research.
This course has got a huge worldwide response, with over 10,000 people
already registered.  Swati’s personal goal is to enroll at least 2000
doctors /health professionals/ students interested in research, from
India for this introductory course, which is free. The faculty is
world class and have made a great contribution to global health.

Please get as many people to enroll as possible. Share this  with
others who may be interested in clinical research. Please help to
circulate to faculty/ students and others interested in research.

Free Online Harvard School of Public Health Course on Clinical
Research Premieres in October for a Global Audience

To learn more about the free, three-month online course and to sign
up, go to the following web address:
https://www.edx.org/courses/HarvardX/PH207x/2012_Fall/about

How to register.

Anyone can register for this course at the following address.

https://www.edx.org/courses/HarvardX/PH207x/2012_Fall/about

The Course Number is  PH207x

Classes Start Oct 15, 2012

Classes End Jan 18, 2013

People interested in taking the course should estimate that it will
require about 10 hours per week of effort.

About the Faculty

The course is taught by two well respected Harvard School of Public
Health professors, Earl Francis Cook and Marcello Pagano.

WHO’s role in documenting attacks on health workers and facilities


Public Health Dentistry

Public Health Dentistry (Photo credit: Trinity Care Foundation)

World Health Assembly adopts resolution on WHO’s role in documenting attacks on health workers and facilities

Wednesday, 30 May 2012

 

At the 65th session of the World Health Assembly last week, an important resolution was adopted on WHO leadership in collecting and disseminating data on attacks on health care in complex humanitarian emergencies.

 

Health providers are on the frontline during complex humanitarian emergencies. They, as well as their patients, deserve protection. However, in situations of crisis and armed conflictt, health-care workers are at greatest risk of assault, arrest, obstruction of their duties, kidnapping and death. Health facilities and ambulances are also at risk of attack.

 

Complex humanitarian emergencies

Resolution (EB130.R14) is titled WHO’s response, and role as the health cluster lead, in meeting the growing demands of health in humanitarian emergencies. Among others, this resolution states “that there is a need of systematic data collection on attacks or lack of respect for patients and/or health workers, facilities and transports in complex humanitarian emergencies.”

The resolution thus calls on the Director-General of WHO: “… to provide leadership at the global level in developing methods for systematic collection and dissemination of data on attacks on health facilities, health workers, health transports, and patients in complex humanitarian emergencies, in coordination with other relevant United Nations bodies, other relevant actors, and intergovernmental and nongovernmental organizations, avoiding duplication of efforts.”

 

FOR IMMEDIATE RELEASE: May 29, 2012
Contact: David Nelson, IntraHealth International, tel. 919-313-9139

May 29, Washington, DC—The Safeguarding Health in Conflictcoalition commends the World Health Assembly—the governing body of the World Health Organization (WHO)—on its unprecedented step to protect the lives of health workers and patients in humanitarian crises by spearheading global efforts to document the number of attacks on medical services.

In violent conflicts, where health needs are most urgent, health workers are at risk of assault, arrest and sometimes kidnapping and death, compromising their ability to deliver care and remain on the job. But such attacks usually go unreported; with a body of evidence, the global community can better protect fragile health systems and those on the frontlines. “Systematic data collection will be the basis for developing prevention strategies and holding perpetrators accountable,” said Maurice I. Middleberg, vice president for global policy at IntraHealth International.

The Safeguarding Health in Conflict coalition urged passage of the new World Health Assembly resolution—requiring the WHO to lead international data collection of attacks on health workers, facilities, transports and patients—for more than a year, and on Friday, WHO member states at the 65th  World Health Assembly in Geneva adopted it.

Health care services and the health workers who provide them are never more desperately needed, but never more vulnerable, than when violence convulses a society,” said Leonard Rubenstein, senior scholar at the Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health.

Numerous organizations joined coalition members in a statement encouraging the WHO member states to adopt the resolution so that the work of developing methods to collect data and report on attacks can commence. The statement was made on behalf of the World Health Professional Alliance, which includes the World Medical Association, International Council of Nurses, International Pharmaceutical Federation, World Confederation for Physical Therapy and World Dental Federation, and the statement was supported by the American Public Health Association, CARE, Center for Public Health and Human Rights at the John Hopkins Bloomberg School of Public Health, Doctors for Human Rights, International Health Protection Initiative, International Federation of Health and Human Rights Organisations, International Medical Corps, International Rehabilitation Council for Torture Victims, International Rescue Committee, IntraHealth International, Management Sciences for Health, Medact, Merlin, Physicians for Human Rights, Women’s Refugee Commission and World Federation of Public Health Associations. Going forward, the coalition will advocate for effective implementation of the World Health Assembly resolution.

The Safeguarding Health in Conflict coalition promotes respect for international humanitarian and human rights laws that relate to the safety and security of health facilities, workers, ambulances and patients during periods of armed conflict or civil violence. Founding members include IntraHealth International, Center for Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health, Doctors for Human Rights, International Council of Nurses, International Health Protection Initiative, Karen Human Rights Group, Medact, Merlin – UK and Physicians for Human Rights.

Immediate Release-Jan Swasthya Abhiyan Calls For National Debate for ‘Universal Health Care’


Press Statement on the occasion of World Health Day – April 7th 2012

Jan Swasthya Abhiyan Calls For National Debate On Design Of Proposed System For ‘Universal Health Care’

Ensure quality, free health care for all as a right: Give priority to expansion and improvement of Public health services, regulate Private medical sector

Over the past year there has been a lot of interest in and visibility of the concept of Universal Health Care. The Planning commission had set up the High Level Expert Group (HLEG) on Universal Health Care (UHC) which has submitted its recommendations in Nov. 2011. The Planning Commission is now considering implementation of Universal health care in some form during the XIIth Five year plan. JSA welcomes this interest and commitment to Health care for All by the Government of India. On the occasion of 7th April, 2012 World Health Day, JSA would like to set out clearly our views on the issue as well as express serious concern with the direction in which the discourse on Universal Health Care seems to be taking.

THE HLEG AND PLANNING COMMISSION STEERING COMMITTEE REPORTS

The JSA welcomes a number of key aspects of the HLEG-UHC report. Most importantly we appreciate:

 The emphasis on the concept of “universal”, of including every citizen, unlike the currently dominant approach of “selective” approach of targeting the poor

 Clear emphasis on tax-based financing of the health system, rejection of insurance in the financing and provisioning of universal health care.

 Recommendation to abolish user fees in the health system.

 Definite commitment to “Free Medicines for ALL” in the Public Health System.

 Recommendation of strengthening and the expanding the public sector

 Recommendation to establish Urban UHC system.

Defining the need and urgency of private sector regulation, as well as outlining a potential regulatory structure.

 Bringing Community based accountability mechanisms to the center stage.

More recently the Steering Group on Health of the Planning commission finalized its report which incorporates (interprets) the findings of the HLEG into the Planning Commission process. However the Steering committee report contains recommendations that would defeat the purpose and spirit behind any evolving process of Universal Health Care.

 The reduction of the comprehensive Essential Health Package suggested by the HLEG into just RCH and National Health Programes. This is NOT a Universal health care entitlement.

 The concept of giving financial and operational autonomy of the public health facilities is also very problematic. Financial autonomy means leaving the public health system to “fend for themselves”. This will be very damaging to any hopes for a Universal System.

 The concept of “provider choice” to choose between private and public providers is also unacceptable. Especially during last 20 years, the public health system has been neglected and made sick whereas the private sector has received encouragement for un regulated growth.

 JSA believes that the private sector should play a complementary / supplementary role, on the terms defined by a strengthened public health system accountable to the people.

 Steering Committee report suggests that one district in each state pilot this concept in the first year of the plan. We would strongly suggest that the unit of pilot should logically be the state, and more over that such pilots be initiated only after full discussion and public debate.

JSA’s VISION FOR A UNIVERSAL HEALTH CARE SYSTEM

We firmly believe that the public health system has to be the back bone of any universal health system. Our emphasis should be on strengthening of the Public Health system, especially the primary level of care. The public sector should be brought up to its full functional capacity and expanded.

The private sector needs to be involved in the UHC system only on the terms of public good. Integration of the public and private sector is to be seen in terms of an integration of the “logic” of the health system. Corporate profits should not be allowed to lead or define health provision. The health system has to be effectively and transparently regulated with its primary goal being the people’s welfare rather than private profit. It is only under such circumstances that we can develop a UHC system that will truly serve the needs of the people equitably.

UHC system should be based on tax based financing. Present models of publicly financed commercial insurance (such as Arogyasri scheme in Andhra Pradesh) have proved to be highly problematic in terms of scope and rationality of care, and become financial drain on the exchequer without delivering anything like Universal health care.

The governance of the whole UHC system must be firmly people centered and rights based, with a community led and focused process. We visualize institutionalizing a process of community based monitoring, planning and action for health which is evolved based on experiences in a number of states of the country in which JSA partners are involved.

Jan Swasthya Abhiyan call for action on Universal Health care

Given this situation the JSA calls for the following:

 A national public debate on the contours of the proposed universal health care system. Such an important issue cannot be rushed through and its various strands need to be understood, discussed and commented upon widely by the people.

 Definition of a clear, transparent and time bound road map for strengthening and expanding the public health system while improving its functioning and accountability; this must include allocation of adequate, enhanced budgets.

 Enactment of adequate laws guaranteeing the right to health, including National and State Health acts, which would lay down the framework for regulation of the health system, particularly relevant for private medical providers. Providing entitlements must be accompanied by a clear framework for accountability and grievance redressal.

 While developing and operationalising the universal health care system, highest priority must be given to significant expansion and improvement of public health services. Regulated private providers should not be competing with public providers for common resources, rather they may be in-sourced to provide services, but never as a substitute to the public sector.

 Ensuring forums for participation of community members, community based groups and civil society organizations along with elected representatives and public health functionaries at various levels, for planning, monitoring and reviewing the functioning of the universal health care system.

We must be aware that the direction of developing universal health care in India must be towards strengthening the public health system and socialization of health care, rather than promoting further expansion of unregulated, profit-oriented private medical care. Hence a national debate is essential and there should be no haste in rolling out these concepts – even the looming large of the General elections should not become an excuse for the government to short circuit and distort the concept of Universal Health Care for narrow political gains.