#India- Rakku’s Story: Structures of Ill-Health and the Source of Change #Freedownload


Cover of Rakku's Story

This book turns the usual approach to health analysis on its head. It begins by looking at continuing ill-health in India through the life of a labouring village woman, exploring the forces which keep her from adequately feeding and caring for her children and herself. It probes the source of ill-health, not by focusing on missing nutrients, drugs or skills, but by looking at the way disease and malnutrition are distributed in society – an approach which necessarily sheds light on the distribution of food and all resources, and thus also, the distribution of power. Inequalities within the existing healthcare system thus become a window on the structures and forces operating throughout society.

This study takes ill-health out of the medical realm into the arena of poverty and powerlessness. It analyses that poverty within a social and political context, not as an immutable or inevitable situation but rather as the result of specific and historical forces in process in the country. It argues that the existing socio-economic order which perpetuates underdevelopment, contains within it an inherent ill-health “logic” as well. Such a perspective demands a re-assessment of the relevance of current “primary health care” activities in the country.

The purpose of the book is to shift the attention and efforts of health workers to the poverty – dependency – ill-health dynamic, and to suggest how issues of ill-health can be used to strengthen the broader struggle by the labouring poor for health and social justice.

The file is 96.7 MB so it might take some time to download on slower connection.

FREE DOWNLOAD FULL BOOK

Anybody ill here and seen a doctor yet?


 

KRISHNA D. RAO,  The Hindu

 
GLOOMY PROGNOSIS: For the hardship that rural doctors have to endure, government service offers relatively little in terms of quality of life. Photo: Singam Venkataramana
The Hindu
GLOOMY PROGNOSIS: For the hardship that rural doctors have to endure, government service offers relatively little in terms of quality of life. Photo: Singam Venkataramana

Addressing the scarcity of medical practitioners in rural India is fundamental to achieving universal health care in the country

The Planning Commission’s draft 12th Plan for health has attracted much debate and controversy. Critics have been quick to direct their attention at two issues in it — the proposed increase in government health spending from one per cent to 1.58 per cent of GDP, and the “managed care model.” The spending increase was rightly felt to be grossly inadequate to move India towards achieving universal health care. The “managed care” model was expected to relegate the government’s role to a purchaser of services and undermine its role in the service provision. By focusing on these two issues, the debate on the 12th Plan for health, and indeed the Plan’s approach paper itself, ignores some of the more fundamental obstacles to achieving universal health care in India. For one, the scarcity of rural doctors currently prevents the delivery of even basic clinical services to needy citizens. Simply spending more or changing the way health services are purchased will not solve this problem.

Urban-rural divide

People deliver health services. Urban Indians can be forgiven for thinking that there are enough doctors in the country. Indeed, our cities are abundant with all manner of clinics, diagnostic centres and hospitals. But having a qualified doctor nearby is a rarity for the vast majority of Indians who inhabit the country’s rural spaces. According to the 2001 Census, there is a tenfold difference in the availability of qualified doctors between urban and rural areas i.e. one qualified doctor per 8,333 (885) people in rural (urban) areas of India. Addressing this rural scarcity is fundamental to efforts for achieving universal health care in India.

There are several notable reasons why doctors are reluctant to serve in rural areas. Fundamentally, the professional and personal expectation of medical graduates is not compatible with the life of a rural doctor. Their ambition lies in becoming medical specialists. Once they specialise, the professional, income, lifestyle, and family life opportunities in cities make rural jobs unattractive. Moreover, with private medical schools and their high fees dominating medical education, it makes little sense for medical graduates to take up jobs that don’t offer them the opportunity to recover their investment.

The scarcity of rural doctors places an important responsibility on the government. However, its efforts to place government doctors in rural posts have been largely unsuccessful. For the hardship that rural doctors have to endure, government service offers relatively little in terms of remuneration, quality schooling for their children and a chance at a decent family life. Human resources in the State health services are also poorly managed.

For instance, there is little transparency about transfers and postings because they are a source of both corruption and political patronage in the health system. Absenteeism is another issue. Indeed, most of the court cases facing State health departments have to do with human resource issues. However, given the professional and personal expectations of doctors, it appears unlikely that large increases in salaries and management changes will attract adequate numbers to government jobs and rural posts.

Situation abroad

Interestingly, many high, middle, and low-income countries also face a scarcity of rural doctors. Many of them have ameliorated this problem by using non-physician clinicians to deliver basic health services. In the United States, the United Kingdom, many countries in Africa, and even in South Asia, individuals such as nurse-practitioners or medical assistants, who have some years of basic clinical training, perform many of the clinical functions normally expected of fully qualified doctors. In sub-Saharan Africa and many parts of Asia, clinical services in rural areas are possible only because of these non-physician clinicians. They provide a range of clinical functions, including basic clinical services, manage deliveries, caesarean sections and abortions. Importantly, assessments from a variety of settings have shown that they perform as well as doctors.

Clinician cadre

India, however, has had an uneasy relationship with mid-level clinical cadres. At the time of India’s independence, licentiate medical practitioner (LMP)s, who underwent three years training, comprised nearly two-thirds of the qualified medical practitioners (the other one-third being doctors) and they mostly served in rural areas. LMPs were abolished after Independence but doctors never really occupied the space that LMPs vacated. Now, the shortage of rural doctors has forced some States to look towards non-physician clinicians for relief. Clinicians with around three years of clinical training currently serve at government rural health clinics in Chhattisgarh and Assam. Importantly, assessments of their performance in Chhattisgarh have shown them to be as competent as doctors for delivering basic clinical care. And because their training focuses on serving as rural clinicians and their career ambition is to have a government job, these clinicians, as the Chhattisgarh experience shows, have a greater likelihood of staying and serving in rural areas. The Central Health Ministry has proposed to expand this clinician cadre nationally through the Bachelors of Rural Health Care (BRHC) course. Unfortunately, expanding this cadre has met with considerable opposition and a former health minister even labelled them as “qualified quacks.”

The road to universal health care in India necessarily requires a serious assessment of basic problems that afflict the health system like the lack of human resources in rural areas. While this piece has focused on doctors, the rural scarcity of other health worker cadres such as nurses, lab technicians and pharmacists is equally acute and equally deserving of serious attention.

Higher government spending on health or how health services are purchased will do little to ensure that all Indians have health care if there are inadequate numbers of trained health workers with the right skill mix. The experience of other countries and two States in India show that non-physician clinicians, whether they are three-year trained clinicians or nurse-practitioners, can be part of the solution.

(Krishna D. Rao is senior health specialist, Public Health Foundation of India, and visiting faculty, Department of International Health, Johns Hopkins University, U.S. The views expressed are solely his and not of his affiliated institutions.)

 

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.

Archives

Kractivism-Gonaimate Videos

Protest to Arrest

Faking Democracy- Free Irom Sharmila Now

Faking Democracy- Repression Anti- Nuke activists

JAPA- MUSICAL ACTIVISM

Kamayaninumerouno – Youtube Channel

UID-UNIQUE ?

Enter your email address to follow this blog and receive notifications of new posts by email.

Join 6,234 other followers

Top Rated

Blog Stats

  • 1,760,118 hits

Archives

September 2019
M T W T F S S
« Jun    
 1
2345678
9101112131415
16171819202122
23242526272829
30  
%d bloggers like this: