Review of Healthcare in India

edited by Leena V Gangolli, Ravi Duggal and Abhaya Shukla; Cehat, Mumbai, 2005; pp 330 + S-45, Rs 250 (soft bound).

Health and Healthcare in Maharashtra: A Status Report

by Ravi Duggal, T R Dilip and Prashant Raymus; Cehat, Mumbai, 2005; pp 67 (price not mentioned).

KANNAMMA RAMAN

T

he anthology edited by Leena Gangolli, Ravi Duggal and Abhaya Shukla was compiled to support the activities of the People’s Health Movement – India (‘Jan Swasthya Abhiyan’). The book brings together a broad gamut of issues and possesses a certain ideological clarity. However, the rationale for the classification and sequencing of articles is ambiguous. For instance, the book shifts focus from macro issues such as health systems to very specific ones like healthcare for children and programmes like immunisation, and then back to the broader issues like health financing and regulation of the pharmaceutical industry. There is also considerable overlap and repetition, and the statistics presented in the articles are not always in an agreement with one another. Careful editing would have ironed out discrepancies, including those in spelling authors’ names in the index, and made the volume compact.

Health Policy and Access to Healthcare

The introductory article by Ravi Duggal and Gangolli summarises the basic features of public health services in India and provides an outline of the book under review. Duggal and Ritu Priya’s articles give an overview of the healthcare system and policy in India. Duggal traces the shift from what he calls the golden days of public health in the 1980s to the days of retreat in the 1990s. Ritu Priya’s article contextualises the public healthcare system within the larger issues of development, and the deliberate decision taken at the time of independence to accept the technological and biomedical intervention model currently in vogue. This decision has proved the cause of a number of subsequent problems, as highlighted by several authors in this book.

Ritu Priya also provides a review of the public health reforms launched by the states. Duggal and Ritu Priya’s articles reveal that, with the sole exception of Kerala, decentralisation has merely been an attempt to delegate duties rather than devolution of powers. Hence, it is hardly surprising that despite attractive slogans like “people’s health in people’s hands”, the real needs of the people have not been met. Ritu Priya also highlights the misplaced priorities of premier research bodies such as the Indian Council for Medical Research and the National Institute of Nutrition.

Ravi Duggal’s article in the section on “Health Systems and Resources” validates the argument that India’s investment in the public health sector has been dismal, and that a more equitable distribution of health resources across various regions and sub-regions could have improved access. What is alarming however is that, as T R Dilip points out in his article ‘Extent of Inequity in Access to Healthcare Services in India’, 40 per cent of those seeking in-patient treatment in the public sector services in rural areas and 21 per cent of such people in urban areas are falling into debt (involving borrowing/sale of assets) due to out-ofpocket expenditure. It is likely that this is, to a large extent, a result of the so-called health reforms initiated due to pressure exerted by the international financial institutions (IFIs).

Dilip reveals (with suitable statistical data) gender, caste and class based inequities that persist in India. While he has analysed a number of issues, several statistical details have not been given due attention. For instance, how does one explain the fact that morbidity is marginally higher among females than among males in both rural and urban areas, although it is generally noticed that the weaker sections of society do not seek treatment either due to lack of funds or poor healthcare consciousness. Similarly, the data on sources of outpatient treatment (1995-96) reveals that those in the lower 25-50 monthly per capita expenditure (MPCE) quartile in both urban and rural areas are more likely to seek healthcare from the private sector than those in the higher 50-75 MPCE quartile (p 254). The rationale behind this trend needs to be examined. Likewise, the data on average inpatient medical expenditure incurred reveals that the average medical expenditure in rural areas incurred by scheduled castes is much higher than that for others seeking care from the private sector (p 256). If the NSS data is correct, then an explanation for the same needs to be given.

The article by Gangolli and Gaitonde (‘Programme for Control of Communicable Diseases’) is vital in view of the resurgence of communicable diseases such as malaria, ‘kala azar’, encephalitis, dengue, leptospirosis and more recently chikungunya. The main reasons for this sorry situation are the failure to develop general health systems, inability to recognise and regulate the private sector and refusal to acknowledge the complex socio-economic, cultural and political dimensions of health. The article, like many others in this book, reveals that the marginalised sections of the society are more vulnerable to diseases. Gangolli and Gaitonde suggest that the introduction of user fees has not only adversely impacted general health, but also blocked access to information and therefore awareness. It is unfortunate that user pay persists even though a number of studies have shown that it has never accounted for a substantial part of the budget of public health centres.

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Anant Phadke’s article, ‘New Initiatives in the Immunisation Programme’ reveals the futility of the present polio-eradication programme which does not seek to control its spread through the faeco-oral route. It is appalling that, although Rs 1,100 crore was allocated for the polio-eradication campaign in 2004 (an amount greater than the total expense on all other vaccines in the extended programme for immunisation), no additional funds were allocated for sanitation. Better watersupply and sewage-management would have helped reduce polio occurrences and deaths due to diarrhoea, Hepatitis A and E, enteric fever and other gastrointestinal infections. Phadke also correctly questions the logic of a universal Hepatitis B vaccine programme given the fact that as over 77 per cent of births take place at home, a majority of newborns will not receive the dose within the first 12 hours to ensure that they are protected from vertical transmission.

Rama Baru covers the issue of healthcare provided by the private sector. The healthcare private sector is made up of large corporate hospitals, small nursing and maternity homes, clinics, diagnostic facilities and pharmacies. It has, as Baru correctly notes, always flourished due to the patronage it receives from the government, a trend that has been accentuated by the current neoliberal economic regime. Additionally, as the private sector remains outside the realm of regulation, the prices charged for treatment vary outrageously and the quality of service provided is uneven.

T Sundararaman examines the role of community health workers in public health. He provides an overview of two of the pioneers in the community health worker programme, namely, the Comprehensive Rural Health Programme (Jamkhed) and the Rural Unit for Health and Social Affairs (Vellore). As Sundararaman notes, there is a growing trend of contracting out entire state health systems to non-governmental organisations (NGOs). While some of their efforts are commendable and need to be replicated, this practice raises the

fundamental question whether we should welcome the move to hand over PHCs and sub-centres to NGOs, and thus condone the abdication of responsibility by the state. We also need to be wary of such efforts given the vigorous manner in which the IFIs have encouraged such a handing over of responsibility.

Leena Abraham (‘Indian Systems of Medicine (ISM) and Public Healthcare in India’), traces the history of ISM and the reasons for its systematic neglect. It is amazing that medical pluralism continues despite the strong homogenising tendencies of modernity and efforts to cleanse society of its so-called unscientific and traditional practices. The ISM has fortunately survived efforts made by those promoting narrow, cultural nationalism to co-opt it to suit their agenda. Of course, now that India is keen on exploiting its niche in traditional medicines such as unani and ayurveda, the ISM might get its due attention after all. However, as noted by Abraham, ISM has to address issues such as the lack of uniform standards, safety, efficacy and quality

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assurance. The high dosage of harmful substances in ISM medications is a serious matter. So also, though arguably to a lesser extent, are the rampant cross-practices and misuse of allopathic medicines by ISM practitioners.

Population Policies and Reproductive Rights

Mohan Rao analyses the population policies in India. He highlights the incredible popularity of the two-child norm among the population and the human rights violations being condoned in the name of population control. It is difficult to digest the insensitivity of those who suggest that people who violate the small family norm should be punished with rigorous imprisonment for a term of five years and a fine no less than Rs 50,000. A study by the ministry of health has already indicated the deleterious outcome of the imposition of the two-child norm on eligibility to contest elections. A large majority of those disqualified on this ground are dalits, adivasis and women from poor families, thus defeating the very notion of democracy.

In the article, ‘Reproductive Health Services: The Transition from Policy Discourse to Implementation’, the Sama Team highlights the planners’ obsession with demographic goals, and describes how birth control is generally viewed within the hegemonic, nationalist image of Indian women as mothers. In the west, the movements for birth control and the availability of contraceptives were located within the larger women’s rights movement; in India, however, birth control is advocated in the name of population control. The article also brings to light the fact that, due to reasons such as the low social status of women, powerlessness and poor quality of child-delivery systems, maternal mortality rates remain high at 408 per 1,00,000 live births, and range between 29 per 1,00,000 live births in Gujarat to 76 in Tamil Nadu and 677 in Rajasthan. What is also to be noted is that, as pointed out by Dilip, 66 per cent of rural deliveries are not attended by health professionals.

The inclusion of Aparna Joshi’s article on mental health in India is noteworthy since this issue has not hereto been given due attention by health activists writing on healthcare in India. As a result, even basic necessities like decent hospitals with trained personnel have been denied. Joshi provides a very comprehensive outline of the enormity of the problem at hand and the gross atrocities committed against those suffering from mental and behavioural disorders. The article also provides suggestions for a comprehensive mental health policy and services.

Poverty amidst Adequacy

S Srinivasan’s article highlights what he very eloquently calls a situation of “poverty amidst adequacy”. The pharmaceuticals sector has witnessed tremendous growth over the past few years, from a turnover of Rs 5,000 crore in 1990 to over Rs 50,000 crore in 2004-05. The industry has carved a niche for itself in the international market. Yet, as Srinivasan correctly points out, drugs continue to be beyond the reach of a very large number of people. One of the reasons for this is the unbelievably high margin paid to retailers and wholesalers. The huge variation in the prices of similar drugs is also quite inexplicable. It is worth noting that India submitted, in the World Trade Organisation’s Special Discussion on Intellectual Property and Access to Medicines held in June 2001, that “access to medicines for what are life-threatening diseases for people in developing countries is a fundamental human right”. Yet, this fundamental human right has been violated time and again within the country.

Healthcare of Women and Children

In the section on women and children, Vandana Prasad evaluates some of the special programmes meant to protect the nutritional standard of children in India. Overall, it is clear that children suffer due to inadequate schematic implementation mechanisms, lack of funds, corruption and apathy. One cannot but be appalled by the knowledge that, in the case of health and nutrition projects meant to impact infant mortality rates and malnutrition, no expenditure was incurred on therapeutic food against the allocated Rs 7,67,00,000. Equally distressing is the fact that even milk was not made available in some of the crèches serving infants.

Padma Deosthali and Purnima Manghnani cover the issue of gender-based violence and the role of the public health system. The gist of the article is summarised very clearly in their own words: “While the public health system is recognised as one of the most critical sites for addressing violence, it currently lacks the capacity and sensitivity to adequately and effectively respond to the needs of victims and survivors” (p 172).

S V Joga Rao ‘Fundamental Right to Health and Healthcare’ examines the role of judicial intervention in recognising and enforcing the right to healthcare and regulating healthcare delivery. Abhaya Shukla’s concluding essay synthesises the material presented in all the chapters within the “healthcare is a human right” framework.

Healthcare in Maharashtra

The second book, Health and Healthcare in Maharashtra: A Status Report, clearly highlights that Maharashtra has not been able to translate its advantages in terms of income, industry, urbanisation and literacy to achieve superior health outcomes. Nearly 50 per cent of children under the age of three years are underweight, 40 per cent stunted and 21 per cent wasted. What is equally noteworthy is the wide rural-urban differential in health standards, and variations across regions and districts within Maharashtra. The book clearly illuminates the appalling lack of even basic facilities in first-stage referral units; 48 per cent of primary healthcare centres do not even have a telephone, and 40 per cent did not have functional vehicles at the time of survey. In addition, some of the district hospitals do not have an obstetrician or gynaecologist.

The book also raises fundamental questions about the commercialisation of the healthcare sector and the leasing out of district hospitals for paltry sums. The concluding suggestion that there “is a clear need for more resources for healthcare in the public domain to achieve better equity in health outcome” is stating the obvious. This calls for political will which, as things stand, is the weakest spot in our polity.

The issues highlighted by both books include the lack of infrastructure, divide between rural and urban areas, inability of the weaker section to access healthcare, undue dependence on out-of-pocket expenses and increased privatisation of healthcare due to structural adjustment programmes.

While I do agree with B Ekbal in the preface in that the Cehat team members deserve kudos for compiling these documents, one can be forgiven for feeling a sense of déjà vu while reading the books. This is partly because we have heard these

Economic and Political Weekly November 4, 2006 same complaints repeated over the years and yet, as recent data bears out, they have by and large fallen on deaf ears. We need to move on from the tired faith that we seem to have reposed in the Bhore Committee report. While we should aim for a robust public healthcare system, we need to be pragmatic enough to promote measures to provide succour within the present scenario. It is in this context that the silence of the book on a number of vital issues is disappointing.

The anthology does not examine the likely impact of the General Agreement on Trade in Services as the service sector is thrown open to foreign competition. Trade in services can occur through a number of recognised “modes” of supply. These include cross-border supply, wherein the service is provided remotely from one country to another through, for example, telemedicine (mode 1), attracting overseas patients for healthcare (mode 2), increasing foreign direct investment in health

services (mode 3) and travelling to another country to supply a service there on a temporary basis (mode 4). While such developments will arguably generate much needed resources, the portent danger is that they could further skew the healthcare system in favour of the healthy and wealthy, and weaken public health. We are already witnessing trends in that direction that merit examination.

Health-tourism is the new buzzword, and the catchphrase used to promote it is, “ensure first world treatment at third world prices”. Figures differ, but the general ruleof-thumb calculation is that one can avail of services in India at one-fifth to one-tenth their cost in the west. It is this disparity which India is seeking to capitalise on in order to become a “global health destination”. Cost is not the only factor weighing in India’s favour; the much touted slogan is that, in a corporate hospital, once the door is closed you could be in a hospital in America.

Even the 2002 National Health Policy legitimises the concept when it states that steps will be taken to encourage the supply of services to foreign patients, with payment made in foreign exchange treated as “deemed exports” and hence eligible for all fiscal incentives extended to export earnings. The government of India has also introduced a “medical visa” to be issued to foreigners seeking speciality treatment, both allopathic and in ISMs, in recognised and registered hospitals or treatment centres. The government of Maharashtra has collaborated with the Federation of Indian Chambers of Commerce and Industry to form the Medical Tourism Council of Maharashtra (MTCM) to boost medical tourism; the 830-bed Wockhardt Hospital in Mumbai is part of this initiative. Similar endeavours are already in place across the country. There is already some discussion on promoting medical tourism through the setting up of a MediCity on the outskirts of Delhi by 2007. The Bengal Health City project envisages 100 hospitals over a sprawling 800 acres, about 20 km from the city of Kolkata. The All-India Institute of Medical Sciences is already a destination for medical tourists from neighbouring countries. However, the notion that public

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hospitals should also be encouraged to attract medical tourists is problematic because, as the books under review have pointed out, existing public health facilities are barely able to meet the requirements of the people within the country.

We are already witnessing some results of this aggressive marketing. The health-tourism market in India, estimated at Rs 15.48 billion in 2004, grew by about 25 per cent and is predicted to become a Rs 93 billion-a-year business opportunity by 2012. A mere decade ago, hardly 10,000 foreign patients visited India for medical treatment; in 2004, approximately 1,80,000 patients arrived from across the globe. India has also become increasingly open to foreign direct investment in the health sector.

Another significant issue of concern is the notion of public-private partnership, as promoted by the World Bank and international health agencies including the World Health Organisation. Several state governments have started exploring new contracting techniques like Build Own Operate and Transfer (BOOT), Build Own Lease and Transfer (BOLT), etc, for infrastructure projects. In view of the propaganda attached to PPP, the books should have examined this issue at length.

There has been a growing interest in India in exploring the potential of health insurance as a tool of improving the health of the population, and especially that of the vulnerable groups. Since all the contributors have expressed concern over access to healthcare, it is surprising that health insurance has not been dealt with comprehensively. The neglect of the ongoing struggle for accreditation of hospitals is intriguing given that Cehat has been involved in this effort since its inception.

The books are nevertheless a useful addition to the growing literature on public healthcare. Perhaps we can expect a more detailed analysis of some of the aspects mentioned above in subsequent publications from Cehat. Email: kannamma24@gmail.com

EPW

Economic and Political Weekly November 4, 2006