Volume 5, No. 8, August 2004

The current health situation in India is a sad story of deprivation. Unless one is fobbed off by displays of hi-tech medical care and use of state-of-the-art medical technologies in five star deluxe facilities of a few select urban centres, the tale of utter helplessness and callous carelessness is so apparent that it is now frequently taken as a matter of course. The blatantly paradoxical spectacle of buying and selling of health improvements as a consumer goods by the well-off minority in the metros on the one hand and the denial of basic health facilities to the vast majority of the population along the length and breadth of the country on the other hardly evokes any comment.

While we analyze the grim details of the situation which we find ourselves in, we should not get carried away by the so-called achievements of ‘Indian Health’ since the transfer of power, which are trumpeted by the press and other agencies of the state.

Besides the fact that the morbidity and mortality levels in the country are still unconscionably high and that the still-unsatisfactory health indices are, in turn, an indication of the limited success of the public health system in meeting the preventive and curative requirements of the general population, the data presented by the Government would fail to indicate the nature and extent of neglect and deprivation of health of the vast majority of the population.

Part of the story will be evident from statistics showing very uneven levels of attainment of health across the rural-urban divide as also across the geographical divide between the better-performing and the poorly-performing (Bimaru) states (Table 1). It cannot be a matter of pure coincidence that all the better performing states (Kerala, Maharashtra, Tamil Nadu) are known to have better preserved public health systems right down to the PHC level as opposed to the poorly performing ones, where even the physical infrastructure and the manpower resources are grossly inadequate and frequently non-existent.

In states like Uttar Pradesh, the State Health Service is currently serving no other purpose than administering the Pulse Polio Programme. In states like Bihar and Jharkhand, the doctor or the compounder/pharmacist posted with the designated rural health centre will visit the village market weekly or fortnightly and run some sort of an outpatients’ department service. This is because either the physical infrastructure (building etc.) is nonexistent or is too dilapidated or has been acquired for some other purpose. In still more remote areas, even such service is unheard of. In fact, the State Health Service simply does not exist for large parts of the population of these and other states and the latter survive and die at the mercy of the private sector health services (the commercial enterprises and the NGO hospitals) — in other words, at the mercy of the market. As we all know, markets are merciless.

Now we shall be able to understand how the national averages of health indices (as in Tables 1 and 2) can and do hide wide disparities in public health facilities and health standards in different parts of the country. In fact, these are the very statistics which are often trumpeted as successes of the Indian state after 1947. Given a situation in which national values of most health indices are themselves at unacceptably low levels (often comparable to the least developed nations like those in the sub-Saharan Africa, vide Human Development Reports), the wide disparity implies that, for vulnerable sections of society in several states, access to health services is nominal and health standards, at the very best, are grossly inadequate. Applying current norms to the population projected for the year 2000, it is estimated that the shortfall in the number of SCs/PHCs/CHCs is of the order of 16 percent. The shortage is as high as 58 percent when disaggregated for CHCs (rural hospitals) only.

One of the gross manifestations of class bias among Indian policy planners is the abysmal lack of class-disaggregated health data in any official document. Whatever data is there, is treated almost like an official secret and is hard to get. This is reflected in policy documents like the National Health Policy 2002 (NHP-2002), where the extremely uneven distribution of the public health system among the better-endowed and the more vulnerable sections of the society is acknowledged but the accompanying data is embarassingly woeful (Table 2).

The accompanying comment in the document only mentions ‘women, children and the socially disadvantaged sections of the society’ as being part of the ‘other disadvantaged’ group. Other than being a hopelessly inadequate description, the presentation of the data is such that its veracity is impossible to judge and it can be hardly called ‘class-disaggregated’ data.

From the 1990s the world has witnessed a phase of neoliberal capitalist domination, a phase known as globalisation. Consistent with the character of the Indian state that has unwaveringly pursued the path dictated by the IMF, W. Bank India has entered the globalist nexus, quite willingly.

The policy shifts in the health sector, like other sectors, have been, inter alia, an increasing stress on private health care, recognizing healthcare as an industry, application of industrial standards of operation and discipline upon healthcare workers including doctors, ‘liberalisation’ of patent laws, increasing stress on user fees, further contraction of public health services and increased fees structure and privatisation of medical education. All these neoliberal concerns have been adequately addressed in the NHP-2002.

Still there is a certain squeamishness among the Indian ruling classes that provokes them to adopt a posture of double hypocrisy regarding the response to globalisation in various policy documents that betrays an underlying sense of unease and guilt. NHP-2002 is no exception. One is the contention that the policy initiatives in response to the process of globalisation are inevitable, as globalisation is a matter of fact, not a matter of choice, in other words TINA (There Is No Alternative). The facetiousness of such a line of argument does not deserve any comment.

There are also ill-disguised attempts to underplay possible consequences of globalisation. For example, NHP-2002 has identified only one scenario among many (a TRIPS-aligned patent regime for drugs resulting in an across-the-board increase in cost of drugs and medical services) that could adversely affect the health of the Indian populace. The policy response is equally vague and inadequate— a patent regime that is consistent with TRIPS on one hand and assuring affordable access to the latest drugs and therapeutic discoveries on the other, as good a contradiction in terms as you could get.

Though NHP-2002 is an official acknowledgement of the policy imperatives inspired by the process of globalisation as applied to the field of health, the policy shifts were in force much earlier, from the 1990s itself, or even earlier than that. There have been, from time to time, some official acknowledgement of the damaging health impacts of economic inequity and social deprivation spawned by this process of globalisation. The oft-quoted NFHS-2 bears ample testimony to that. The Report, which is based on data from a survey conducted during 1998-99, is a damning indictment of the state of Indian health during this phase. At the risk of repitition, let us quote from some of the bleaker aspects of the factsheet :

1) In spite of declining IMR, 1 in every 15 children still die within the first year of the life and 1 in every 11 die before reaching age 5.

2) 19% of total fertility is contributed by very young mothers (age 15-19).

3) Continuing low levels of education among women contribute to the high IMR and MMR. The IMR for illiterate mothers is more than 2.5 times the rate for mothers who have completed at least high school.

4) Mothers giving 20% of births receive all of the various types of antenatal care. Less than half of all deliveries are attended by a health professional and only 1/3rd of births take place in a medical institution.

5) More than 1/3rd of women aged 15-49 years are undernourished (according to the body mass index) and almost half the children under the age of 3 years are underweight or stunted. By the age of 6 to 11 months, almost 1/3rd of children are malnourished.

6) More than 1/2 the women of age 15-49 years and almost 3/4 of children of age 6-35 months are anaemic.

7) Only 2/5 of all children of age 12-23 months receive all of the recommended childhood vaccinations.

8) Lastly (this would seem obvious to many of us), the study found that the households that have a low standard of living perform distinctly worse on most demographic and health outcome indicators than households that have a relatively high standard of living.

The National Human Development Report 2001 (NHDR-2001), brought out by the Planning Commission, indicates the continuation and, at times, intensification of the trends reported by the NFHS-2.

For example, while the expectation of life at birth in urban India has been 66.3 years during 1992-96, the same for rural India has been 59.4 years. Quite a big gap indeed! Similarly, the expectation of life at the age of 1 year in rural India is 63.9 years, whereas it is 68.9 years in the urban areas. Among persons not expected to survive beyond the age of 40 years in 1991, 16.9% were male while 19.1% were females. The rural-urban dichotomy continues in the IMR figures : 84 vs 51. More eyecatching is the disparity in the age-specific mortality rate for the age-group 0-4 years (1991) : 40.8 and 16. Similar is the case for the crude death rate— 9.6 and 6.5 in 1997, and so on.

We have in our hands a European Commission-funded, Government of India-approved report of a survey (1997-2001) that specifically delves into the efficacy of the so-called ‘safety net’ part of the economic reforms agenda and the impact on the health of vulnerable groups that this agenda induces. The study has been conducted in 3 of the states (West Bengal, Andhra Pradesh and Tamil Nadu) that have been at the forefront of the reforms programme. Some of its conclusions are revealing.

1) The safety nets as they exist do not act as a buffer.

2) Across all social groups there is rising indebtedness owing to the growing cost of health care.

3) The declared policy of targeting the poor for preventive services alone is questionable owing to the rising pandemic of chronic diseases which affect all social groups, although the poor are at risk from both infectious and chronic conditions.

4) Despite stated preference for better-funded and resourced public provision among providers and users, the majority are forced to rely upon different types of private health care for their basic health needs.

5) The gap in provision between rural and urban areas remains as wide as ever and needs to be addressed and a reduction of resources in social sector expenditure as advocated by reformists can only worsen existing disparities.

6) The share of medical expenditure as a proportion of total household expenditure is on the rise due to the cost of health care as well as the changing profile of health needs.

These conclusions remarkably match the diagnoses of some of the ailments of India’s healthcare system in the NHDR-2001. Coming from the Planning Commission, it is a remarkably candid assessment. Some of its findings were :

1) Persistent gaps in manpower and infrastructure, with wide interstate differences, especially at the primary healthcare level, disproportionately impacting less developed and rural areas.

2) Suboptimal functioning of the existing infrastructrue and poor referral services.

3) Significant proportions of hospitals not having appropriate manpower, diagnostic and therapeutic services and drugs, particularly in the public sector.

4) Increasing dual disease burden of communicable and non-communicable diseases because of persisting poverty together with ongoing demographic, lifestyle and environmental transitions.

5) Increased dependence of people on private healthcare services, often leading to indebtedness in rural areas.

6) Escalating costs of health care, ever widening gaps between what is possible and what is affordable.

7) Technological advances, while broadening the spectrum of possible interventions, go well beyond the financial reach of the majority.

8) Inadequate integration of public interventions in the areas of drinking water provisioning, sanitation and urban waste disposal with public health programmes, thereby failing to exploit potential synergies that reinforce health attainments of the people.

9) There is perhaps a misplaced emphasis on development and maintenance of private healthcare services at the expense of enlarging and deepening of a public health care system targeted essentially at controlling the incidence of communicable diseases in rural areas.

10) In case of preventive health care, among the five levels of prevention, namely, health promotion specific prevention, early diagonosis and prompt treatment, disability limitation and rehabilitation— there is little that has been done by way of strengthening the institutional and delivery mechanisms of public policy and programmes, at least in the case of the last two.

11) Finally, continuation of a universally free public healthcare system— preventive as well as curative— is considered to be unsustainable in the present form, both in the NHDR-2001 and the NHP-2002. However, it is recognised that there is inadequate policy movement on creating an alternative, accessible, affordable, viable and dependable healthcare system for the majority of the population.

This is an official acknowledgement of the policy bind that the state faces. This is a recognition of the fact that the state, in spite of knowing what the ills are, and knowing full well that its policies might very well have aggravated the ills and have let things drift in a particular direction, is quite happy to let the drift continue.

What is the administrative-financial template on which this globalisation of the health sector has been envisaged to take shape? Global experience has shown that the quality of public health services, as well as the attainment of improved public health indices, is closely linked to the quantum of investment through public funding in the primary health sector. Let us take a look at India’s position on this count on global scale (Table 3).

This Table is a pointer to one or two remarkable things. It is a point to note that among the countries listed above, China is India’s nearest neighbour as far as health spending and health standards are concerned. It is worth noting that some of the most regressive health policy measures including a drastic stress on privatisation of health services were taken, globally speaking, in post-Mao China. That country is now reaping the harvest. One dramatic example would suffice. Revolutionary China had wiped out venereal diseases within a span of two decades by clamping down on prostitution. Now China and India are two potential flashpoints of the global AIDS pandemic. Such dramatic epidemiological upheavals are being noticed in disease after disease.

Where do we go from here? There is little doubt that the public sector health efforts are going to be demolished. The personnel running the show there would be an army of poorly paid disgruntled employees who would not have any material or moral incentives. In the new milieu where markets have broken into our homes, concepts like ‘serving the people’ or the ‘country’ will be viewed as mushy sentimentalities or shibboleths. So in basic public health services too, there would be deterioration in quality because of below par efficiency, commitment and honesty. Even the maintenance or quantitative expansion of such services would largely depend upon the quantum and quality of foreign aid.

In the health services, along with rampant privatisation, globalisation (e.g, telemedicine) and promotion of health insurance, managed healthcare promises to be the feature of the future. ‘Managed care can be defined as healthcare services under the administrative control of large, private organisations, with ‘capitated’ financing (which means that an employer— private or public— or a public agency prepays the managed care organisations (MCOs) a negotiated sum of money per covered person per unit of time, typically a month). Copayments are made by the insured persons’. This is the system covering most of the insured persons in the US right now. Since 70% of all American MCOs are for-profit enterprises, new markets are needed to sustain growth and return on investment. That’s why the healthcare and social security funds of Third World countries have become a major source of new capital and high rates of profit for capitation payments. No wonder that with an ideology that says that ‘health is a private matter and healthcare is a private good’, the World Bank would pursue the globalisation of managed care as a cherished goal. In December 1999, the World Bank, IMF and USAID along with the WHO and the Pan American Health Organisation (PAHO) used the International Summit for Managed Care at Miami Beach to promote an expanded role for MNCs in healthcare throughout the world. India was an active participant at the summit.

As public systems are dismantled and privatised under the auspices of managed care, MNCs predictably will enter the field, reap vast profits and exit within several years. Then countries like India will face the awesome prospect of reconstructing their public systems. Managed care reforms will produce fundamental changes in clinical practice. These changes involve the subordination of health professionals to an administrative-financial logic and a drastic reduction of independent professional practice, since professionals have to offer their services to insurance companies or the proprietors of large medical centres. This has begun to happen in India for some time now. Like in the U.S.A, the questions of life and death, literally, are being taken, not by qualified professionals, but by accountants, people who know the balancesheet rather well. This promises to be the order of the day in the numerous deluxe private sector hospitals that are springing up in our cities.

So globalisation, by means of its economic logic and direct and indirect effects on health will be a telling blow to the toiling millions on the one hand, and, on the other, a large portion of the supposed beneficiaries of globalisation, those who have the means to be consumers of health, are unknowingly going to get a degraded, less valuable form of medical care. As medical care, as we all know it, that involves the personal interaction between the patient and the carer (the physician and his/her team, including the nursing and paramedical personnel), changes irrevocably under the double whammy of managed care and telemedicine, it is ultimately the consumer (the patient, in this case) who gets short changed, as always.

This is the logical culmination of a process that has involved the transformation of health as a public good and as one of one’s inalienable welfare rights to a set of deliverable commodities. All in all, not a very rosy prospect awaits us as we venture onto a new road to health that is paved with the bricks of the dicta of assembly line production.

This has been made possible by a quiet acquiescence to the neoliberal philosophy that claims that the purpose of keeping people healthy is to promote economic development, a philosophy suitable for a society of ants or bees, really. For civilised humanity, it would have been more sensible to say that the purpose of economic development is to promote health.

All this has been made possible by a lack of awareness and concern regarding health issues. As we have seen amply, the agenda of health is ultimately related to the broader discourse of political economy. To raise demands regarding the claims of basic health needs as one of our fundamental rights and to question the ambience of consumerist health culture are to challenge the projects and practices of development and to question the agenda of the state. In order to throw the gauntlet down on these issues in any significant manner, it requires movements that derive their sustenance and power from grassroots mobilisation. To paraphrase slightly David Werner’s famous words : A revolutionary approach to health care would require a revolutionary process in society as a whole.

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