(In India, the UPA Government is on the point of enacting a National Health Bill that promises health care ‘reforms’. Will the ‘reforms’ ensure access to healthcare of a uniform standard to all, irrespective of wealth? Or will it take us a step closer to a US model of health care – with the poor left at the mercy of the markets? Interestingly, the US too has recently passed a Health Reform Bill after intense debate. Padma looks at the recently enacted US Health Bill to see if it offers any substantial ‘reform’ of the privatised and unequal healthcare model prevailing in the US; while Indira Chakravarthi looks at the UPA’s Draft National Health Bill to assess its agenda. Dr. Debashish Dutta, President, People’s Health (a W Bengal-based organisation of health activists) shares the experience of the impact of privatisation of health care in West Bengal. While history is witness to the fact that existing healthcare provisions have been won by Left-led working class struggles the world over, and countries like Cuba, in spite of their economic weakness still boast better healthcare than their mighty superpower neighbour, it is unfortunate that West Bengal ruled by the CPI(M)-led Left Front has also capitulated to the neoliberal prescriptions as have most other Indian states.- Ed/-)
Draft National Health Bill:
Health ‘Reforms’ for Markets, Not People
In January 2009 the Indian government put out a working draft of a National Health Bill “to provide for protection and fulfilment of rights in relation to health and wellbeing, health equity and justice, including those related to all the underlying determinants of health as well as health care; and for achieving the goal of health for all; and for matters connected therewith or incidental thereto”.
The Preamble admits that the persisting inequities, denials and violations in the matter of health in the country are cause for concern to all. Hence “the need to mandate, enable, authorize, guide, and where necessary, limit, health policies and actions (emphasis added) by all the relevant stake-holders, including the communities/ civil society, within a rights based approach, so as to lead to actualization of right to health for all”. According to the draft Bill there is also the need to (i) set a broad legal framework for providing essential public health services and functions, ……… principally through the State and local public health agencies, in collaboration with others in the public health system….; (ii) to have an overarching legal framework and a common set of standards, norms and values to facilitate the Governments’ stewardship of private health sector as a partner (emphasis added).
Section II lays down several general obligations of central and state governments towards realization of health and well-being. Such as the general obligation “to provide free and universal1 access to health care services and ensure that there shall not be any denial of health care directly or indirectly, to anyone, by any health care service provider, public or private….”. However, the nature of healthcare services that will be “free and universal” is not clearly defined anywhere. If one were to go by the mention in the preamble of the need for a legal framework to provide essential healthcare services, one can assume that it will be only these essential services that will be free and universal. This is an area of grave concern, because the Bill will end up institutionalizing, making irreversible the ideological shift that has taken place since the 1980s in provision of welfare services by the state. There has been a shift from provision by the state of comprehensive health services2 through a publicly funded, universal, national health system, to free provision of just a minimum, essential package of services only to those identified as poor by the state.
Historical Significance of Comprehensive Healthcare & National Health Services
Since the early 20th century, when medical care began to be provided as a public service on a large-scale3, the provision of such services has been characterized by a debate on the role of the state - should it directly provide the services, or should it only finance the provision, or should it only address the needs of the poor leaving the rest to be provided for by the private providers? Only few countries (such as UK and Cuba) adopted the National Health Service (NHS) system of the then Soviet Union – namely direct provision by the state of as complete a health service as possible4. It is the working class struggles of the late 19th-early 20th century that made profound contributions towards this concept of collective responsibility for provision of basic welfare services, and especially regarding the provision of health services.
In India, around 1947 many eminent doctors and planners for health were influenced by the Soviet and British National Health Systems (NHS). The oft-quoted Bhore Committee of 1946 framed a blueprint for provision in the country of comprehensive health services through a national health system. Given the need then for a vast health service for the vast rural population and the difficulty faced in attracting medical practitioners to the countryside, it concluded that “the most satisfactory way of meeting the situation was to provide a whole-time salaried service, which would enable government to ensure that doctors are made available where their services are most needed”. These were the recommendations that were adopted in the post-colonial period by the Indian state. Several other Committees later made valuable recommendations to achieve these goals. These were implemented to an extent, and some progress made in terms of creation of infrastructure in the initial five year plan periods.
However, the public health services in India did not grow as envisioned due to factors such as lack of political will; inadequate budgets; pressure from international agencies such as WHO to implement vertical5 programmes for population control and against specific diseases such as malaria; corruption; and reluctance of doctors and specialists (trained in urban medical colleges oriented to western standards) to work in the rural health facilities. At the same time the private healthcare sector in India got subsidies and concessions, and conditions favourable for its unimpeded, unregulated growth, giving rise to a ‘passive privatization’ process.
Several events of the 1960s and 1970s, including the failures of vertical programmes, led to the Alma Ata Declaration of 1978 and the goal of achieving Health for all by 2000 AD6. The Alma Ata declaration, to which all WHO members including India were signatories, re-incarnated the importance of national health systems, although in a tortuous manner through the concept of comprehensive Primary Health Care (PHC). Implementation of PHC had socio-political implications, where governments had to address the underlying social, economic and political causes of poor health, and also build their national health systems.
Many governments, including India, did not implement it seriously. Instead a ‘selective PHC’ approach was advocated by the group of World Bank (WB), Ford and Rockefeller Foundations, USAID, and UNICEF. These institutions argued that the comprehensive PHC of Alma Ata was too unrealistic and costly7; if health statistics were to be improved, high risk groups must be targeted with carefully selected, cost-effective interventions for a limited number of diseases; that, until health care systems are adequately resourced and organized, it is better to deliver a few proven interventions of high efficacy at high levels of coverage, aimed at diseases responsible for the greatest mortality. ‘Selective PHC’ also promotes a biomedical orientation to disease & ill-health: it relies on delivery of ‘medical technologies’ amenable to vertical programmes. Just as smallpox was eradicated through a concerted global effort, for instance, it is argued that diarrhoeal disease, malaria and other common diseases can be tackled in a similar way. It is such ‘selective’ interventions that are largely being delivered as the minimum, essential package of services.
Health Sector Reforms – the Trojan Horse
The inefficiencies of the public sector healthcare system, arising largely from its deliberate neglect, have been used to justify imposition of a series of health sector reforms (HSRs) by many governments, as part of conditionalities of WB loans. The WB has been advocating that governments in poorer countries should focus their scarce public resources on providing a free ‘basic’ or minimum package of preventive and curative services for the poor, while withdrawing from the direct provision of other services. It argues that by encouraging the relatively rich sections of society to use the private sector, the public sector will be able to redirect its resources to those most in need. The assumption is that it is more efficient and equitable to segment health care according to income level – a public sector focused on the poor and a private sector for the rich. This is a major departure from the concept of universal, comprehensive healthcare services.
There is no evidence that such a system is better, more equitable or efficient. On the contrary, the private sector draws on a limited pool of health professionals, and takes away more health care resources than it relieves the public sector of workload8. Segmentation is attractive to private investors, as they can provide health care as a profitable, commercial product to those who can afford it. This is true especially for countries like India, where there is a huge private healthcare sector, as well an upper- and middle-class market to sustain the development and financing of the private health sector.
One finds that the draft National Health Bill intends to provide a legal framework for such a segmented system of healthcare services, thus re-inforcing the inequities and inequalities. Nowhere in the draft is it mentioned that the deficiencies of the existing public healthcare system will be rectified, and that it will be transformed into an universal, efficient, effective and accountable system as envisioned, catering to needs of all sections.
It is not surprising that the National Health Plan (NHP) 2002 shall be one of the plans guiding the National Health Act until other policies and plans are specially notified.
The NHP 2002 is quite emphatic about the need to move towards private provision of health services. According to this policy, “The health needs of the country are enormous and the financial resources and managerial capacity available to meet them, even on the most optimistic projections, fall somewhat short……….. In the context of the very large number of poor in the country, it would be difficult to conceive of an exclusive Government mechanism to provide health services to this category. It has sometimes been felt that a social health insurance scheme, funded by the Government, and with service delivery through the private sector, would be the appropriate solution”. It welcomed the participation of the private sector in all areas of health activities – primary, secondary or tertiary, and said that “The contribution of the private sector in providing health services would be much enhanced, particularly for the population group which can afford to pay for services”. The Policy also encouraged the setting up of private insurance for increasing the coverage of the secondary and tertiary sector under private health insurance packages. In keeping with the selective PHC concept, it prioritized TB, Malaria, Blindness and HIV/AIDS, and called for separate schemes to cater to health needs of women, children, tribals and other socio-economically under-served sections.
The National Health Bill provides for a National and a State Public Health Board (Sec IV) for implementing and monitoring of the Act. The functions of the State Board include: developing mechanisms for initiating public-private partnership in implementation of public health programmes that ensure equity and quality of health care services. Thus, while the centre will continue to deliver certain minimum services for the poor, through the existing infrastructure of peripheral institutions (sub-centres, primary health centres (PHCs), and community health centres (CHCs), the state governments can deliver other services through public-private schemes. The private sector, through direct provision and insurance, will cater to the affluent. Once again, the draft Bill, like the NHP 2002, holds out promises of regulation of this sector.
Questions to be asked
The government’s claims that finances, infrastructure and managerial capacity are insufficient are not very convincing. Is there actually a shortage of financial resources? Or is the ‘shortage’ due to the abysmally low allocations to health in the central and state budgets, despite promises to increase it? Secondly, since the mid-1990s loans were availed from World Bank for health system strengthening (Health Systems Development Programmes -HSDPs), in nearly a dozen states – Punjab, Andhra Pradesh, West Bengal, Karnataka, Maharashtra, Uttar Pradesh, Orissa, Uttaranchal, Rajasthan, and Tamil Nadu. In almost all states the loan amount is of several hundred crores rupees, repayable at 11-12% interest. The loans were exclusively for: constructing / improving infrastructure at secondary levels; development of management skills; policy reforms; and improving the performance of the healthcare system. What is the outcome of these programmes?
Several irregularities have been reported by the Controller Auditor General (CAG) of India in the HSDPs in almost all the states. Apart from corruption in states like Orissa, what is of major concern is that while the buildings and equipment are there, they are not being utilized due to lack of human resources, shortage of doctors and other staff, and acute lack of specialists, such as surgeons, anaesthetists, and paediatricians. Why are state governments not employing doctors and utilizing this infrastructure effectively? On one hand, we actually have a large number of doctors passing out each year and either leaving the country or joining the private sector. On the other, there is no genuine effort to create favourable conditions to recruit and retain doctors for the public health services. Under the reform measures and WB prescriptions, many appointments are either contractual or ad-hoc, or under specific programmes, or specialists are contracted in as and when required. The general policy of cuts in staff and freeze on recruitments has severely affected public health services in several states. Thus, loan money is being wasted and not utilized for the purpose for which it is being taken.
Together, all this raises questions about the sincerity of the government’s intentions to fulfill (and protect) people’s rights regarding healthcare, and about the objectives of the reforms it is implementing with assistance from WB and other international agencies. While public health services are in dire need of improvement, the on-going HSRs and the proposed National Health Act are ‘reforming’ it, not with interests of the common people in view, but that of commerce and markets.
1 Services for all on the basis of citizenship, rather than ability to pay or insurance scheme criteria.
2 Services covering and meeting all kinds of healthcare needs, from infancy to old age; and not just for specific illnesses or physical illness only, but also preventive and curative.
3 Initiated in Russia in the 1860s through district assemblies.
4 In this system medical and public health services are provided by salaried physicians and other health personnel who work in government hospitals and health centres, the entire population is covered by such services, practically all services are included, and provided free of charge
5 Vertical programmes refer to exclusive programmes for specific diseases, with separate planning, management and implementation structures.
6 The Alma Ata Declaration has to be seen also in the context of the Cold War politics. It was an attempt to deflect the proposals by USSR in the early 1970s that WHO should support developing countries in developing their national health services, instead of supporting vertical programmes.
7 The Cuban health system belies such arguments.
8 The US experience of public funding and private provision shows that it actually increases administrative expenses.