How the Indian State metamorphosed from protector of the poor to facilitator of the private health industry

If there is correlation between two incidents of the Central Government announcing cuts in the health budget and dengue patients being refused treatment in Delhi’s private hospitals, it is rarely discussed in the ongoing media debate on the subject. A new collection of researched essays edited by public health scholar Imrana Qadeer in the Social Development Report (SDR), a biennial publication venture by the Council for Social Development and Oxford University Press, has tried to find these critical linkages.

The essays, by some of the foremost scholars in the country — Utsa Patnaik, Deepak Nayyar, Rama V Baru, Usha Ramanathan, among others — give a perspective about why the poor lack access to healthcare, how India denies this basic right to its people despite being the hub of five-star hospitals and medical tourism, and whether the private sector is a panacea for India’s healthcare needs.

Reading them, one understands how events in Delhi during the dengue outbreak were not an isolated phenomenon; they were the inevitable consequence of the deliberate dismantling of the public health sector by policy planners. In this interview, Qadeer outlines how the Indian State has metamorphosed from being the protector of the interests of the poor to a facilitator of private business and revenue generation in the health sector. Excerpts:

Dr Qadeer, you write about boundaries of public health being marked by the political perspective of the State. Give us a perspective of the Indian State, especially in the context of how economic liberalisation impacted health policy and planning.

If we go back to the post-independence policy approach, it figures that there was an effort to adopt broad-based welfare measures. There are policy documents such as the Bhore Committee report, which talked of basic health services free of cost

The concept of ‘basic’ structure also evolved as not some rudimentary care but an institutional approach in terms of primary, secondary and tertiary care. The evolution of these structures has a history originating from health being envisaged as overall development and well-being of the individual. Bhore Committee talked about poverty being the main driver of disease. The first few Five Year Plans created structures and conceptualised public health as being more inclusive, which identified the needs of the larger population.

But by the Fourth and the Fifth Five Year Plan, the need to regard health as industry started getting reflected. Techno-centric health, which necessitated the exclusion of some people, started taking the lead and welfare — which included housing, sanitation, employment, and empowerment — began to be neglected. This was coupled with the arrival of international aid which focused on national programmes that were technology-intensive.

Another factor in the shift in policy from welfare to technology was that till the 1970s, the World Bank had not really accounted for health sector as an industry that could aid in revenue generation. But by the 1980s, this recognition had been felt. With the heralding of economic reforms in 1991 and the 1993 World Bank report, the shift from welfare to technology — namely, industry and revenue — was complete. The 1993 report played a critical role in condemning the public health sector in India as “inefficient” and hailed the development of private health sector as the panacea for our problems. We assumed that we cannot augment and improve our public health institutions and started facilitating the growth of the private sector.

These developments also coincide with how the health industry evolved over the years. The first phase in the growth of this industry involved mass coverage — national programmes for malaria, filarial, small pox and so on. The second phase in medical technology development — of fibre, chips, high-cost equipment and invasive technology — was curative and not preventive like some of the earlier vaccination programmes.

The latest technological developments did not need mass application. They needed a moneyed clientele and the market was restricted. Accordingly, the industry pushed for private-sector growth. These developments were focused on wealth generation through medical technology. They needed suitable policy measures and the political class, along with the more articulate sections of the Indian middle-class, supported these policy transformations to facilitate the private sector.

The Indian State thus reduced inputs into healthcare, opened up not just the tertiary-care sector, which saw the mushrooming of five-star hospitals on government land and subsidies, but also secondary and primary care. A 2002 report of the Confederation of Indian Industry lays conditionalities on the Indian government for them to enter the primary healthcare institutions and tells us how much revenue they can generate if their conditions are met.

The situation now is that the Indian State is stewarding and looking after the interests of the private players in the health sector through pushing PPPs (public-private partnership), insurance and similar measures.

Whatever public sector remains is also being commercialised. Spaces in public hospitals are being allocated to private diagnostic centres. We have examples from West Bengal where government hospitals are opening up their spaces for setting up of private labs where MRIs and other tests are performed. This is the extent of takeover of health sector. From the only provider of healthcare, the State is now only an ‘ensurer’ of healthcare through PPPs, insurance and so on, which basically mean spending public money for private profit.

Where are poor people located in this? We have medical tourism, reproductive tourism and five-star hospitals while common people die of common ailments. Is there anything more morally reprehensible than this? The poor have been left to their devices while the State has become a protector of the medico-industrial complex in this country.

Give us a comparison of the role played by the State in provisioning, financing and regulating health sector in western welfare capitalist economies, with the exception of the US, which too has now accepted State responsibility.

I’ll tell you an interesting story about a Chinese delegation which came here to study how we are balancing the healthcare needs of the population with the penetration of the private sector. In China, private penetration is about 10-20 per cent and they are anxious to study other examples to understand whether the needs of the population are met. But we in India have no such priorities. The balance here is 20-80 per cent in favour of the private sector and you have seen the results — among the highest out-of-pocket expenditure on health, casualties from common ailments… anything that can go wrong, has gone wrong. Health has become a vehicle for generation of wealth for a few.

To answer your question about best international practices, you have to study how other countries have responded to the challenges of the Structural Adjustment Programmes (SAP). In the UK, which was historically the leader of universalising healthcare, private sector has made deep inroads and the National Health Service is being severely undermined. But in Brazil, which too had embraced SAPs, the results were similarly disastrous for the health sector. Costs went up, unnecessary procedures started getting performed routinely and people were fed up. But it is the strength of their democratic process that this process is now being reversed. Here in India, we are not even asking the question ‘How much of our population has access to basic services?’

How would you characterise the present scenario where development is only economic development and even the ostensible focus on social sector, the so-called “human face” of globalisation adopted by the previous regime, has been diffused? Have things become worse in the last 16 months?

To be very honest, the present regime is only accelerating the process that was set in motion by the Congress. The decline of the public health sector started in the 1980s and was pursued through the last three decades by successive regimes. The difference is in degrees. There were programmes such as MNREGA (Mahatma Gandhi National Rural Employment Guarantee Act) which helped boost rural employment which, in turn, helps in nutrition levels and so on. The Congress was only toying with dismantling the PDS (public distribution system), and labour laws were not reversed drastically. All these questions are being settled now. The NITI Ayog chief does not approve of public sector. Whereas the JNNURM (Jawaharlal Nehru National Urban Renewal Mission) at least gave some consideration to the urban poor. But now we have a concept of Smart City. This is the area of selection. The focus is in narrowing coverage. The shift from inclusive politics is clear.

I will tell you how, in the name of state insurance, public money is being channelled into private hands by sheer exploitation of the poor. We have a study from Andhra Pradesh in this volume of SDR which shows the extent of apathy of the government. Private institutions organise a camp in rural areas where people come in hordes, hoping for treatment. They assess people as cattle; the case which can be milked for maximum procedures is selected. Others, who may be deserving but not eligible for expensive treatments, are rejected. The selected candidates are ferried to their five-star hospitals, where they are treated as second-class patients and forced to undergo procedures. If they want a second opinion on whether a procedure is indeed needed, they are asked to pay the entire sum billed against them. They are not allowed to leave till they pay up.

Is this the best we can do for our people? We had a strong public sector in health. That would have been a model. But now people do not have the option. They can’t choose.

Policy planners argue that the system does not have the capacity to absorb what is allocated towards health sector.

This is not a new argument. They dismantle a system for three decades, reduce the personnel strength to one-fourth, casualise services of doctors and nurses. No one is committed to the institution. Then you tell us that the system cannot absorb. If you have destroyed a system for 30 years, let it take at least a decade to recover and then tell us otherwise.