The problem

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India, along with other WHO member-nations, became a signatory to the Alma-Alta declaration promising ‘Health for All’ by the year 2000 a little over two decades back. The expectation was that with adequate investments in health infrastructure and an appropriate mix of public health strategies, the country would be well-placed to meet this laudable goal. It’s a sad commentary on the times that even into the target year, we can at best claim partial success in meeting the goal of a healthy population.

There is no running away from the many achievements over the decades – increased life expectancy, reduced infant mortality, declines in fertility, some success in eradicating basic communicable diseases. More significantly, over the last five decades India, unlike many other Third World nations, has succeeded in setting up a complex medical and health infrastructure involving teaching, training and research, drugs and medical instrument production, and medicare, including at the tertiary level. And yet, as end beneficiaries of the medical and health system, the consumers remain deeply dissatisfied with the services they receive, both in terms of cost and quality.

Some of this is reflected in macro statistics. Life expectancy still hovers below 60, infant mortality rates at 64 per 1000 live births. The percentage of children affected by stunting stands at a high 65, while 27% of all children suffer wasting. 470 per 100,000 continue to die as a result of communicable diseases and average annual incidence of TB per 100,000 population is a high 220. We have only 0.41 doctors per 1000 population, 0.7 hospital beds and the nurse/doctor ratio remains a low 1.1.

True, some of the above can be explained through an inadequate health expenditure, not unexpected in a poor country. Few, however, realize that private health expenditures are four times the public spending, and together they stand at around 6% of our GDP. Far more serious is the fact that a disproportionately large amount of our health spending remains concentrated in urban, technologically intensive, curative medicare. Even the systems of training, teaching, research or the production of drugs and medical equipment remain directed to serving the better-off sections of the population. Little wonder that disaggregated statistics by class, caste, gender and location present a far more dismal picture.

It is not that the correctives are not known. Even prior to Independence, the Bhore Committee (1946) advocated a focus on preventive health (nutrition and clean drinking water), control of communicable diseases, and the establishment of a rural medicare system. The ICSSR-ICMR Health for All report (1978) reiterated the Bhore recommendations. Dozens of significant health experiments such as those of K.S. Sanjeevi in Chennai, the Aroles in Jamkhed, Sudarshan in the B.R. Hills of Karnataka, SEWA Rural in Gujarat, the Gonoshaytha Kendra in neighbouring Bangladesh, just to name a few, provide worthwhile proposals/models which we could draw upon.

Each of these experiments have convincingly demonstrated that it is possible to train even unlettered men and women to effectively run the health services, at a fraction of the costs incurred by the health establishment. And yet, while awards have been conferred on these pioneers in plenty, when it comes to formulating policy, these voices remain marginal. What is most depressing has been our inability to even match the Bangladesh Drug Policy which banned all but 150 essential drugs. It’s another matter that the policy, like so many well-intentioned measures, was subsequently whittled down. And the pressure came not just from the multinational pharmaceutical industry (which stood to lose markets), but the local medical profession, and even the WHO. Maybe there is a lesson in this.

At least part of our problems can be traced to the equation of medicare to health care, to the willful abrogation of our rights over our bodies and health to the tribe of medical professionals. Whether or not one goes along with Ivan Illich and the thesis proposed in the path-breaking Medical Nemesis, with doctors being classified as a ‘disabling profession’ and iatrogenesis being identified as a major cause of ill-health and sickness, there is little doubt that the mystique surrounding the profession (not surprising since the doctor is seen as governing life) has resulted in a medicalization of health, a fixation with intrusive and high technology, and the acceptance a set of standards which downgrade if not rubbish people’s abilities to take care of themselves.

It is no one’s case that the spectrum of diseases today has not dramatically changed from what it was even a decade back. Industrialization, lifestyle changes and an incursion of global fashions have resulted in not only the new diseases of affluence (hypertension, cardiac problems, cancers) but in irretrievably altering our perceptions of what constitutes good health and treatment. No wonder, given our political economy and iniquitous power structure, our health establishment, such as it is, remains fixated on responding to the problems of the elite. AIDS, as the new global scare, excites greater attention than control of tuberculosis, malaria, kala-azar or water borne diseases.

The previous decade’s experience with reforms, including in the health sector, generate a mixed response. Throughout the decade of the ’90s, while we have witnessed a proliferation of private medicare facilities, including the setting up of super-specialty hospitals, the primary and secondary health care system, mainly public, seems to have slipped into a state of terminal decay. If anything, the burgeoning of the private sector, instead of adding to the overall quality and quantity of services available and thereby reducing pressure on an overstretched public system, seems to have further depleted the public health care system, most of all through hiving off trained medical personnel. This has hugely damaged the referral back up for primary and secondary facilities.

The introduction of the new WTO guidelines, both by opening up the domestic drug and instrumentation market for multinational firms and through introducing changes in patent regimes from being process to product based, too has impacted on the consumer. Prices, including those of essential drugs, have touched a new high.

Accompanying this increasing corporatization of health and medicare is the growth of the user-fee ideology, ostensibly advanced by the neo-liberal institutions of the West. Partly, this was to be expected because private providers of medicare demand adequate returns on investment. What is unfortunately inadequately realised is that the emerging system is both technology driven and expensive and for its sustenance demands either state subsidies or a new system of health insurance – a trend which is already visible. Simultaneously, pressure develops on a cash strapped state, afflicted with fiscal deficits and public debt, to cut down expenditures and focus only or primarily on basic health services.

Most critiques of our health sector reforms only bemoan the growing commercialisation of the profession and plead for a substantial expansion of the public system. While there is no gainsaying the need for meeting the WHO recommended target of spending six per cent of GDP on public health, a mere ‘more of the same’ will do little to correct the structural imbalances. We need systems that can ensure openness, transparency, accountability and fairness of the medical establishment – whether public or private.

The current approach, of extending the Consumer Protection Act to the medical profession, is clearly inadequate. For one, it does not cover the doctors in the public hospitals. Given the sorry state of their diagnostic services and record systems, it remains virtually impossible for a patient to question the treatment provided and seek redress. The private practitioners, in seeking to protect themselves from possible tort law cases, have both rushed to secure insurance cover and hide behind an even more elaborate system of tests prior to treatment. Like in the West, this trend has contributed to a further escalation in costs without in any way strengthening the rights of the patient. What is needed instead is a wide-ranging debate on medical ethics so that the profession can both remain self-governing and approximate the ideals of their Hippocratic oath.

There are at least two other areas that demand urgent attention. The first relates to our continuing obsession with fertility control. This despite the tragic experience of the Emergency, the ICPD Conference in Cairo, even the renaming of the family planning programme as Reproductive and Child Health programme. Whatever our policy-makers may claim about having given up a target-oriented approach and accepted the importance of women’s education and empowerment, the Health Ministry’s preoccupation remains population control, and that too through intrusive surgical interventions like vasectomy and tubectomy. Gender sensitivity clearly remains only a catchword.

The second issue concerns the upgradation and integration of indigenous, non-allopathic systems of medicine in our overall health policy. Even now, a majority of our populace consults non-allopathic practitioners, though their popularity has been steadily declining. These systems – ayurveda, unani, homeopathy, folk and tribal medicine, yoga – it is claimed are both more holistic in their approach to the patient and generate fewer side-effects in treatment. Countries such as ours need to explore systematically these claims and make use of their insights.

Simultaneous to altering the cognitive power balance between allopathic (modern western) systems and others, we need to correct the growing imbalance between doctors, nurses and paramedics and between general and speciality doctors. The current system of medical education ensures an over-supply of specialists (whatever be their quality) who crowd around urban tertiary service centres. This, while our primary health care system, mainly in rural areas, remains starved of trained personnel. What’s more, professional management training for record keeping and data collection has taken precedence over clinincal training of field based paramedical workers.

Health for All demands that health care be placed back in the hands of the people. In a democratic system they must remain the final arbiter of their fate. This issue of Seminar debates some of these crucial concerns.

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