Shrinking spaces

IMRANA QADEER

GIVEN that an entire generation of planners was fed on the wisdom that population numbers are the biggest danger to the nation’s health, it is not surprising that the National Family Planning Programme acquired the dimensions that it did. It is only after the failure of the programme over the 1960s and ’70s that some rethinking was triggered within official circles and a guarded appreciation of the critiques of this isolated and vertical programme became perceptible.

While these critiques involved different perspectives, all accepted the premise that population is neither the single-most critical problem nor is it a number’s game. It was argued that a population policy has to be integrated into a planning process that aims at growth with necessary levels of welfare for all. Numbers are important only to the extent that they determine the content and nature of the planning process.

In fact, critics argued that coupling growth with welfare itself becomes an instrument for promoting balanced growth. In situations of undesirably high growth rates, it ensures availability and access to means of fertility control. It also directly influences those values and institutions that determine birth rates by providing security and job opportunities which affect desired family size, adoption practices, changes in family dynamics, and so on. These arguments were based on research work done in India starting in the late ’50s (UN and GOI 1961), followed by a range of scholars who highlighted relationships between social structure, productive processes and the organisation of work, and their key role in determining family size (Mamdani 1972; Mitra 1974; Djurfeldt and Lindberg 1975; Banerji 1982; Rao 1994).

 

 

Despite the rethinking, and some amount of integration with family welfare, the programme continued to dominate the health scenario in India and, in the name of integration, usurped resources meant for other health initiatives. This only reflected the rigidity of a significant section of decision-makers who, convinced of what they had learnt in the ’60s and, therefore, indifferent to the ongoing debate, continued to push the agenda of population control through technological intervention. It is therefore not surprising that the history of the programme is essentially the story of the successive retreat and reassertion of these decision-makers. Rejection of disincentives and incentives in principle, and the acceptance of a target-free approach, came only at the turn of the 20th century (GOI 1993).

These changes were an outcome of the changing perceptions of demographers and their influence within major international funding agencies (Preston 1984). In India, issues such as sex ratio (Mitra 2001), female education, work participation, need for interventions to change social norms rather than fixing inappropriate demographic targets (Bose 1987) and son preference and gender bias (Das Gupta, et al. 1998) attracted increasing attention. An older concept – the notion of population momentum – came to the forefront.

It was pointed out that this is the most significant component of the overall population growth (61%) while the unwanted component of growth is only 18.6 % (Visaria et al. 1996). This called for more restrained expectations from the family welfare programme and greater emphasis on welfare/developmental inputs that actually influence the desired family size. Issues such as the space for human rights in population policy, its exclusive focus on women, the safety of contraceptives, rising female foeticide, and the implications of poverty became part of the demographic debate.

Unfortunately, these pertinent questions and the emerging concern for evolving a broad-based family welfare programme as a part of the primary health care system never adequately penetrated the main body of political decision-makers and planners. Added to this was the official acceptance of the structural adjustment programme in the ’90s and its justification of cuts in the welfare sector. Not only was any possibility of a comprehensive approach to population planning lost, but the urgency of number control was heightened.

 

 

This obsession with demographic goals is clearly visible in the National Population Policy (NPP) (GOI 2000). Despite a preamble that speaks of the well-being of people as well as a comprehensive and broad-based approach, the strategies proposed remained techno-centric, demographically oriented, focusing on women, and fragmentary. Instead of being the focus of strategies for well-being, women became the instruments for population control. Thus, even in a limited sense and despite all the promises made in the preamble, it was not women’s overall health but reproductive health that eventually mattered.

The NPP calls for a target-free comprehensive approach on one hand, but projects replacement level fertility rates by 2010 and a stable population by 2045. Inevitably, it is riddled with contradictions. For example, India has drastically reduced investments in sectors that critically affect health, such as the food security system, education and transportation services. Yet, despite all the noise about ‘convergence of social sector programmes’, effective social sector planning finds no space in population policy. Within the health sector, even though the official models (European and American states) invest substantially in this sector (44-100% of the total investment in health) (WHO 2000; US Government 2001), resources in India continue to be poured into an isolated Reproductive and Child Health (RCH) strategy.

 

 

Similarly, while the draft document includes control of communicable diseases as a part of its integrated approach, it proposes to deal with RCH, HIV/AIDS, and sexually transmitted diseases through vertical and independent programmes. This can only be at the cost of these very problems since they cannot be tackled in isolation from the problems of the existing health care infrastructure. As RCH becomes the prime mover for fertility control, it is inevitable that both the concept of primary health care and a comprehensive approach to fertility control get undermined.

Added to these is the inherent contradiction between claims of promoting a target-free, voluntary approach to service on the one hand and inclusion of incentives on the other. These incentives are in the form of petty insurance for emergency services for the under-served population groups, or linking of continued facilities with observance of small family norms. In other words, basic services have been transformed into incentives and the policy presents this transformation as the benevolence of the state!

Yet there is an obvious insensitivity to the plight of women. Legalisation of abortion as a health right has been openly transformed into a population control tool. The draft document talks of making abortions more ‘attractive’ for women and not of ensuring a situation wherein no woman is forced to make such a choice. To promote abortions, for instance, it is proposed to ‘eliminate the cumbersome procedures for registration of abortion clinics!’ At the same time it is assumed that even without any conditionalities, it would be possible to ensure safe abortion by simply formulating and notifying standards.

 

 

Yet another contradiction is that while the budget is actually doubled for the family welfare department, ostensibly to strengthen manpower and infrastructural facilities, for actual provisioning of services the document indicates greater reliance on corporate and NGO sectors and their managerial, professional and technical expertise. Even decentralisation through panchayati raj is to promote mobilisation of resources rather than devolution of administrative and financial powers!

There is little evidence that the investments will be directed towards bringing about internal improvements, and it is assumed that the market will provide the critical means for provisioning health services. What then is the purpose of doubling the ministry’s budget? Does this essentially mean that state resources will now go to subsidise private enterprise? There is every indication that this may be so, since accreditation and training of private practitioners, and involving the corporate and NGO sectors are the sheet anchors of the population policy.

The interpretation of this document by the states shows that the message has gone home. One after the other, state population policies have glorified a vertical, woman-centred, techno-centric approach to population planning. There are no bars to any technology – whether it be injectable contraceptives (harmful for the ill-informed, anaemic, malnourished, and overworked women who have no access to care) or Norplant pellets, whose trials themselves became controversial (Gupta 2000).

Irrespective of the strength and efficiency of their health infrastructures, Uttar Pradesh, Madhya Pradesh, and Maharashtra are prepared to use coercive methods. Although unable to effectively utilise the huge funds provided by international agencies, Uttar Pradesh has taken a retrogressive step in announcing that services – even for RCH – will not be free of charge. Madhya Pradesh has proposed to penalise those adults who were unfortunate to be married at a young age, and Maharashtra has come forward with the most innovative cruelty of proposing denial of food rations and free education to the third child! These policies are still being debated and the saner elements in the Department of Family Welfare may still be trying to bring some balance into the state policies, but it is amply clear that the loopholes in the NPP were not accidental (Qadeer 2002a).

 

 

Two key draft policy documents, circulated after the NPP, leave little space for doubt that the population policy preamble was more of a smoke screen than a genuine commitment for social change. These are the drafts for the National Health Policy (NHP) (GOI 2001a) and National Strategy for Social Marketing (NSSM) (GOI 2001b). Both consciously promote fragmentation and commercialisation of health services.

This was certainly not inevitable but has happened today, because both the political commitment for the welfare of civil society, as well as the accountability of public servants have lost their value in retaining political and administrative power. Power today rests on one’s ability to enter value-free ‘partnerships’. Once in power, then staying on in power defines the logic of policies and not vice versa. In other words, like population, political control too has become a numbers game – a fragmentation of the political process.

 

 

To understand this process one needs to appreciate the power of the free market and private capital to transform anything and everything into commodities, be it body or intellect. Public health is no exception. Its most popular (though not necessarily effective) tools – drugs, equipment, and vaccines – the products of biomedical success, are the market favourites. Research into new products has become an extremely expensive affair. Thus, the most powerful transnational and multinational companies now forge partnerships with private capital, governments and UN bodies in the name of progress and science to reduce their costs, enhance profits, find easy access into new markets, acquire respectability and marginalise competitors.

These global formations, referred to as GPPP (global public private partnerships), have invaded even UN institutions that, along with the IMF and World Bank, influence policies in the Third World (Buse, et al. 2000). Third World economies that cannot withstand international monetary and financial pressures, succumb by letting their benefactors plan for them. Thus, in the prevailing economic crisis, while the First World countries juggle to protect and retain their own welfare institutions, they join hands to pressurise the weak to get hold of their markets, as is evident from the GATT proceedings (Koivusalo, et al. 1998).

The 1992 World Bank document on ‘Indian Health Sector Financing: Coping With Adjustment’ (World Bank 1992), is a perfect example of the arm twisting methods of the funding agencies, but the draft NHP currently being circulated is no less a reflection of a poor nation planning its resources for the benefit of the richer nations and, of course, its own elite. The draft NHP fragments public health by ignoring the role of the welfare sector and highlights an isolated techno-centric approach.

 

 

It rejects even the previous selective primary health care approach (Newell 1988) by severing the linkages between public sector institutions, thus ‘liberating’ secondary and tertiary care institutions to become commercial. It shifts focus and invites the private sector to take over the state’s responsibilities. To keep the conscience of the middle class unblemished, it claims that those below the poverty line would be provided free care. It is clear, however, that this is a tall claim, since there are hardly any means to identify the poor in a country of over one billion. Even those at and just above the poverty line are no better off.

In its highly commercialised vision, the draft NHP document reconfirms the dependence on NGOs and the corporate sector for medical care and promotes opening the public sector to private investment. It sees urban medical institutions as service production units that are at par with production units and, therefore, important sources of earning foreign exchange, even if at the cost of the poor. Disease control programmes are donor driven and vertical (cf. tuberculosis, malaria and HIV/AIDS control programmes). The policy document exempts these from its proposed integrated disease control strategy (Qadeer 2002b). This leaves only RCH services to be provided through the primary health care network as leprosy control is in any case a vertical programme and filaria a regional public health problem!

It is evident from our reading of the two draft documents that the comprehensive view of health promoted by the state over the ’70s and ’80s has been effectively marginalised. Campaigns and camps have replaced the slow but steady growth of infrastructure and, as a result, the latter is reduced to a conglomerate of unconnected institutions. This fragmentation of health service infrastructure is readily conducive to commercialisation of the Indian public health system. It reduces concepts, such as comprehensive population and health care planning, into mere slogans and gives centrality to privatisation and commercialisation of services, especially medical care at all levels.

 

 

The notion of public-private partnership is projected as a means of acquiring adequate population coverage, even when the reluctance of the private sector to grow in backward areas is well demonstrated (Baru 1993). Cleverly, the draft NHP creates an illusion that primary level care would be strengthened as investment in the public sector is increased. Not only would service quality be improved through better training and supply of drugs, but access to services would also be improved. However, this illusion is exposed by the third draft document that brings out the real strategy of convergence – not of services, but of powerful commercial interests.

The draft National Strategy for Social Marketing (NSSM) puts all our illusions to rest. It blatantly proposes both: (a) differential quality of services, and (b) provision of services on payment. Thus, ensuring equity and minimum quality of health care are removed from policy focus.

 

 

This may not have been considered alarming were it a policy proposed by the industrial houses, but coming from the Department of Family Welfare of the Government of India, it raises serious doubts about the intentions of the ministry. The main arguments put forward to support social marketing are: (i) it encourages socially beneficial behaviour; (ii) it helps reach out to the population that is unserved or inadequately served; and (iii) it improves coverage and availability by lowering costs. Not only are these arguments invalid, they are based on highly questionable assumptions.

To begin with, the acknowledgement by the NPP of ‘unmet needs’ among a substantial section of the population, indicates that socially beneficial attitudes already exist. Policies need to focus on improving systems of service provision rather than concentrating on changing behaviour. More critical than changing behaviour is the challenge of meeting these needs.

This brings us to the second argument that social marketing is a means of serving the unserved and the under-served. In a situation where the private sector is not interested in taking up simple preventive programmes or services that do not promise expected profit margins without substantial subsidies, and where existing public health services are actually saturated while being undermined, the idea of substituting simple medical products with popular commercial ones may sound attractive to those unfamiliar with its history.

However, the question here is quite different. Social marketing is being proposed for a vast range of drugs and services that need medical supervision. In this case we need to know where subsidies give better results in private sector supported social marketing organisations or in the public sector? It is obvious that social marketing has limited scope as it cannot provide goods that require supervised administration. The health infrastructure on the other hand can provide a range of services. The draft NSSM assumes that the shift of utilisation pattern from public to private sector justifies broadening the scope of social marketing to services as well. The fact is that this shift is taking place because of the saturation of public sector services given the falling investments in the health sector.

 

 

In addition, the introduction of user charges that make public sector services as accessible or inaccessible as the private sector services, has led to a shift towards the private sector, specially in case of minor illnesses (Iyer, et al. 2000). Reforms and resource investment can put them back on the rails. Subsidy to the private sector, however, goes into private pockets and does not contribute to the emergence of necessary infrastructure. There is no evidence either to show that social marketing substantially increases coverage. The draft document itself concedes that social marketing was experimented with as far back as the ’60s and ’70s, found wanting, and therefore abandoned.

The third claim is that social marketing improves coverage through lowering costs. There are three problems with this assumption. First, the low cost of social marketing simply means that state subsidy is being directed to the corporate, NGO or other private social marketing organisations (SMOs). These organisations do make their infrastructure available but only on the condition that they make adequate profits.

With declining state control, the use of multiple channels for provisioning of services and products further increases the probability of these channels maintaining their initial financial profit margins, especially in the absence of any monitoring. Thakur points out that SMOs such as Population Service International (India), sold the same condoms, earlier marketed at 33 paisa, at thrice the price after repackaging and changing the brand name (Thakur 2002).

There is a range of other issues that are equally critical. For example, the question of quality. The draft document for social marketing pronounces three shades of commodities (with literally three colours of packaging) to distinguish the socially marketed products from the ‘inferior’ quality free services of the public sector network and the ‘superior’ commercially marketed packages. If the source of these products is the same and the multiplicity of the agencies is primarily to increase outlet points, then the assumption that the socially marketed product is relatively superior is incorrect.

 

 

However, if the SMOs are producers of the products as well, then the question of quality control cannot be left to them as proposed by the draft. The office of the Drug Controller will require strengthening to monitor and regulate quality. Neither does this urgent get the attention it deserves, nor are the actions against offending SMOs clearly articulated in the draft policy. In a way then, the acceptance of differential quality of products rationalises and legitimises poor quality services and inadequate controls for the marginalised.

The differential pricing policy is presented as an intentional step through which the upper class users are made to subsidise the poor. This is fallacious as the profits are going to the pockets of the SMOs and not to any common pool that is reinvesting in service provision. In fact, with the changing taxation system, the very basis of risk pooling is being undermined and, if anything, the burden of care shifted from the rich to the poor (Evans 1997). It also needs to be pointed out that it would be unethical for the state to entice NGOs (that claim to be non-profit organisations) into social marketing based on the principle of retaining the profit margins!

 

 

Interestingly, the policy document proposes that: ‘As the consumer ability to pay increases, he will graduate from relying upon the public sector network to the multiple social marketing outlets for the same products, and eventually to commercially marketed products for meeting their needs. Facilitation of this shift is the rationale of the NSSM.’

Why those among the not-so-poor, who can use good subsidised products, would move out to the purely commercial market is not explained, nor is any economic logic offered to justify this optimism. With job opportunities on the decline, poverty levels increasing (Sen 1996) and economic growth rates dropping in real life, the roots of such absurd assumptions can only lie in the narrow vision of the strategists who can barely see beyond the Indian upper middle class.

The current policy proposal for social marketing does not confine itself to the supply of condoms. It talks of low hormone pills, emergency contraception pills, intrauterine devices, unspecified new contraceptives (which could even be the controversial injectable contraceptives), STD drugs, tubal ligation, and no scalpel vasectomy, along with other ‘socially beneficial health products’ including Indian systems of medicine.

Products such as rehydration salts, iron folic acid tablets, and mosquito nets are already being socially marketed, i.e. being subsidised. This is serious as the policy proposes introducing unsafe drugs into the market but does nothing to ensure the safety of the user. At the same time, even the little that was reaching the majority of the poor will now be priced. The document envisages ‘expanding the basket with time and experience.’ Does this mean that, not satisfied with user charges, the state has now decided to let privatisation in through the back door?

 

 

Perhaps the U.P. population policy was a forerunner, as it proposes charges for even the RCH services right from its inception. This impression is substantiated by the fact that social marketing is to use not only the outlets provided by the usual networks but would also be done through government agencies such as the primary health centre network and the integrated child development services! The fate of care provided to the poor in a situation where, even officially ‘better services’ would be provided through paid channels, is obvious. Also obvious is the confidence of the state, that when people are confronted with death and disease, they can be forced to pay!

The direction in which state policy is moving is further reflected in the agencies from where the state is seeking comments and inputs. It is worth noting that both the European Commission and USAID in their comments on the draft suggest that mention of commitment to health improvement planning is not consistent with the policy of social marketing and hence should be deleted from the vision statement of the draft. Need based planning is perceived as a danger for social marketing. The latter must pursue the commercial market and not be diluted (GOI 2001c).

 

 

This draft NSSM document then is the essence of the new vision of globalisation inherent in the drafts NPP and NHP. The NPP used a liberal language and was hesitant as well as vague in actually spelling out the role of the market. However unacceptable, the NHP confined its proposal for commercialisation to medical care and, though it saw the private sector as a partner in the provision of primary level care, it let the public sector alone at least at this level.

The draft NSSM calls a spade a spade and brings in the stakeholders’ real interest centrestage in the policy-making process. It pushes policy in a direction that changes priorities – need-based comprehensive health planning becomes peripheral while the interests of the private sector are legitimised. In the name of better management a host of private consultants, technical support groups, experts, corporate units and NGOs will get business. As a result, state subsidies will be shifted to the private ‘partners’ and the public sector will be left high and dry. This massive shift of state support is not based on any convincing evidence of the SMOs superiority or efficiency (Baru, et al. 2002).

The message of the draft NSSM is loud and clear. In matters of life and death (as well as births!) when the state services are falling apart out of sheer neglect and indifference and people have no alternatives for survival, they can be forced to purchase the services even if it is at the cost of their future security! Therefore, there is no need to invest state energy into public sector health services.

This is the time to create new health markets that may open up, both in rural and urban areas. In the process capital will grow faster on the living corpses of the poor. Thus, a universal logic is unfolding. If school children are failing in schools run in the slums and resettlement areas, privatise the schools (TOI 2002); if people going to the PHCs continue to be sick, privatise the PHC. Never raise the issue of accountability, so that the same politicians, bureaucrats and administrators, who were responsible for the failures of the past, may continue in power.

That Mahalanobis’ pioneering experiment with national planning would end up in such an abysmal heap of contradictory, at times inane, policy documents is a sobering thought. It is also a message that when markets assume such supremacy, fragmentation, commercialisation and individualism cannot be fought through state planning exercises. Civil society will have to reassert values such as accountability, equity, and universality of welfare services.

 

 

It must be asked whether it is an act of social responsibility that the same Ministry of Health and Family Welfare should float three documents speaking three different languages? And if the principles of the National Population Policy are being negated by the draft NSSM, would it not be correct to reject one or the other outright? The ‘real’ intentions must be made clear, since empty phrases about the nation’s well-being are no more sufficient or convincing.

 

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