THE abdication of public responsibility in health is evident when one examines the gap in mortality indicators across social groups, the resurgence and outbreak of epidemics and the poor and unequal access to basic needs for large sections of the population. The gap in mortality indicators between different social groups, viz. scheduled tribe, scheduled caste and others, reflects the extent of deprivation that exists among the vulnerable sections and the relative prosperity of the middle and upper middle classes.

An analysis of the National Family Health Survey data for infant mortality rate and under five mortality rates across ST, SC and the general population reveals that for both the scheduled categories the infant mortality rate and child mortality rate is significantly higher in both rural and urban areas when compared to ‘others’ in the population. The reasons for these variations can only be explained in terms of the deprivation of access to basic needs in terms of livelihoods, nutritional security, safe water, and shelter and health services to these sections.

Another important indicator of deprivation of vulnerable sections is the repeated outbreak of communicable diseases, referred to as the ‘diseases of the poor’ like malaria, gastroenteritis, kala azar, Japanese encephalitis and so on. While some of these have been reported in the press, many smaller epidemics have largely gone unnoticed. An analysis of the outbreak of epidemics shows both a regional and social variation. These outbreaks have been largely confined to the poorer states like Bihar, Madhya Pradesh, Orissa, Andhra Pradesh and Rajasthan. Within these and other states it is the tribal and dalit population who disproportionately bear the burden of mortality.

 

 

Investigation into the causes for these outbreaks reveals the interaction of several social and economic factors. During the mid-90s there was an outbreak of gastroenteritis in the Adilabad district of Andhra Pradesh. The cause for the outbreak was investigated by civil liberties groups, which provided some valuable insights. The report revealed that the tribal population in this district had no access to livelihood for several months before the outbreak, as a result of which they were unable to even fulfil the basic caloric requirements. The public distribution system was practically nonexistent and due to severe drought the forests could not be tapped for food sources. This was further compounded by lack of safe water supply.

When the outbreak occurred the people resorted to private practitioners since the public health services were neither available nor responsive. It is only when the suffering and death caused by the epidemic was reported in the vernacular newspapers that the government sent a team to investigate the outbreak. This is a clear case of abdication of public responsibility of not only the health services, which should have responded to the disease and death as a result of the outbreak, but more importantly to chronic deprivation due to lack of access to basic needs like safe water supply, food security and livelihoods.

 

Health services are just one input for improving the health status of the population. Therefore, their availability and accessibility is a domain of public responsibility and cannot be treated like any other commodity and left to market forces. The major reasons are the vulnerability of people who suffer from illnesses when they approach a health service provider, the asymmetry of information between the provider and receiver of care, and incomplete information regarding the service being provided since it is mediated and influenced by the doctor. These reasons become compelling arguments for advocating the importance of the state in financing and provisioning of health services.

 

 

The last two decades have witnessed many debates centred on the role of market and state in health services. There was a strong section that supported privatization of health services and others who argued about the importance of publicly provided services and how privatization undermined the values of equity and universality. Recent evidence from different countries points to ‘market failures’ in health services and thus a need to re-examine the role of the state. For public health researchers, the real challenge lies in re-examining and reasserting the role of public institutions in providing welfare services. At this juncture there is a need to creatively study the causes for their decline rather than merely describe their inadequacies. The important issues that need to be addressed are financing, responsiveness and accountability of public institutions in the context of increasing privatization and the important role that the private sector has assumed in provisioning and utilization of services.

 

 

The coexistence of the public and private sectors for provisioning gets reflected in the patterns of utilization of health services in India. Several analyses of the National Sample Survey data, National Family Health Survey and the NCAER household survey show a fairly consistent pattern of utilization. These surveys show that there is a high reliance on private providers for the treatment of minor ailments but for conditions requiring hospitalization there is variation in utilization across income groups. The middle and upper middle classes have moved out of public provisioning and rely more on the private sector for hospitalization compared to the poor who depend on the public sector.

The 52nd Round of the NSS shows that for the treatment of minor illness, the poor use public health facilities three times less as compared to the richest quintile. In case of hospitalization, the share of the richest 20% for in-patient days is nearly six times more than the poorest. This shows that in states where the private sector is not very significant, the rich and middle classes still resort to public hospitals. In the poorer states of Bihar, Madhya Pradesh, Orissa and Rajasthan the richest 20% had utilized more than 50% of total inpatient days.

This essentially implies that the poorer sections who constitute a large proportion of the population are going without care for reasons such as high opportunity cost and lack of resources, availability and accessibility. The rising cost of care for treatment in public and private hospitals explains why the poor are not utilizing services. In fact studies have shown that the poor spend a disproportionately higher percentage of their income on health services than the rich and as a result delay seeking treatment. When they do go for treatment they often have to borrow or sell what little assets they have to pay for health services.

There are several barriers that the poor and sections of the middle class face while accessing the public sector. These include lack of transportation, inadequate financial resources and insensitive treatment in public hospitals. Given the inadequacy of financial resources the poor rarely resort to private hospitals because the costs are prohibitive; even for the middle class an episode of serious illness can wipe out family assets.

 

 

Large sections of the population in this country are, therefore, faced with a difficult choice between the public and private sector. A public service, for which they have to incur opportunity costs, though less expensive, is often not easily accessible, unresponsive and lacks accountability even as the private sector is expensive, exploitative as also lacks accountability. It is in this context that one needs to redefine and reassert the importance of public responsibility in health services.

During the last three decades there has been a great deal of criticism of public health services with several studies highlighting their inadequacies. The criticism of public services in the social sectors has come from both the ‘left’ and ‘right’ for very different set of motives and reasons. Representing the interests of the working classes and poorer sections, the ‘left’ highlighted the inability of the state to address the needs of these sections while the ‘right’ which viewed welfare services as wasteful, focused on its limitations to legitimise privatization. Those who were concerned with the ill-effects of privatization put their energies into investigating the private sector and its inadequacies. However, these studies while highlighting ‘market failures’ in health services rarely addressed the reasons for the inadequacies of the public sector.

 

 

Most studies on the problems of public health services begin with the proposition that they are inefficient and unresponsive but without adequately studying the underlying causes. These studies look at the public and private sectors as independent of one another and therefore do not analyse how increasing commercialisation and accommodation of private interests within public systems affects public services in the long run. Even the comparison of quality between the public and private sectors has been fraught with conceptual and methodological limitations.

The studies on public hospitals cite inadequate funding, lack of infrastructural facilities, inadequate supply of drugs and equipment as important reasons for poor functioning. These are no doubt important factors with policy consequences but there are other processes that inhibit public services. While inadequate funding and infrastructural issues offer explanations at the level of structure, they do not adequately uncover the processes at the ‘deeper’ level in institutions and society at large in terms of changing values and norms of personnel and users of services.

The changing values and norms within public services are not isolated from what is happening in society at large. It is here that increasing commercialisation and consumerism have a deep impact on values, norms, aspirations and lifestyles, especially of the middle classes. The providers and users of medical care are largely drawn from this strata and over time they start comparing the public and private sectors in terms of salaries, patient loads and the quality of physical infrastructure. This comparison has resulted in the devaluation of public institutions that are to start with already underfunded and overcrowded with poor infrastructural inputs.

Therefore, the commercialisation of health services is not merely an increase in the number of private hospitals and clinics but at a deeper level it devalues all that the public sector stands for. Worse, it increasingly equates the ability to pay with better quality. Little surprise that the underfunded public sector was devalued by a large section of the providers and consumers. The yardstick of comparison becomes the larger private hospitals that seem to offer better care, higher salaries for doctors, better working conditions and, as a consequence, higher status.

 

 

One thus needs to locate the analysis of the abdication of public responsibility in health services at three levels – first, in terms of the changes in the structures of provisioning in the public and private sectors; second, the extent and nature of inter-relatedness between the two, and third, the changes in values, norms and aspirations in society with increasing consumerism and commercialisation during the last three decades. The process of commercialisation and consumerism has challenged collective responsibility and, therefore, undermined public institutions as well.

An analysis of health status indicators and utilization of health services acts as a window through which one can see the many realities in which we live. More than the gaps across classes, there is increasingly a certain callousness and lack of concern among the middle classes for those who live at the edge. Among the middle classes the notion of a collective responsibility in the social sectors is being replaced by individual responsibility and greater dependence on the private and non-government sectors, which may explain why there is so little pressure on the state to invest more in these areas.

 

 

In Britain the National Health Service enjoys support from the middle and working classes unlike the Indian urban middle class that has ‘exited’ from publicly provided services over the recent past. When Margaret Thatcher tried to privatize the National Health Service in Britain there was strong opposition from the middle and working classes; the ‘voice’ of protest and resistance came from both the providers and consumers and acted as an alternative to ‘exit’.

In the Indian context, the ‘voice’ within and outside the public services has remained weak. The middle class ‘exit’ from public services without giving adequate ‘voice’ in order to improve its quality has contributed to their rapid deterioration. An important question that needs to be posed is whether this deterioration should be used as a justification for dismantling the state or do we look for reasons why the state remains important and how it can be made more accountable to its citizens.

A recent research project on ‘Rights, Representations, and the Poor’ conducted in Delhi showed that citizens continue to have high expectations of the state to meet their basic needs. The survey was conducted across different residential settlements covering planned colonies, unauthorized regularized, unauthorized unregularised, and jhuggi jhompris and slums. A high percentage of those surveyed were of the opinion that the government was responsible for meeting their basic needs and saw its role in solving their problems. Many had approached the government directly, followed by political parties and the judiciary, while a small proportion had approached ‘big men’ for help. This study provides a contrast to the conventional middle class perception of the state which is marked by cynicism. For the poor, the state continues to be an important player despite the problems of poor governance, ineffectiveness and its withdrawal from key welfare areas. Therefore, even when the government is in the process of handing over welfare services to civil society organizations, the poor continue to have high expectations of the government.

 

 

This study shows that the perception regarding the role of the state in providing basic needs varies across classes. The middle and upper classes see the government’s role as redundant and advocate privatization, while the poor perceive the state to be ‘central to individual and collective life.’ This both reiterates the importance of state involvement and challenges some of the assumptions underlying privatization. The fact that the poor want the government to provide basic needs cannot ignore the poor quality of services that they receive. Instead, this perception of the state as central to collective life should be used to pressurize decision-makers to invest more in welfare services.

 

References:

Neera Chandoke, ‘The State in Popular Imagination’, The Hindu, 4 April 2004.

Rama Baru, Private Health Care in India: Social Characteristics and Trends, Sage, Delhi, 1998.

Rama Baru and G. Sadhana, ‘Resurgence of Communicable Diseases: Gastro-Enteritis Epidemics in Andhra Pradesh’, Economic and Political Weekly, 30 September 2000.

Albert Hirschman, Exit, Voice and Loyalty: Responses to Decline in Firms, Organisations and States, Harvard University Press, Massachusetts, 1970.

R. Misra, R. Chatterjee and S. Rao, India Health Report, New Delhi, Oxford University Press, 2003.