Gita Sen’s article in The Hindu “Getting India’s Health Care System out of the ICU” (“The Sunday Story,” Sept. 2, 2012) does an elegant job of masking the technological fix that grips the imagination of those who are redrafting the 12th Plan’s approach to Universal Health Coverage (UHC). Thus, Sen consistently uses the term “health care” when actually she means “medical care.” The latter only addresses illness, but the former includes the treatment of illness, along with all national programmes and welfare measures that determine health. This makes it convenient to mislead the reader into believing that the public health care system is “seriously broken” merely because there are no “free drugs,” “lack adequate staff and equipment,” and “treat patients with scant respect.” The deliberate actions of an elitist state for over 20 years in starving the public sector of resources, subsidising the private sector, and promoting the growth of the burgeoning corporate sector, (although partially acknowledged by Sen) have not been linked to the broken state of the public health care system.
“Ensuring universal health care is a major concern of governments the world over,” may sound good as an apologia for state intervention, but the fact is that different nations have different visions and contexts. The United Kingdom, Canada, Brazil, Thailand, Mexico have been mentioned approvingly by Sen, but without comparing poverty levels, the proportion of GDP invested in health, and — most critically — the fact that costs of health care in these countries are sky rocketing. Through this generalisation, therefore, Sen ignores how the Indian public health system has been commercialised and medical care opened to commercial and corporate medical care providers, merely to add to the revenue of a state driven by a neo-liberal commitment to economic growth, even though the gap between rich and poor widens and health indicators stagnate. It is only by concealing these linkages that an appealing argument can be made that “one cannot ignore the reality of the private health sector” and it “ought to be made to play its part in the move towards universal health coverage.”
Can UHC be provided without prescribing minimum standards for food, drinking water, housing and public sanitation (a point so vividly made almost 35 years ago by the Alma Ata Declaration)? What is the process of defining an adequate package of health care? Will epidemiological priorities and the needs of the marginalised determine health care, or the cost-efficiency of technologies and the need for revenue generation? Why is the Health Ministry opposing the recommendations of the draft chapter on health for the 12th Plan prepared by the Planning Commission, if its objective was that, “a strengthened public sector must be the bedrock of reforms”? Sen evades these questions by merely highlighting “management reforms” to back up more investment, “regulation” of “ad-hoc” public-private partnerships and land subsidies and tax-breaks to ensure accountability, and “independent” bodies that would ensure “standard treatment guidelines” for “high quality clinical services” through “cash-less” smart cards! This methodology of clinical medical practice widely known as “managed care” is the thrust of the 12th Five Year Plan. Designed by insurance companies to optimise their profits and control providers, it has failed globally to provide even good clinical care, what to speak of comprehensive primary health care.
“Citizen participation and accountability” are the other buzzwords that Sen uses — even though, in this regard, the failures of the panchayats and the district health committees in ensuring the rights of the underprivileged are well-known and the High Level Expert Group (HLEG) report has nothing on social monitoring mechanisms. The reality is that if the public sector service is to be made transparent, responsive and responsible, with a focus on the health-care needs of the most needy, then a relook at its priorities through an epidemiological and socio-economic lens, a review of its technological choices, and rejuvenation of its demoralised and corrupted personnel are the non-negotiables. This service may not fully provide the rest of the welfare inputs but it must prescribe objectively the standards for these and demand that these be provided by other sectors if health for the people is to be achieved. Health-care planning has to recognise the complexity of public health and judiciously use clinical facilities to change the history of disease and not to simply use them to enhance medical markets and revenues. It has taken the state over 20 years to undermine what was built in the first 40. To tackle the complexity of health care and ensure people’s right to it will take at least another 10 to 15 years so that a public sector can be rebuilt to act as the most critical regulatory force for the private sector.
To emphasise only the urgency of UHC based on creating “access to medical care services” is to deny the complexity of public health and people’s right to it.
(Imrana Qadeer is retired professor, Centre of Social Medicine and Community Health, School of Social Sciences, JNU.)