P. Sainath

There's a clamour for 'public-private' partnerships in the sphere of Indian health care. But there is very little that is public left in the sector.

THE OLD idea that the media are not interested in issues like health needs some revision. They seemed interested in little else in Mumbai these past three weeks. True, there were limitations. This was solely about the health of one man. And it is hard to recall a moment in history when anyone's digestive tract hogged the limelight the way Amitabh Bachchan's did. (The earlier record - now a poor second - came when Aishwarya Rai fractured her small toe and was 'air-dashed' from Nashik to a Mumbai hospital.)

This time it was dedication beyond the call of duty. We do know scores of journalists covered Mr. Bachchan's illness. But over 20 media personnel even slept in their vehicles outside the Lilavati hospital for several nights. That is, on those nights they could sleep. A few were spent in watching which celebrity's car went in or out. This meant hours of squatting on the pavement in top alert. Worse, the hospital had seven gates and you never knew which one Mr. Bachchan might escape from. Quite a few of the reporters saddled with this assignment themselves felt it bordered on the insane.

Leave alone the gruesome diagrams some newspapers rejoiced in carrying. One channel had its anchor quiz a doctor against the backdrop of a huge poster showing a large intestine. This vanished shortly after when someone figured out it was Mr. Bachchan's small intestine that was the cause of concern. But why let the facts get in the way of a good story?

A fraction of that focus on the exploding public health crisis in the country would be nice. This is a nation where millions have lost what little access to health they had. Where the user fees game has added to the numbers of the poor who cannot pay what is demanded of them. Where farmers have mortgaged their lands to pay hospital bills.

And where the vice-like grip of a rapacious private sector makes escape impossible.

Medical care is now the second most common cause of rural family debt. The number of people not taking any treatment in the mid-1990s because they couldn't afford it was double what it was a decade earlier. By 1996, nearly one in every four rural Indians and one in five urban Indians fell into this group. Things have only worsened since then.

Bill Gates made a striking statement during his recent visit. The health of children, he said, is far more important than computers. Now you can figure the thinking behind those words in two ways. One, maybe the noble statement of a basic truth. Two, the astute businessman in Mr. Gates recognises a much larger industry than most imagine. There are big bucks being made. Household or family (out of pocket) spending was close to Rs.100,000 crore in 2003-04. The same year, as NSS data show, just 1.4 per cent of urban families had Net-connected PCs. In rural India, they are almost non-existent.

Many of India's giant corporate hospitals got millions of rupees in public subsidies. These came in the form of almost free land. In the waiver of import duties on costly equipment. And much more. All these against the promise that some 30 per cent of their beds would be free and reserved for the poor. It wasn't all that long ago that the Delhi High Court pulled up such outfits for their betrayal of that pledge.

"'Helping' the rich often means empowering the poor," an editorial in a major newspaper recently argued. In truth, it amounts to looting the poor to reward the rich.

Meanwhile, those caught up in the agrarian crisis fare worse. Suicide-hit Vidharbha households surveyed recently by The Hindu had incurred health costs of tens of thousands of rupees. Most of it borrowed. In Anantapur, Andhra Pradesh, last year, a farmer rushed to hospital by friends after consuming pesticide, was furious with those who had saved his life. "It took four years to run up the Rs.1 lakh debt that made me attempt suicide," he complained. "It took four days to run up this hospital bill of Rs.45,000." As the state spends less and less on the needs of the poor, their problems grow more and more.

None of this has stopped claims that the way out is to further enlarge the role of the private sector in health. One misguided notion is that great changes in rural health can be brought about "without substantial increases in public fund allocations." All it needs is that mantra, "public-private partnerships." Odd, since there is very little that is public left in the sphere of health care. Since public spending is a mere 0.9 per cent of GDP. Down there with the worst levels in the world.

"Among the most privatised"

"The Indian health sector is among the most privatised in the world," points out K.N. Nagaraj of the Madras Institute of Development Studies. "Our health expenditure data show that clearly." Very few nations have lower public health spending (as a share of GDP) than our own. Those include Myanmar, Burundi, and Azerbaijan. On the other hand, maybe just 12 developing nations exist where private spending on health (as a share of GDP) is more than in India.

As Dr. Nagaraj points out: "If we look at private spending as a share of total health expenditure, it gets worse. In India it is 78.7 per cent." Are there any nations where private spending is higher? Yes. Myanmar, Cambodia, Togo, Sudan, Guinea, and Burundi.

Do corporates account for the major share of that 'private' spending on health? Hardly. Their share is just 3 per cent. Does external funding (a la Gates) make up a chunk of it? No. Just 2 per cent. Do NGOs mean much on that front? Not at all. Just 0.3 per cent. The rest of the more than Rs.100,000 crore that is spent on health comes from ordinary households. It's what the Indian people pull out of their own torn pockets. And their spending is growing at about 14 per cent a year.

The damage has much to do with the gutting of basic public services. With mindless privatisation. It has a lot to do with rising inequality. As the UN Human Development Report 2005 puts it: "Some of India's southern cities may be in the midst of a technology boom, but one in every 11 Indian children dies in the first five years of life for want of low-technology, low-cost interventions." The poor cannot hope for even the bare minimums now. Not in the age of market fundamentalism. The rot is now worldwide.

The single biggest reason that General Motors is closing plants and throwing out 30,000 workers is: health costs in America. It will not honour its deal with its workers on that front. As Paul Krugman writes: "If the United States had national health insurance, GM would be in much better shape than it is." Because last year "GM spent $1500 per vehicle on health care." In Japan, Toyota spent just $97 per vehicle on the same head.

In 2003 nearly 15,000 people, mostly senior citizens, died of a 'heat wave' in France. Hardly that country's first heat wave. But France had seen quite a few cuts in health care budgets. China was the worst hit by SARS, which caused global panic. When thousands of factories were shut down in that nation, millions who accessed their health through workplace facilities lost that access. Countless dispensaries and hospitals ceased to exist. The loss of that early warning system did untold damage to China.

In the United States, thousands of elderly Americans cross the border into Canada each year to buy the drugs they cannot afford in their own land. The same drugs are sold both sides of the border. But in the U.S., the corporations marketing them have total control over pricing. Who does the state help? Police have raided chemists in Michigan to confiscate genuine but cheaper drugs.

In Moscow, once capital of a superpower, hundreds die of hypothermia in winter. Even as more Mercedes Benz cars are sold each year. In Russian Karelia, which once enjoyed the same standards as those of neighbouring Finland, things changed after the old public health system collapsed.

Once, life expectancy was the same both sides of the border. Now a Finn could live 15 years longer than his Karelian neighbour.

Africa has also lost billions of dollars in health personnel to Europe and the United States. South Africa and Zimbabwe, with a huge HIV-AIDS problem, are losing doctors at a deadly rate to the west. Their public health systems are a shambles. There are now more African doctors in the U.S. and Europe than in all of Africa.

Yet, we celebrate the inequality we daily entrench. And the damage we are doing in sector after sector impacts adversely on public health. This is a nation where water-borne and water-related diseases are linked to a huge share of public health problems. And yet the deadly race towards privatisation of water at all levels. Imagine the outcome on people's health of reducing water to a commercial good. India needs a strong public health system. But our direction is the opposite. Public ill health, private profit. That's the partnership we are forging.