Year : 2013 | Volume
: 57 | Issue : 4 | Page : 231--235
Contradictions of the health-care system in India and a strategy for health-care for all
Senior Advisor, SATHI-CEHAT, Co-convenor of Jan Swasthya Abhiyaan, Maharashtra, India
8, Ameya Ashish Co-operative Housing Society, Kokan Express Hotel Lane, Kothrud, Pune - 411 038, Maharashtra
The contradiction between the socialized nature of the modern health-care system (inclusive of both clinical and social medicine) versus the narrow control over it is obvious in private health-care. However, this contradiction is present to some extent, in its own way, even in the public health facilities in India. To formulate a program for health-care for all in India, it is necessary to grasp these contradictions in both private and public health-care and accordingly conceptualize a strategy to overcome, resolve these contradictions.
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Phadke A. Contradictions of the health-care system in India and a strategy for health-care for all.Indian J Public Health 2013;57:231-235
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Phadke A. Contradictions of the health-care system in India and a strategy for health-care for all. Indian J Public Health [serial online] 2013 [cited 2021 Jan 18 ];57:231-235
Available from: https://www.ijph.in/text.asp?2013/57/4/231/123256
The discourse on the goal of health and health-care for all (HCA) was inaugurated in India by the report of the Bhore committee in 1946. Since its inception in 2000, the Jan Swasthya Abhiyaan, which co-ordinates the people's health movement (PHM) in India, is putting forth, the demand and program for health and HCA,  whereas in October 2011, with the publication of the report of the high level expert group (HLEG) on universal health coverage (UHC),  a new phase has started. Discussions on recommendations of the HLEG inevitably bring up the nature of public and private health-care in India. Different analysts highlight one aspect or the other of these two components of the health-care system in India and accordingly their program for achieving "HCA" is shaped by this understanding. Some analysts take into account only the negative side of the Indian private health-care - it's total lack of regulation, it's exploitative, greedy nature and hence do not see any role for private providers in universal health-care. On the other hand, some analysts harp on only the deficiencies, distortions in the public health system (PuHS) - it's hierarchical, bureaucratic, insensitive, corrupt tendencies and are quite skeptical about its capacity to play a leading role in the Universal Health-care (UHC) system. Both these types of analysts miss out on the contradictions of the private and public health-care in India and hence do not throw light on the way to resolve the contradictions to develop the system of UHC beginning from what we have today. This note written within the framework of an activist of the PHM, briefly outlines contradictions within both private and public health-care in India in order to clarify the conceptual basis of using the potential in both these components to develop the UHC system in India.
Contradictions of the Modern Health-care System
In order to grasp the contradictions of private and public health-care in India, we need to go beyond purely formal categories of private and public health-care sectors, as in Indian health-care system, there is some "private" in PuHS and vice versa. Hence it is better to conceptualize our complex reality in a broader framework. On one hand, there has been progressively increasing socialization of the process of health-care, whereas on the other hand there are the "private", narrow interests of the owners, controllers of the health-care system. Thus on one hand, all the ingredients of the modern health-care system in India-production of medical knowledge, training of health-care providers, production of diagnostic, preventive and therapeutic modalities are being more and more socialized during last 150 years; there is a clear need that health-care decisions follow socialized medical sciences and are not guided by personalized understanding of health and health-care. However, on the other hand, actual decisions making about clinical interventions and about public health measures continue to be influenced either by the myopic private, commercial interests of the medico-industrial complex or by myopic interests of the ruling class and it's State. The latter are realized by a handful of state officials who are directed by ministers and are hardly accountable to the people. These contradictions are reflected in the generation of medical knowledge.
The private, especially the corporate health-care, is a clear example of this contradiction between socialization of health-care versus myopic, privatized control over decision-making. The medical industrial complex has its focus more on treating rather than preventing ailments; its preventive strategies are also such that the result is more of perpetuation of the dominance of the medico-industrial complex and less of prevention of diseases. Overall, in this health-care system, people become more of raw material for the profits of the medico-industrial complex rather than the controller of their own health and well-being. What seems surprising is that even the PuHS reflects this contradiction between socialized nature of modern health-care versus control by narrow, vested interests.
Contradictions of the Public Health-care System in India
Like parliamentary democracy, the PuHS is the result of and an assertion of some of the democratic and human rights of ordinary people. Hence in India after Independence there was considerable growth of public health services, which were more or less free at the point of service and a number of public health programs were launched, which helped to curtail epidemics. The PuHS was, at least during the immediate post-independence period, not directly affected by the interests of the Indian medico industrial complex, which was itself under-developed then. This substantial development of PuHS was on one hand a gain for the ordinary people. However, the PuHS does serve some narrow interests and hence has its negative aspects from the point of view of the people. Overall it functions for the benefit of and under the hegemony of the ruling class. Moreover, the extremely hierarchical nature of the PuHS perpetuates the dominant culture of "command and obey," which it inherited from the Colonial State. Secondly, the health-care offered by the Indian PuHS is seen more as a patronage of the state and less as people's right. Thirdly, the policies of the post-colonial PuHS have been substantially influenced by Western experts directly or indirectly tied to imperialist interests. This is despite the opposition to this imperialist influence by some Indian experts and their very sound, scientific, pro-people work. This imperialist influence has led to the domination of vertical health programs, executed in the fashion of military interventions. The "advice" of the Western experts has been followed even when it violated the science of public health. Thus in the polio eradication program, the concept of "eradication" was twisted to suit the needs of this ill-conceived program.  The biggest and the longest program executed by the Indian PuHS, the so-called family planning program has, among other things, led to so much oppression of people, especially of women. Fourthly, the PuHS is partly riddled with the private sector dynamics and influences such as legal and illegal private practice, extensive linkages to private labs, medical stores and imaging centers and referral linkages to private hospitals. Lastly, during last 20 years, due to the policy of neo-liberalism, the Indian PuHS has been influenced directly by the corporate sector. The recent vaccine policy draft published in April 2011 is an example of this tendency; it legitimizes vaccines of questionable cost efficacy and safety getting pushed into the PuHS for the benefit of the corporate sector.
It's not merely a question of corrosion of the Indian PuHS by the private interests. The various problems such as corruption, negligence, illegal absenteeism of the doctors during duty hours, the callous attitude of many medical officers towards patients etc. all denote unaccountable power of these officers. Similarly, the bureaucratic privileges of the babus, especially of the higher officials, their lack of accountability to the ordinary people, the lack of transparency in their functioning-all this means that the health bureaucracy has partially "privatized" the Indian PuHS to serve its own interests.
The health bureaucracy is hand in glove with the larger public bureaucracy. The health-care expenditure incurred by the Government for the bureaucrats compared with that for ordinary people gives an idea of the bureaucratic privileges of the Indian Public bureaucracy. As mentioned in a National Commission on Macroeconomics and Health background paper, in 2000-2001 when the annual health expenditure of central and state Government together was around Rs. 300 per capita, the out-patient and the in-patient expense per card issued to retired civil servants and dependents in the Central Government Health Scheme was Rs. 10,170 in a year. 
To grasp this reality of partial "privatization" by the bureaucrats of the PuHS, we need to draw upon learnings of the debate on the nature of social formation in the Soviet Union.  In this debate, the difference between juridical public ownership and the real control over social production and appropriation of surplus by the bureaucracy was emphasized. From the other end, we also have to learn from the Canadian experience.  Canada has one of the best UHC systems and yet majority of the hospitals are not owned by the Government. Though the State pays for most of the health-care, most doctors and hospitals in Canada are in the non-profit Trust sector. This indicates that the actual decision making rather than juridical ownership can be more important in certain conditions. In India, there is no doubt that the Public Health Service will have to be the backbone of the UHC. For this to happen, the Public Health Service needs to be expanded and strengthened substantially. This will ensure that it becomes a critical and formidable player in the health-care system so that through its strength and quality, it would make the "in-sourced" private providers play a more socially responsive role. However, we should clearly acknowledge that the PuHS needs to be not only expanded and strengthened, but also needs to be reoriented so that it stops serving certain local, national or international private interests.
Certain commonality between the formally distinct private and public health-care is clear also when we come to the second basic contradiction of the health-care system - between the producers and consumers of health-care. In the field of health-care, this contradiction attains significance because the consumers of health-care, the patients are inherently vulnerable vis-a-vis health-care providers. In the framework of commodification of health-care, this vulnerability results in commercial exploitation of patients. Moreover, with the rise of the monopoly medico-industrial complex, it is no more a mere question of commercial exploitation of patients, but also of medicalization of life and of expertism, which further erodes the autonomy of the citizens and self-care becomes an anathema. Medicalization of life and expertism is not restricted to private health-care and is seen even in nationalized health-care in UK or the erstwhile Union of Soviet Socialist Republics. Expertism and statism convert people into an appendage of the paternalistic health-care system rather than people becoming prime movers of this system as part of the process of controlling their own lives. The new left critique of statism, expertism, racism and patriarchy of the health-care system goes beyond a critique of its nature as a commodity. ,, For example, the new left critique points out that our health-care system is not only shaped by the logic of the market but also by patriarchal relations. The medical industrial complex needs ever expanding markets and within the dominant paradigm of patriarchy, the woman's reproductive system offers a convenient arena for the expansion. This encroachment of women's reproductive health goes beyond the logic of private health-care. Women have been convenient targets of the official family planning program. Widely prevalent unsafe use of female contraceptives in the PuHS and focus on tubectomy instead of vasectomy is due to a combination of patriarchy, corporate interests and unaccountable power of the PuHS.
Finally, especially since 1990s, the public and private health-care has become an organically linked complex. Many public doctors indulge in private practice by breaking service rules with impunity. It is an open secret that a substantial section of doctors in rural hospitals and district hospitals spend more time in their own private hospitals than in the Public Health Facilities (PHFs). Some of them turn up for duty only a few days in a week! Across different levels of PHFs, patients are diverted to private hospitals. The private medical sector operates as an extremely powerful "magnet" for doctors, especially specialists, drawing them away from working in public services.
Despite these limitations and problems of the Indian PuHS, there is no doubt that it is a higher form of social organization compared with the private sector, and has a very crucial potential to contribute to the goal for 'Health Care for All'. However, let us not restrict our understanding of the PuHS by considering only its formal separation from private health-care. We have to insist that the decision-making in the PuHS has to be fully "Public", has to be more democratic both within and outside. The extremely hierarchical relation between the Nirman Bhavan in Delhi and the Mantralayas in the State capitals with the rest of the health bureaucracy is quite obsolete. Hence is the command-obey system from the Minister to the directorate of health services to the lowest worker in the primary health-centre. This has to go and decision making within public health services has to be progressively more and more democratic, transparent, evidence based, sensitive and accountable. It has to be not only people-centric, but ordinary people should have some active, effective role in the decision-making process. For rendering the health services more accountable and sensitive to the people, the on-going experiment in Maharashtra and certain states, of the community based monitoring and planning of public health services has to be improved and generalized.
Given this whole background, when we want to make a convincing case of a realistic dream of the UHC system, we will have to go beyond the framework of mere strengthening the PuHS and argue for thoroughly reforming it. We have to formulate a broad outline of a plan for democratizing and fully socializing the Indian PuHS.
Overcoming the Contradictions in Private Health-care
In the private health sector, the contradiction between socialized nature of modern medicine and private ownership/control is the most acute one. Hence, the concrete implication of overcoming this contradiction through "democratization" of the health-care systems would be different for the private providers.
Private providers, who opt to work for the UHC system and are selected, would have to accept the principle that the State would purchase standardized care from them at standard rates; they would act more as an extension of the PuHS. In the UHC system, in-sourced private providers will obviously have to follow the same evidence based medicine (EBM), scientific guidelines that doctors in PHFs have to follow; will have to tune in their clinical practice with the goal and logic of public health. EBM has its own limitations and politics. To give a couple of examples: Firstly, it will take a long time to make all practice of medicine strictly, rigorously scientific; medicine would and should continue to be both science and art of healing. Secondly, the framework of EBM can be "misused" to push protocols which favor certain corporate interests. However in the 21 st century, if there is sufficient public, political pressure, "private interests" will have to progressively lose ground in this field because of the very nature of modern, socialized clinical and social medicine. Hence, the scope for individual practitioners for commercial cheating and exploitation would be progressively reduced. In fact, the private clinic would then remain a private property only for the name's sake.
Adequate law, policy, regulatory structure and payment on observance of certain norms - all this will be required to ensure regulation in practice. The regulatory framework should be participatory and would have an element of self-regulation. Secondly, all of them will have to respect, observe patients' human rights and should have adequate, just grievance redressal system. The overall regulatory framework 10 would be common to all private providers. However at the same time, we need to have different strategies for different layers of private providers.
In India, we have a very large, numerically predominant section of general practitioners running their small individual clinics. In this "unorganized" sector, the private practitioners are like other middle class professionals who sell their services to people. We need the following strategy about these clinics in our conceptualization of the program of HCA: Their practice should be regulated as regards their location, quality and pricing. Secondly, the regulated doctors required for UHC should be in-sourced in sufficient numbers into the publicly managed UHC system by the state (for example, as in case of NHS in UK). They can then be converted from their current role. Currently, they are subsumed under the logic of market, of the medico-industrial complex and indulge in commercial exploitation of patients. However, they can be converted into a stratum like that of any other middle class professionals, which provides services to people to earn a relatively secure, honorable and comfortable living, but cannot exploit patients. Once further democratization, socialization of medical practice occurs in one form or the other, through standardized, rationalized care, the scope for individual practitioners for commercial cheating and exploitation would be progressively eliminated and these doctors will have to follow the logic of the Social Medicine, of the UHC system. In fact, the private clinics would then remain "private" more or less nominally; in effect they would primarily serve social purposes as the content of their practice would be progressively socialized.
Similar is the case with smaller, medium hospitals. Some of these can be in-sourced into the UHC system under the condition that they follow overall the logic of the UHC system. The state can then encourage co-operatives of these small hospitals and can thereby further undermine their "private" nature.
The 'Trust hospitals' are legally registered as non-profit entities and hence if sufficient public pressure can be generated, they will have to function as genuinely non-profit entities, especially because they have generally received public subsidies in some form or the other. This can be done by pinning them down to their declared objective in the trust deed. Secondly more stringent laws, rules will have to be formulated so that all aspects of their functioning follow the logic of the UHC system. The current practice of indulgence in money-making and yet showing no profits in the balance sheet cannot be continued! Secondly their internal functioning would have to be further democratized-the doctors and other staff working in these hospitals should have adequate say in the functioning of these hospitals and their democratic rights should be respected.
The strategy towards the corporate sector would depend upon balance of socio-political forces. Most of the members of this section would be least amenable to serve social goals. They are less likely to be part of a genuinely regulated UHC system. In any case all corporate hospitals will have to be regulated even if all of them remain outside the UHC system. An unregulated corporate sector would adversely affect the overall culture in health-care even if it serves only the rich. Progressive social control over the medico-industrial complex with internal democratization should be the direction we should advocate. Actual progress in this direction depends upon the level of political pressure that can be generated toward this end. Overall it is true that comparatively, the private health system by its very nature is less amenable to internal democratization because of the constitutional sanctity to private property. However, good unionization and furthering of democratic culture in society at large can curtail to some extent the arbitrary power of the owners vis-a-vis the employees.
The contradiction between the socialized nature of modern health-care versus private, narrow control over it is obvious in private health-care. However this contradiction is present to some extent, in its own way, even in the PuHS in India. To formulate a program for 'Health Care for All', it is necessary to grasp these contradictions in both private and public health-care and accordingly conceptualize a strategy to resolve and overcome these contradictions.
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