Book Review

Political Economy of Health in India

Health beyond Medicine: Reflections on the Policies and Sociology of India, Edited by Vikas Bajypayee and Anoop Saraya, Aakar, Delhi.


There is no dearth of books on the critique of health care system in India, its policy paradigm, practices and programmes, and, in particular, on the utter neglect of the public health segment of it with consequential adverse impact on the health outcomes of poor and the marginalized sections. Therefore, yet another book on the subject should not ordinarily attract much attention. The reason why the book ‘Health beyond Medicine: Reflections on the Politics and Sociology of Health in India’ does so is not because of its catchy title and the expectation it generates about alternative therapies for treatment of unwellness and disease which turn out to be wrong on reading it, but because the maladies of health care system, so incisively dissected in it, have been coherently integrated with a political framework embedded in historically entrenched caste and class relations and its alignment with the interests of the capital (industry and business), national and international, in the post 1990 globalized market economy in India. This alignment of political forces has been systematically decimating the public health sector and promoting private health care industry and providing it clout and space to influence health policy in all its varied dimensions, corner public resources for its growth and destroy the very social basis of medicine.

The book consisting of nine carefully selected of papers, some published earlier, is intended to unravel the entrenched thinking of people at the helm in policy establishment (the ruling elite) that providing curative care services would address the health needs and concerns of people. It would also take care of the conditions of the economically poor and socially marginalized groups in society as it has been objectively designed to be the best arrangement to protect their interests. This claim is unquestioningly accepted not only by the larger sections of people but also by the highly literate upper strata of society including medical professionals. The authors argue that the development of health services, their structure and processes are not a straight forward, neutral and equitable phenomenon free from social, economic and political influences as is made out to be, but are determined by the class interests of the policy makers and health professionals as also the training given to them, (its contents, pedagogy, methodology and infrastructural requirements etc.). These determinants characterize their thinking on social and economic issues including health development. This thinking is the prism through which problems of people are understood and prioritized and influences their strategic choices and technological options to solve them. In these decisions, the common people, who are numerically the largest segment of the intended beneficiaries of the health services, are not consulted. In fact it is not even considered necessary to do so as they are presumed to lack the knowledge and capacity for articulating a meaningful opinion on it. The policy planners feel that they know what is in their best interest. This ‘elitism’ in policy construction and its institutional provisioning and choices is the result not only of their social distance from the common people and inability to appraise various options in terms of how they would affect different sections of society, but quite often these strategic choices and options are imposed by international donors financing health programmes. The authors marshal information and analytical evidence to establish how the policies crafted and programmes designed by the ruling elite fail to deliver the desired health outcomes and end up by increasing and widening inequalities in accessing health services and their utilization. The effort of the authors in the book is to bring out these undercurrents fashioning our health policy and programmes and moulding health of the people which has resulted not only in one of the most privatized and iniquitous health care system in the world but also the one with the largest out of pocket expenditure by the people on health. From this perspective emerges the direction and content of changes suggested by them. These changes, they argue, would require dismantling the structural dominance of class and caste elite in health system planning and development and its institutional arrangement, and its replacement by those from lower segments of society. The current balance of political forces, however, is not conducive to induce this change and would need to be altered through political mobilization.

Health system planning and development apart from being influenced by class character of the policy makers also contains a heavy imprint of external impact. The Bhore Committee report which constituted the foundation of the modern (allopathic) health system in the country was considerably shaped by the Beveridge and Dawson Committee reports and the National Health Service in U.K. But post-independence development policies in India were more influenced by American experts who offered advise along with aid and shaped the thinking of our experts and those in the establishment in the field of agriculture, rural development, higher education, irrigation besides that of health. Experts of indigenous health systems were neglected both by the colonial and post-colonial governments. These two streams of thinking – British and American – were responsible for the design of health policy and programmes which failed to take into account the historically entrenched social and economic inequalities across social groups, virtual absence of any health infrastructure and services in rural areas, heavy reliance of rural people on folk medicine and indigenous health systems, poverty and lack of civic amenities, widespread discrimination faced by some social groups in accessing public services etc. This resulted in several dichotomies and distortions the foremost being conceptualization of health as a technical issue rather than a social one and provisioning for health as medicinal intervention rather than comprehensive social economic development which focused on provisioning of nutrition, drinking water, sanitation housing and employment. The other was that medicinal intervention privileged curative health care over preventive and promotive and focused on secondary and territory care services rather than primary health care and within curative health care, pushed high end technologies instead of simple effective, cheaper and affordable options. The third was that certain diseases were prioritized for concentrated attention overriding epidemiological approach and and vertical intervention was chosen as the mode of service delivery rather than tackling them at primary health care level as the approach to get effective and expeditious results. With the shift to market economy and the increasing clout of the private sector, the policy making has resorted to the strategic purchase of health care services from the private health sector through publicly financed health insurance schemes rather than strengthening public sector health care for provisioning of cost effective health care free for all as the preferred route for reducing high levels of out of pocket expenditure. The entire approach to health development planning right from beginning has been one of top down intervention rather than a bottom up strategy with community participation in order that health policy gets designed as per peoples’ needs taking into account their socio- economic conditions and level of health care infrastructure and personnel available in rural and semi-urban areas.

Health policy and development has been influenced by two ideological frameworks of political economy – welfare economy in the pre-1990 phase and market economy thereafter. In the former, health care system by and large followed, broadly, the path laid down by the Bhore Committee report though with some minor changes being introduced as a result of numerous committee reports. In this pattern the state was the dominant provider of health services and health care was dispensed free and without discrimination, though during the later part of this period, private sector health care began to be promoted with incentives and concessions as an alternative provider. Health sector being integral to overall development planning, it was inevitably influenced by the social goals and the priorities contained in the Five Year Plans. The shift to a market economy in pursuance of the acceptance of the Structural Adjustment programme imposed by the IMF led to a number of major structural reforms in the economy including the health sector. As a result, the dominance of public sector health care in provisioning of health services, its cost free nature with no differentiation in quality of services rendered was reversed and private health care was promoted more pronouncedly to the extent of opening up of public health care to it with a view to achieving resource efficiency, reduction in cost and accommodating consumer choice. These reforms entailed cuts in health sector public investment, the introduction of user fees, outsourcing of clinical and non-clinical services in public sector health units and techno- centric public health interventions. These reforms were reflected in the National Health Policy (2002) which sought to provide greater role to private sector in provisioning of health services. The latter has since grown phenomenally with the entry of corporates in the field. The privatization of health care has penetrated deeper in the National Health Policy 2015 where the health sector gets transformed from a service providing sector to an instrument of economic growth generating national wealth. In this conceptual frame, service provisioning becomes incidental to this growth objective and financial considerations take precedence over public health needs in promoting access to medical care. The vigorous promotion of the private sector health industry has resulted in corporate hospitals acquiring a dominant position in provisioning of health care and even the setting up of medical colleges. This has led to a spurt in growth of private medical colleges charging very high fees. It has also contributed to the emphasis on curative care over preventive and promotive and use of high end technologies in medical intervention. In the field of medical education, the entry of private sector has changed the orientation and content of medical education in terms of pursuit of specialization and super specialization in clinical disciplines and hospital based dispensing of medicines. These changes influence the career choices and ethical values of medical graduates.

The book extensively investigates the problems faced by Public hospitals and identifies five areas of concerns. These are 1) inadequate and dilapidated infrastructure 2) shortage of manpower 3) excessive patient load 4) indifferent quality of services 5) high out pocket expenditure. The authors attribute these problems to several factors. One, health services are modeled on the western health care system which is neither sensitive to local needs nor relies on local resources. Two, the access to elitist medical education is captured by privileged sections of larger cities and oriented towards technology driven costly curative care. Three, there is a sharp rural – urban dichotomy in the provision of health services and allocation of resources. Four, the orientation of health policy is towards medicinal intervention for promoting good health rather than provision of social development. The measures suggested to overcome these problems include guaranteeing right based universal statutory entitlement to food, health care, drinking water and sanitation, education, free of cost and provision of employment, reinvigorating and expanding peripheral services by improving living and working conditions of health personnel reversal of commercialization of health services, democratization of access to medical educated and a host of other measures. There is little to disagree with these suggestions some of which have been made by progressive sections of health professionals, researchers and social activists from time to time. The implementation of these suggestions however, face different challenges. As for the right based statutory entitlements, we already have laws in respect right to food and unskilled work for 100 days and education. But the experience has shown that enacting a law is no guarantee that it would be implemented and, further, that it would not be diluted, ignored or subverted or even outrightly violated by the government. In the current dispensation, laws enacted for the poor have been undermined by lack of sufficient financial allocations, lack of interest in implementing them and violating / ignoring it when it did not suit the interests of the government in power and the dominant class. Regrettably, no political party has taken up the issue and mobilized the poor against these attempts, not even the one which enacted these laws and to hold the government accountable for this lapse. The poor have, therefore, lost hope in the efficacy of law as guarantor of their rights. This does not mean that there should be no right based entitlements but only to stress that it is not sufficient to get laws enacted but equally critical to get them implemented and ensure that they are not diluted, ignored or violated. This would require strong political mobilization of the poor which is nowhere in sight. The reversal of commercialization of health services is most unlikely in the existing situation as there is a consensus across the political divide on the existing neo-liberal pattern of economic growth being pursued. All political parties vigorously court private capital for boosting growth when in power in States or the Centre. Democratization of access to medical education would come in conflict with Supreme Court’s enforcement of open competition and equal opportunity in entry to all avenues of higher learning through all India tests like JEE, NEET etc. In this arrangement, candidates from rural areas, lower classes and poor families and those educated through vernacular medium stand no chance to compete. The court has even struck down the proposal to give preference to doctors working in government hospitals for admission to postgraduate courses which is the best that could be done to fill up huge vacancies of specialists in public health system. Therefore, it is unlikely that the proposal to set up District Medical Colleges where admissions to courses would be restricted to candidates from local areas with obligation to serve in that area after completion of the course would ever get approval of the Court.

Even the not so radical changes are unlikely to be introduced for the very same reason that have been responsible for existing trajectory of health planning and development – the elite dominance in policy making and pervasive control of market which according to authors constitute the two principal contradictions in the health care system. The secondary contradictions are those between private and public health care and between needs of the elite and the masses. The two are intertwined. That is why the authors argue that health is a political issue, implying that the pressure for change must come from the political forces representing poor, lower classes and other disadvantaged groups in the country to push these changes. This would happen when these political forces capture power and replace the existing health system with one that serves their interest. There are at present no political parties, organizations or leaders or movements demanding this radical change. In fact, there is little awareness in our legislators and others in politics about the layers of interests which influence health policy making and multi-dimensionality of issues involved in it. The issues relating to health system do not even find any significant mention in the manifestoes of political parties and their priorities in the agenda of governance. The utmost that the ruling political parties at the state and central level show their interest on health issues is on providing ambulance services or insurance for hospitalization for catastrophic illness or setting up super-specialty curative facilities in the State capital. The legislature – state and central, rarely if ever, discuss various ramifications of the deteriorating health conditions of people. In such a situation, what would lead to emergence of political forces for radical change should be the starting point for discussion on health sector reforms.

In the density of issues that crowed health system debate, what is buried is the most fundamental conceptual issue – what social objective should the health care system serve? Should it be provide a service or to generate wealth? It cannot be both. If both are combined the latter one would be at the cost of the former. A health care system which is expected to generate wealth or push economic growth would inevitably focus on ways to earn more revenue by charging fees from patients. Such a system would be restrictive to those who can pay this cost. This would exclude those seekers of health care who cannot afford it. Historically, the health system has evolved as a service and a social good rendered free of cost without any expectation of any material returns or reward. Health care provider in such an arrangement was compensated by society for this service. This system was therefore inclusive in character. The current model of health care has upturned this historically evolved ethos of health system leading to several adverse consequences. It has created a health care system dominated by the private sector with differentiated access to and quality of care and biased towards those who can afford to pay, thereby dismantling its universalist, egalitarian, and cost effective character. This system makes health care extremely costly and out of reach for the majority of population. Secondly, due to their contribution to economic growth, corporate players emerge as dominant health care providers, get incentives, support and concessions to grow which provides them the clout to influence public policy and penetrate public sector health care to corner its resources. Thirdly, it puts pressure on public health system also to generate resources, at least partially, which leads to differentiated access and quality of service within the public health system too. Fourthly, private health care hospitals even though having grown with state support are even exempted from earmarking a very small percentage of their beds for the very poor free of cost as it would hurt their growth momentum. Fifth, even in the face of its unethical practices, the private health care lobby strongly resists government regulation while there is no evidence that it regulates itself. This conceptual view of health care system influences every dimension of health system – technological, educational, infrastructural, ethical and knowledge creation. Worse, it severely impacts public health sector, affects its ability to provide service and sustain motivation of its personnel. The service objective in public health system can only be pursued when there is no pressure on it for generating resources or expectation of a reward for service providers. The only way to arrest this downward slide of the health system is to resurrect the service objective of public sector health system, strengthen it through the infusion of public resources and urgently address other reforms of the system towards which reference has made in the book.

The authors rightly lament that promoting good health and well-being of people has been narrowed down by State to just providing health care as the social goal of health policy. The former implies stress on comprehensive social development – provision of drinking water, sanitation facilities, nutrition, and housing and poverty alleviation which contribute to keeping a person healthy. Investing in these services would reduce the burden of disease and incidence of falling ill and consequently expenditure on health care. This understanding has not taken roots in health policy and planning. The domain of the Ministry of Health, the nodal agency in respect of all issues relating to health, is confined to provision of healthcare and planning and development thereof. To be fair, development policy since independence has been providing for these social services as necessary social goods for improving the quality of life of the people. But the implementation of these programmes does not ensure that their focused integration with the geography of disease and social groups afflicted with it. As a result, the investment has not had the desired impact on improving health outcomes of the people who are extremely poor and socially marginalized and also suffer most from ill health .Currently, this focused integrationof social services with people and areas related to disease spread in the country which also happen to be the people and areas of deprivation and deficiency does not take place institutionally at any level. It is assumed that mere provision of these services in general across the country would reach those in need and necessary integration would take place on its own without any external intervention. It also does not take into account diversion of resources to undeserving areas and problems faced by needy people in accessing these services, their lack of awareness and power. The integration also becomes difficult because each of this sub-sectoral activity has its own separate agency hierarchy of officials and a chain of command, budget provision and schemes with norms of provisioning governing them. There is no coordinating agency either at the top level or at the grass roots to ensure that different programmes and facilities reach specific locations and communities afflicted with health problems. At the apex level, Planning Commission was supposed to discharge the role of effecting such inter-departmental integration, and, at the district level, the District Magistrate is assumed to perform this role. But integration of this type to be effective is best done in a local geography –ie., the panchayat or at most block level. Neither of the two levels have the capacity, power and control over staff and budget of these agencies to discharge this role. Also, there is no mapping of areas / communities requiring focused access to these facilities and dovetailing of this information into the programme guidelines of each sub- sector in order that the allocated resources get directed at places / groups that need them the most and are not cornered by the people and areas with a political clout. This governance deficit remains unaddressed in the absence of which even higher allocation of resources in these social sub- sectors may not yield the desired result.

Overall, it is difficult to resist the conclusion drawn by the authors that health issues have never acquired priority and primacy either in public discourse or in policy deliberations and governance unlike those of growth, infrastructure and security. Even elected representatives give larger importance to road connectivity, law and order, electricity, rather than provision of health services. The poor, who suffer most from ill health too assign primacy to issues which affect day to day survival such as employment, wages, access to food until they fall ill and are unable to work. There is lack of appreciation in the policy establishment that neglect of health issues may affect productivity of people and therefore growth itself. But it also highlights the utter powerlessness of the poor and the marginalized sections to influence policy and governance notwithstanding the political equality they have been endowed with in the Constitution. The crisis in health system which the authors have so eloquently analyzed ultimately mirrors the inadequacy if not irrelevance of institutional democracy to the lives of the people and therefore the crisis of politics which underlines it and provides strength and support to anti-people policies. Reform of politics in the direction where the poor and marginalized (numerically dominant but socially subordinated) matter is therefore key to radical change in economy and development paradigm. Changes in the health system suggested by authors would flow from this imperative. It is for this clarity of thinking and the social vision of health underlying it that the book must be read not only by policy makers, professionals, social activists and those in politics but also by the intelligentsia and informed citizenry and its contents in brief disseminated among people in language they can understand.

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