(Weekly Organ of the Communist Party of India (Marxist)
March 11, 2012
Health Sector Reforms in
would require a very brave person to argue that
At the heart of this
malaise is the
Nature abhors a vacuum and the private medical sector has moved in to fill the gap left by a non-existent or poorly performing public system. It has grown enormously over time and covers 60 per cent of in-patients and 80 per cent of out-patients. In spite of some sporadic attempts, the private sector remains largely unregulated. Costs in the private sector has grown by 300 per cent in the last two decades. Not only is private care expensive, it is often of poor quality and there are frequent allegations of unethical practices. The private sector is also undergoing a transformation, with large corporate run hospital chains forming an important segment of private care, especially in urban areas. In contrast, there is a huge pool of untrained and unqualified private providers, who are often the only source of medical care in rural areas. While public systems remain under-resourced, the private sector (especially the large and organised corporate controlled private sector) benefits from indirect subsidies it receives from the government.
The present state of the public health system is a result of decades old neglect by successive governments. The major issues that need to be addressed include issues of resources – both financial and human, and provisioning, i.e. mechanisms for making health care accessible to all. There is substantial global evidence as regards practices that help in building a good health care system. The positive examples – UK, France, Costa Rica, Cuba, Sri Lanka, Thailand in recent years -- straddle different situations, political systems and economic contexts but have one thing in common – they are all primarily built around the concepts of public financing and public provisioning of health services.
It is important, however,
understand that each country has to build systems that are tailored to
specific situation and needs. Models of public financing can include
collection, a mix between tax-based collection and co-payments by
employers, etc. In
Another key component of a
system is the availability of trained human resources, who are also
While the services of
even super-specialists are underutilised in urban areas, the deficit of
specialists is as high as 80 per cent or more in the public health
especially in rural areas. On the other hand, we subsidise the medical
needs of countries in Europe and
To adequately address our needs, human resource development in health must be based on: increased public funding for medical education; a major expansion of training and deployment of different kinds of health workers whose skills are suited to the tasks they need to perform; and restructuring of health systems with judicious task shifting to ensure that physicians and specialists are deployed in situations where their skills are best used.
The growth of the private
The logic of the market, in the medical care sector, has produced a situation where now huge corporate chains are replacing smaller players. It has brought in its wake more centralisation of services, and a higher degree of pooling of skills and expertise in fewer centres. This goes against the established tenets of public health and primary health care, where it is understood that better health outcome is a function of a wide spread of facilities and care providers, across the entire population.
All the above measures, of course, have to be accompanied by a vastly strengthened public health care system that is accessible to all and provides comprehensive health care to all.
Recently, the government
its intention to remedy the present situation by initiating major
reforms in the
health system. While there is broad agreement that immediate and urgent
measures are necessary to remedy the situation, several areas of
remain. There are differing perceptions regarding the concrete contours
restructured health system in
As a lead up to the formulation of the Twelfth Five Year Plan, the government had set up a “High Level Expert Group’ (HLEG), tasked with the formulation of a plan for Universal Access to Health Care (UAHC). The HLEG has made several well intentioned recommendations, including:
· Increase in public expenditures on health from the current level of 1.2 per cent of GDP to at least 2.5 per cent by the end of the 12th plan, and to at least 3 per cent of GDP by 2022. (though inadequate in our view, there is at least a positive recommendation to increase public expenditure)
· Ensure availability of free essential medicines by increasing public spending on drug procurement.
· Use of general taxation as the main source of healthcare financing.
· Advise not to use insurance companies or any other independent agents to purchase health care services on behalf of the government.
· Reorientation of health care provision to focus significantly on primary health care.
The Planning Commission of India has used inputs from the HLEG report and from other committees to develop its first draft ‘Report of the Steering Committee on Health for the 12th Five Year Plan’. Unfortunately this draft report betrays a clear attempt to dilute the positive recommendations of the HLEG report and to imbue the recommendations with an entirely different ‘spin’. The attempt is to pay lip service to the report on one hand, but institutionalise the public-private partnership model of health care delivery, on the other. The report is replete with references to the private sector, and to how important it is to make it part of the country’s health system.
While agreeing that, “Equally worrying is the growing reliance on private providers..” the Planning Commission draft goes on to argue that “With 80 per cent of doctors, 26 per cent of nurses, 37 per cent of beds and 80 per cent of ambulatory services, the private sector has to be partnered for health care delivery”. The draft, further goes on to assert that, “In order to spur competition, and make the providers responsive families need to be provided a choice to opt for a health provider from a panel of public, private or not-for profit providers”.
feature of new-liberal economics has been to promote
primitive accumulation of capital through the privatisation of public
The Planning Commission’s intent is clearly to follow this
prescription. It is
not designed to promote health care access but to use the health care
another medium of capital accumulation by the private sector. These
need to be exposed for