Dr Arun Mitra
Health planning in India started in 1938. The British government had formed a committee, popularly known as Bhore committee under the chairmanship of Sir Joseph Bhore, who was an Indian civil servant and Diwan of the Cochin State. The committee was formed in 1943 to survey the then existing position regarding health conditions and health organizations in the country. The committee submitted its report in 1946 and recommended that “the health programme should be developed on a foundation of preventive health work and that ‘if the nation’s health has to be built, such activities should proceed side by side those concerned with treatment of patients’. It was based on the principles that no individual should be denied the opportunity to secure adequate medical care because of inability to pay; health programme must lay special emphasis on preventive work; health service should be located close to the people; medical services should be free to all without any distinction and doctor should be a social physician. The committee also observed that health and development are inter-dependent and improvement in other sectors like water supply, sanitation, nutrition, employment lead to improvement in health status.
The Public Health definition by C E A Winslow of Yale University that “It is the science and art of preventing disease, prolonging life and promoting physical and mental health and efficiency through organized community effort for the sanitation of the environment, the control of community infection, education of individuals in principles of personal hygiene, the organisation of medical and nursing services for the early diagnosis and preventive treatment of diseases, and the development of the service machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health”
In the first few decades of post-Independence period the direction of the healthcare was based on these principles, which gave priority to public health. During that period much of the health care was developed in state sector with a special emphasis on the need of basic healthcare services.
The Alma-Ata Declaration of 1978, to which India too is a signatory, emerged as a major milestone of the twentieth century in the field of public health, and it identified primary health care as the key to the attainment of the goal of Health for All. It conceptualized ‘health as the core function of development, encompassing the securities of life, livelihood, and basic services, including food, health, education, housing, sanitation, drinking water, electricity, and transportation’. The declaration emphasized the interdependence of health and the overall progress of communities based on principles of self-sufficiency and affordability. In the Alma Ata declaration the global direction was for health for all irrespective of capacity to pay. It raised the hope that in the times to come we will have a system with global support, which would take care of health of all citizens. But it was not to happen. It is around this time only that a shift started in whole policies and the Alma Ata declaration virtually remained on paper only.
But from this holistic perspective there occurred a policy shift towards health, that treats health as ‘techno-dependent and amenable to commodification’. The shift in concept is evident in WHO itself, when in 1996 it proposed a behaviourist model which stressed more on the individual responsibility for better health. So the emphasis shifted to address only population control and some selected communicable diseases at the cost of its earlier broad-based approach. WHO started working under the influence of international monopoly corporates and took position to increase privatization and partnership with multinational companies. As a result the institution, which was supposed to work for inclusive healthcare policies, took lead in destroying its own agenda set at Alma Ata. In our country we find influence on the policies by the World Bank in 1980s whereby health came to be viewed as a profitable business.
Thus in our country we find that the public sector is now responsible for the preventive services while the private sector on the other hand is taking lead in advanced tertiary care with a profit motive. We have seen unprecedented growth of exorbitant corporate hospitals in health sector. There have been reports of public reaction to their fleecing the patients. But they continue to be ruthless without any empathy for the poor. Advanced care is out of reach of low and even middle income group. It is being projected that the public sector health institutions have failed in providing the services, therefore need for corporate entry. Health is being projected only as a curative thing with little talk to improve health determinants like improved sanitation, clean drinking water supply, housing, job security and increase in capacity to spend on nutrition. No wonder the government recognises the fact that every year 6.3 crore people are pushed below poverty line because of out of pocket expenditure on health. But the remedy being offered rather further pushes the people into debt. Ayushman Bharat is to give business to private insurance companies. There is a fear that even these companies may opt out if they do not find the profit viability.
All this has excluded the already marginalised sections of the society from healthcare benefits. Their inability to pay is pushing them to buy loans for health. To make things further worse obscurantist ideas like astrology, Gau Mutra and Tantriks are being highlighted. There is need for reversal of these policies to make healthcare a social responsibility with state taking effective intervention at all levels to ensure healthcare for all. It is the duty of the public health and social activists to educate people on the issues of their right to health in the proper perspective. (IPA Service)