By Dr Arun Mitra
Since independence our country has progressed in many fields. The British colonial rulers squeezed our economy and left the nation with poor education and health status. According to Sanjay P Zodpey and Preeti H Negandhi as per the 1951 Census, India’s population was 36.1 crores. Only 18.33% of the total population was literate then, of which female literacy was 8.86%; only one out of every 11 women were able to read and write. The overall life expectancy was 32 years. The infant mortality rate (IMR) was 145.6/1000 live births. Maternal mortality ratio (MMR) in the 1940s was 2000/100,000 live births, which apparently came down to 1000 in the 1950s. There were only 50,000 doctors across the country. The number of primary health-care centers in the country was only 725. (1)
In the pre-independence period Indian society was largely dependent on the traditional medicines, faith healing and belief system. Modern health planning in India started after the Joseph Bhore committee recommended in 1946 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’. No individual should be denied to secure adequate medical care because of inability to pay; 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.
In the first few decades of post-independence period the direction of the healthcare was influenced by these principles During that period much of the health care was developed in state sector with an emphasis that modern scientific healthcare should reach the remotest rural areas.
Sensing the need for cost effective drugs, Prime Minister Jawahar Lal Nehru went forward to establish drugs manufacturing in the Public sector. He had said “the drug industry must be in the public sector….. I think an industry of the nature of the drug industry should not be in the private sector anyhow. There are far too much exploitation of the public in this industry”. Indian Drugs and Pharmaceutical Ltd. (IDPL) was established in 1961. IDPL played a major role in the strategic National Health Programmes. Recognising its role, the World Health Organisation commended that “IDPL had achieved in 10 years what others have in 50. IDPL products have been examined for quality very carefully by the developed countries and many of them want to buy from here”.
But after the shift in economic policies and neo liberal model of development the whole scenario changed. From the holistic perspective there occurred a policy shift towards health, that treats health as ‘techno-dependent and amenable to commodification’. The shift was seen in the approach of WHO also. Thus in our country we find that the public sector is now responsible for the preventive services while the private sector is profiteering from the advanced tertiary care.
The effect on Medical Education too is evident. At the time of independence, there were 20 colleges out which only one was in private sector. Presently there are 612 medical colleges with 92652 seats. Out of these 313 are government colleges while the rest 299 are run by the trusts or the private sector. Tuition fee in the latter group is exorbitantly high to the extend of over a crore rupees for 4.5 years of MBBS course in some of them. Thus there is complete denial of admission in these colleges to the students from lower and middle income group.
We have seen huge growth of corporate hospitals in health sector. The advanced care has become out of reach of low and even middle income group. 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 is rather further pushing the people into debt. The whole healthcare concept is insurance based which fail to provide comprehensive healthcare. Senior citizens are the worst affected. Even the Ayushman Bharat covers only 50 crore while the rest about 90 crores are left out. It is applicable for indoor care only, whereas 70% of the out of pocket expenditure on health is on OPD care.
Moreover there are several conditions attached to get registered with this scheme. Eligible people also find it very hard to make the card. Other state run insurance schemes offer a limited benefit. For a person to get insured with private or public sector company, she/he has to shelve huge amount. The ESI started in 1952, CGHS in 1954 and ECHS in 2003 provide comprehensive healthcare to the employees to an extent. There is a move to dilute the ESI. The government is planning to handover district hospitals to the private sector to open medical colleges. In these hospitals 50% patients will get free treatment while the rest will have to pay. The free patients will have to get authorization from a designated authority, thus creating several hurdles for them.
To encourage education among the children from deprived families, the National Program of Nutritional Support to Primary Education (NP-NSPE) was launched as a centrally sponsored scheme on 15th August 1995 in 2408 blocks in the country for enhancement of enrolment, retention, improvement of attendance and quality of education and improving of nutritional levels among children. To care for the children of working people Aaganwadi was started in 1975. ASHA worker scheme was started in 2005. They worked as frontline workers during the pandemic. But till date they have neither been regularised nor been given the status of worker.
The concept of universal comprehensive health care was first of all realized by the Soviet Union who in the Soviet constitution 1936 guaranteed that the Citizens of the USSR have the right to health protection. The NHS was launched in the UK on 5 July 1948, by the then Health Secretary, Aneurin Bevan. This gave huge benefit of free healthcare to the population. The Cuban government adopted the concept of social medicine into practice. Its effect is well recognised globally. India has 1:1075 doctors of modern medicine.
India spends around Rs.1753/- on the health per capita in the public sector. India is one of the 15 countries with ignominious distinction of public spending of less than or about 1% of the GDP on health; other similarly placed countries spend twice the amount while developed ones spend 10 times more – says K Sujatha Rao in her book ‘Do We Care’. Cuba spends up to 15%. It is no surprise therefore, that the secretary general of the United Nations, Ban Ki-moon, during a visit to Cuba hailed its healthcare service as, “a model for many countries”.
Our major health indicators are still not up to the mark. Our MMR is 103 (2019) for every 100,000 live births and IMR at 30 per 1000 live births. We ranked dismally low in the current Hunger Index, at 101 out of 116 countries.
Quality healthcare is a dream for an average Indian. The inability to pay is pushing our population to buy loans for health or sell the assets. To make the things further worse obscurantist ideas like astrology, Gau Mutra and Tantriks are being highlighted under the present regime.
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 rights to health in proper perspective. Health should be declared as a fundamental right. “The focus on our health policies should be grounded in the ideology of human welfare and to achieve the three basic goals of health systems – equity, efficiency and quality” – K Sujatha Rao.
In September 2019, a High-Level Group on the health sector constituted under the 15th Finance Commission had recommended that the right to health be declared a fundamental right. This if implemented, will strengthen people’s access to healthcare.
On the 75th year of independence let the country take effective measures for health. Promise to take positive steps so that governments promote, finance and provide comprehensive Primary Health Care. Enhance public spending on health from 1% to 5 % of GDP immediately. Put an end to privatisation of public health services and ensure effective regulation of the private medical sector.
Assure safe drinking water supply through piped water; sanitation in all households and localities, and enforce complete safeguards against air, water and soil pollution by industries, mines and other developmental projects. Eliminate Malnutrition by implementing National Food Security Act 2013. Promote people’s spending power by ensuring sufficient wages so as to meet their nutritional needs. There is need to implement a Rational Drug Policy. Ensure improved availability, accessibility and affordability of drugs including vaccines and sera in the public health system and promote manufacture of drugs in Public Sector Units to make cheap bulk drugs. Medical education should be in the state sector only. (IPA Service)