An idea for PM Modi’s speech on 75th Independence Day: Deliver efficacious, equitable healthcare to all

On 15 August 2021, when we celebrate 75th day of independence from the colonial rule, it is important to review the state of healthcare available to the country’s citizens. This is all the more important in view of the COVID pandemic crisis.

In the pre-independence period, Indian society was largely dependent on 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 with those concerned with treatment of patients”.

It was based on the principles that no individual should be denied ability to secure good medical care because of poor financial condition; medical services should be free to all without any distinction and a 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 and employment lead to improvement in health status.

This report goes in consonance with the Public Health definition by CEA Winslow and Rudolf Virchow who had conceptualised healthcare as ‘social medicine’ and that every doctor is a ‘social physician’.

In the first few decades of the post-independence period, the direction of 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.

It was also during this period that India started manufacturing cheap generic drugs for local and global market. With the vision of Prime Minister Jawaharlal Nehru, Indian Drugs and Pharmaceutical Ltd. (IDPL) was established in 1961. Nehru 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”.

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 neoliberal 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’. This shift was seen in the approach of WHO also.

Thus, in our country we find that the public sector is now responsible for preventive services while the private sector is profiteering from advanced tertiary care.

The effect on medical education too is evident. At the time of independence, there were 20 medical colleges out which only one was in private sector. At present, as per the National Medical Commission, out of 554 medical colleges, 285 are in government sector and 269 are in the non-government sector. This has led to dashing of the hopes of aspiring medical students from the lower socio-economic strata because private medical colleges have exorbitant charges.

We have also seen huge growth of corporate hospitals in health sector. Advanced healthcare 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 only further pushes people into debt. The whole healthcare concept is insurance based which fails to provide comprehensive healthcare. Senior citizens are the worst affected.

Even Ayushman Bharat covers only 50 crore people, leaving out 88 crore people. 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 get the benefits touted by it.

Other state run insurance schemes offer limited benefits. For a person to get insured with a private or public sector company, she/he has to shell out a huge amount as premium.

The ESI started in 1952, CGHS in 1954 and ECHS in 2003 provide comprehensive healthcare to the employees to an extent. But 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 in hard cash. The free patients too will have to get authorization from a designated authority, thus creating several hurdles for them.

To encourage education among 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, Anganwadi was started in 1975. ASHA worker scheme was started in 2005. They worked as frontline workers during the pandemic. But till date they have not been regularised.

The concept of universal comprehensive health care was first of all realized by the Soviet Union whose constitution in 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 benefits of free healthcare to the population. The Cuban government adopted the concept of social medicine into practice. Its effect is well recognised globally. Cuba has a doctor patients ratio of 1:150. In comparison India has 1:1456. Even the developed USA has a ratio of 1:333.

The government of Cuba spends approximately Rs 25000 per person each year on healthcare, while India spends around Rs.1418 on health per capita with the corresponding expenditure in UK being Rs. 2.65 lakh. India is one of the 15 countries with the 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.

Quality healthcare is a dream for an average Indian. The inability to pay is pushing our population to seek loans for health or sell their assets. To make things worse, obscurantist ideas like Ayurvedic medicines for COVID, gau mutra cure etc are being highlighted under the present regime.

There is a need for reversal of these policies to make healthcare a social responsibility, with the State taking effective intervention at all levels to ensure healthcare for all. It is the duty of public health and social activists to educate people on the issue of their rights to health in the proper perspective.

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 this Independence Day, let the country take effective measures for health. The governments must promote, finance and provide comprehensive Primary Health Care. Enhance public spending on health to 5 per cent 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, through quality conscious pooled procurement systems and promotion of manufacture of essential medicines. Strengthen Public Sector Units to make cheap bulk drugs.

(IPA Service)

Views are personal