by dr. Arun Mitra
Since independence, our country has made progress in many areas. The British colonial rulers weighed on our economy and left the nation with a poor education and health status. According to Sanjay P Zodpey and Preeti H Negandhi according to the 1951 Census, India’s population was 36.1 crores. Only 18.33% of the total population was literate at the time, of which 8.86% were women; only one in eleven women could read and write. Total life expectancy was 32 years. The infant mortality rate (IMR) was 145.6/1000 live births. The maternal mortality rate (MMR) in the 1940s was 2000/100,000 live births, which had apparently fallen to 1000 by the 1950s. There were only 50,000 doctors in the entire 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 began after the Joseph Bhore Committee recommended in 1946 that “the health program should be developed on a foundation of preventive health work” and that “if the health of the nation is to be built, such activities should be developed alongside those engaged in with the treatment of patients”. No one should be denied access to adequate medical care because of inability to pay; medical services should be free for all without discrimination and a doctor should be a social doctor. The committee also noted that health and development are interdependent and that improvement in other sectors, such as water supply, sanitation, nutrition and employment, leads to an improvement in health status.
In the early decades of the post-independence period, the direction of health care was influenced by these principles. During that period, much of the health care system was developed in the state sector, with the emphasis that modern scientific health care should reach the most remote rural areas.
Prime Minister Jawahar Lal Nehru felt the need for cost-effective medicines and went on to set up the production of medicines in the public sector. He had said, “the drug industry should be in the public sector… I think an industry of the drug industry nature should not be in the private sector anyway. There is far too much exploitation of the public in this industry.” Indian Drugs and Pharmaceutical Ltd. (IDPL) was founded in 1961. IDPL played an important role in strategic national health programs. The World Health Organization acknowledged its role and praised that “IDPL had achieved in 10 years what others have achieved in 50 years. IDPL products have been very carefully examined for quality by the developed countries and many of them want to buy here”.
But after the shift in economic policy and the neoliberal development model, the whole scenario changed. From the holistic perspective, there has been a policy shift towards health, which treats health as ‘techno-dependent and susceptible to commodification’. The shift was also seen in the WHO’s approach. In our country, for example, we see that the public sector is now responsible for preventive services, while the private sector benefits from advanced tertiary care.
The effect on medical education is also evident. At the time of independence, there were 20 colleges of which only one was in the private sector. Currently, there are 612 medical colleges with 92652 seats. Of these, 313 are government colleges while the rest 299 are administered by the trusts or private sector. The tuition fees in the latter group are exorbitantly high in some of them to over a crore rupees for 4.5 years of MBBS course. Thus, there is a complete refusal of admission in these colleges for the lower and middle income students.
We have seen tremendous growth of corporate hospitals in the health sector. Advanced care has become out of reach for the low and even middle-income group. Health is only projected as a curative thing with little talk to improve health determinants such as improved sanitation, clean drinking water, housing, job security and increasing the capacity to spend on food.
No wonder the government recognizes the fact that every year 6.3 crore people are pushed below the poverty line because of its own spending on health care. But the remedy on offer pushes people even further into debt. The whole concept of health care is based on insurance that does not provide comprehensive health care. Seniors are most affected. Even the Ayushman Bharat only covers 50 crore while the rest is left out about 90 crores. It only applies to in-home care, while 70% of out-of-pocket health expenditure is on OPD care.
In addition, there are a number of conditions attached to being registered with this scheme. Eligible people also find it very difficult to make the card. Other state-run insurance offers a limited benefit. For a person to get insured with a private or public sector company, he/she has to put aside a huge amount of money. The ESI started in 1952, CGHS in 1954 and ECHS in 2003 provide comprehensive health care to the employees to some extent. There is a movement to thin the ESI. The government plans to transfer district hospitals to the private sector to open medical colleges. In these hospitals, 50% of patients receive free treatment, while the rest have to pay. The free patients will have to get permission from a designated authority, creating various hurdles for them.
To encourage education for children from disadvantaged families, the National Program of Nutritional Support to Primary Education (NP-NSPE) was launched on August 15, 1995 in 2,408 blocks across the country as a centrally sponsored program to promote enrollment, retention and improving the attendance and quality of education and improving the nutritional level of children. To take care of the children of working people, Aaganwadi was started in 1975. ASHA workers scheme was started in 2005. They worked as frontline workers during the pandemic. But to date, they have not been regularized nor have they been given employee status.
The concept of universal comprehensive health care was primarily realized by the Soviet Union, which in the Soviet Constitution of 1936 guaranteed that the citizens of the USSR have the right to health protection. The NHS was launched in the United Kingdom on 5 July 1948 by the then Health Minister, Aneurin Bevan. This gave huge benefit of free health care to the population. The Cuban government adopted the concept of social medicine in practice. Its effect is recognized worldwide. India has 1:1075 doctors in modern medicine.
India spends about Rs.1753/- on health care per capita in the public sector. India is one of the 15 countries with an outrageous distinction of public spending of less than or about 1% of GDP on health; other similar countries spend twice as much, while developed countries spend ten times more – says K Sujatha Rao in her book ‘Do We Care’. Cuba spends up to 15%. It comes as no surprise, then, that United Nations Secretary-General Ban Ki-moon, during a visit to Cuba, touted health care as “a model for many countries.”
Our key health indicators are still not up to scratch. Our BMR is 103 (2019) for every 100,000 live births and IMR at 30 per 1000 live births. We were sadly 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 forcing our population to buy health loans or sell the assets. To make matters worse, the current regime emphasizes obscurantist ideas such as astrology, Gau Mutra, and Tantriks.
These policies must be reversed to make health care a social responsibility, with effective state intervention at all levels to ensure health care for all. It is the duty of public health and social activists to educate people in proper perspective on the issues of their right to health. Health must be declared a fundamental right. “The focus on our health policy should be based on the ideology of human well-being and to achieve the three basic goals of health systems – equality, efficiency and quality” – K Sujatha Rao.
In September 2019, a high-level group for the health sector, set up under the 15th Finance Commission, recommended that the right to health be made a fundamental right. This, if implemented, will enhance people’s access to healthcare.
On the 75th year of independence, the country is taking effective health measures. Promise to take positive steps so that governments promote, fund and provide comprehensive primary health care. Immediately increase public health expenditure from 1% to 5% of GDP. End the privatization of public health services and ensure effective regulation of the private medical sector.
Provide safe drinking water supply via tap water; sanitation in all households and localities, and enforce full safeguards against air, water and soil pollution from industries, mines and other development projects. Eliminate malnutrition by implementing the National Food Security Act 2013. Promote people’s purchasing power by ensuring adequate wages to meet their nutritional needs. There is a need for a rational drug policy. Ensure better availability, accessibility and affordability of medicines, including vaccines and sera, in the public health system and promote the production of medicines in public sector units to make cheap bulk medicines. Medical education should be in the state sector only. (IPA service)
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