The fact that public health is one crucial yet overlooked arena in India is no secret. And if recent trends of policy-making(or the lack thereof) are any indication things are largely gonna remain the same.

But what exactly brought about this scenario? The apathy-for that’s what it is, has a cluster of reasons.

The World Bank paradox

One may think that the slide in public healthcare initiatives began with the liberalization in India back in 1991. While liberalization in itself was necessary and long overdue, it’s effects on healthcare has been, well, less than liberating. Governments since then have systematically followed such things as the Structural Adjustment Programme which the Bretton Woods institutions- the International Monetary Fund and the World Bank have practically imposed on the country. The neoliberal policies which governments initiated since then haven’t helped either.

These resulted in a declining public investment both in health-care infrastructure and also medical education. Indirectly, these measures had the effect of higher cost of medicines-thanks to the global trade regime of the World Trade Organization(WTO).

One inevitability of globalization was nations having to adapt economic reforms-causing particularly challenging shifts in the socio-cultural domain of developing countries. Globalization also resulted in the major global institutions governing health to radically change their policies.

Various organs of the United Nations diminished in importance and the World Health Organisation(WHO)-until then the leading agency for global and nation level advocacy for health governance got marginalized. Meanwhile, the World Bank came forth as a key influencer in devising healthcare strategies of nations.

The origin of this phenomenon could be traced back to 1897 when the World Bank document called Financing Health Services in Developing Countries came out. The document contained recommendations galore and formed a basis for policy-making in countries on a path of economic reforms. Some of the key recommendations were:

• Launching of private health insurance schemes
• Rise the amount of money that patients must pay for public health services
• Decentralization of government health-care services

But that was just the beginning. For in 1993, the recommendations were refined in yet another document on world development-this one called ‘Investing in Health.’ The impact of this document was that instead of being a public good, health care became another salable utility- a link in the global chain of trade which could be accessed through the market.

Almost all the developing countries that kicked off liberalization found no issues adopting the World Bank’s recommendations. The main reason for this was that the recommendations were actually conditions for the loans the countries gave to free themselves from the economic crises. But that’s not to say that the recommendations didn’t attract criticisms. And the criticisms were effective-to some extent. For they made the Bank stress less on the pull back on public services. However, the reduced role of the government as the primary health-care provider was continued to be advocated, and as we have seen over the years, implemented.

Effects on India

This resulted in the gradual(one might even say systemic) retreat of the government in India from playing key roles in providing health care.
The following of the World Bank recommendations had a few direct implications:

• Aside from the reduced investment in public health, service charges also began to be levied. Something that was made applicable even for diagnostic tests.
• Health insurance entered the picture-something which brought forth the lack of an efficient public health care system. For if the system was efficient, why would a private health insurance be required in the first place?
• Diminished role of the government in health governance. In fact, many of the responsibilities were put on local communities/ organisations like NGOs. This had a peculiar effect since many initiatives of such organizations were aimed at tackling lifestyle diseases-the reason being the availability of international aid for such diseases. Many NGOs rely on such aid measures for their functioning.

The WHO has recommended a public expenditure of 5 percent of the gross domestic product(GDP). However, in India the percentage has been hovering around the 1 percent mark for the last two decades. The Eleventh Five Year Plan envisioned a target of 2 percent of the GDP. But the investment we ended up with was only 1.09.

Incredibly enough, the target for the Twelfth Plan of the Planning Commission was lesser-1.58 percent. This even though the recommendation made by the High Level Expert Groups(HLEGs) of the Planning Commission and the Ministry of Health and Family Welfare was 2.5 percent. And whether this target will be achieved remains to be seen.

The baffling twelfth plan

The upshot of all this is that there is a significant gap in healthcare provision in the country.

In steps the private sector. The sector has now grown to such a proportion that around 75 percent of the national spend on health is made by it-one of the biggest in the world. By nature of its operations, the private sector is focused on providing tertiary care rather than primary health care to maximize profit.

Then, there’s the fact that the costs of care keeps rising dramatically in the private sector. A whopping 300 percent rise has been observed in the cost since liberalization.

Even though it’s kinda evident that the policy format which we have been following hasn’t done much to improve the healthcare scenario in the country, the government just carries on on the same track as if things are just dandy.

A relief of sorts in recent times was the National Rural Health Mission(NRHM)- the flagship scheme of the United Progressive Alliance(UPA). Though not devoid of faults, it made one thing clear- that it’s possible to bring beneficial changes in the public health system using limited resources.

Another important development isn’t that heartening though: The Planning Commission, for the first time since liberalization openly came out claiming the need for privatization of public health care. This could be seen in the 2015 document by the commission on health and the draft National Health Policy(NHP). The NHP of 2015 even defends the low public expenditure target thus:

“At current prices, a target of 2.5 per cent of GDP translates to Rs.3,800 per capita, representing an almost fourfold increase in five years. Thus, a longer time frame may be appropriate to even reach this modest target.”

New instruments in the making

It’s worthwhile to look at the instruments with which higher private sector participation(and lesser public investment) is made possible.

• The key instrument seems to be public-private partnerships(PPPs) the efficacy of which has been widely debated.
• Health insurance. An instrument that has been introduced as recommended by the World Bank. The instrument does exist in almost all the industrialized nations that boast a highly-evolved healthcare system. The United States is the exception and they have the most expensive medical system in the world. The point to note is that in most of these countries, government insurance schemes have the larger share. Which is so not the case in India.
• Health insurance gets an even greater boost on the Twelfth Plan document which aims at restructuring the health system to accommodate health insurance. As per the plan, the private players are to be the key health service providers while the government supposedly will be a “manager” for these service providers. What this essentially means is that the government is going to buy healthcare using public money and the money will further feed the corporation of the health-care system.

The Rashtriya Swasthya Bima Yojana (RSBY)

This nationwide scheme was launched by the UPA government. It also envisions a future when public healthcare is actually largely private. The HLEG has recommended against existing health insurance schemes. However, that hasn’t stopped the Twelfth Plan document from expanding schemes like RSBY. The current government also has said that health insurance coverage for all will be striven at with the aid of a national insurance policy for health.

In this context, it’s important to note that the health insurance sector became open to private players(a large number of whom have partnerships with foreign insurance agencies) as a result of the General Agreement on Trade in Services(GATS), something that was negotiated with the “blessing” of the WTO.

Patents Act

The Trade-Related Intellectual Property Rights(TRIPS) agreement is one which have had a huge impact on the Indian healthcare sector. The agreement was part of the WTO negotiations. TRIPS made the Indian government change the Indian Patents Act in 1970. The Indian Patents Act of 2005 came conforming to the TRIPS provisions which permitted product patents for drugs. The earlier version of the Act didn’t allow this though it served the domestic pharma industry well.

The 1970 Act allowed just process patents-and that too can be held only for a limited period of time. This meant that pharma companies could come up with various chemical processes and production mechanisms for a drug that’s patented abroad. This helped them produce drugs on a large scale which resulted in India having a huge drug generic drug industry.

In fact, by the 1980s the pharma industry in the country was one of the most developed in the developing world. And the unofficial tag “Pharma of the developing world” was added to India by the 1990s-a result of the fact that the medicines cost just a fraction of the patented counterparts in the West.

Coming back to the Patent Act of 2005, a few amendments were actually made. One significant provision thus added enabled Indian generic drug manufacturers to continue producing patented medicines that they introduced between the years 1995 and 2005.(1995 was when TRIPS entered the picture). For some four or five years, this provision helped offset-to an extent the adverse impact that the new Act had on the health sector.

The repercussions of the new Patents Act have begun to manifest in recent years. As per a study conducted in 2014, of the 140 patented products that were looked into, just 92 actually bore information on whether they were indeed manufactured in India. Of those, it turned out that just four were really manufactured in the country. The other 88 were imported and marketed in India at higher prices.

How doctors become victimized

So much for history and policies. Now, let’s take a look at how doctors often find themselves at the suffering end because of all this.
To understand how, a few background details need to be called upon:

• The inefficient public health-care system has made healthcare pricier
• More patients relying on the private sector for care
• The commercialization of healthcare sector means that patients have come to view the doctors as vendors. A far cry from the elated view that doctors traditionally enjoyed.
• A marginal spend on health care by the government means that efforts to educate the people are also minimal. This leaves a large population- especially the poor and uneducated in the dark regarding the possibilities-and limitations of medicine.
• The poor-who lack access to provisions are forced to spend amounts that could be too high for them in order to avail care.

These last two points are of particular significance given the rise and rise of the assaults on doctors which is seen in India. The lack of knowledge regarding the medical possibilities and processes coupled with a higher spend makes it easy for people to get irate when something goes wrong with the patient. For one thing, they feel somehow ‘cheated’ that they aren’t getting what they paid for. Another fact is that they sometimes place unwarranted expectations on the powers of medicine.

But that’s just one aspect. There are also other factors like the infrastructure constraints under which medicos have to perform. The kind of stress that this brings on, you know it better than anyone else.

References:
Evolution of Health Policy in India(Ravi Duggal)-CEHAT
Making National Drug Policies A Development Priority(Sven Hamrell, Olle Nordberg)
Public Health-cover story(Frontline, August 5,2016)

Image credits: npr.org
Images may be indicative

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