Public health is the State's responsibility

The outcry over the recent deaths in Gorakhpur is justified and must not let up until there is complete reform of the public health system. Early investigations have pointed to a sys­temic dysfunction for which the state government should take full responsibility. If the economically deprived cannot receive healthcare in government institutions, where should they go? And this tragedy is re-lived in many other states where public health facilities are in deplorable condition.

Add to this the dismal state of determinants of health, like poor water and sanitation, poverty and rising prices of food, we have a disaster in the making. It is going to be impossible to rein in health indices and achieve any health goals in this country if the government does not revamp its hospital, primary health network and preventive care programmes.

Non-governmental organisations and health watch groups have been advocating reform and health budget increases for years. While budget allocation by itself is no answer without accountability and transparency, this is one way to build the infrastructure and manpower needed to provide healthcare access to underserved populations in rural areas.

Instead, the Niti Aayog and the Centre have mooted public-private partnerships in government hospitals for diagnosis and treatment of non-communicable diseases. This move has been criticised as a bid to bring market forces into healthcare, a move that will surely raise healthcare costs and worsen inequalities and exploitation of patients. Giving up on its responsibility to provide access to healthcare goes against the WHO Charter on health and human rights.

The WHO constitution enshrines “…the highest attainable standard of health as a fundamental right of every human being.” This right includes access to timely, accessible and affordable healthcare of affordable quality. This is conspicuously absent for much of our population, driving them further into debt and poverty with every health crisis, as they have to bear out-of-pocket expenditure.

Article 25 of the UN Declaration of Human Rights, 1948, says “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family…” The right to health was again recognised as a human right in the 1966 International Convention on Economic Social and Cultural Rights. India is also a signatory to the charter of ‘Health for all by Year 2000’. The Directive Principles of State Policy of our own Constitution provide for “improvement of public health” as one of the primary duties of the state.

It is crucial that the wider social community and the medical fraternity question the indifference of the state to public health and the ominous move to privatise healthcare in India. While privatisation may have worked in other sectors, it is crucial that the government continues to provide healthcare and education to the vast majority of poor and middle class who may not be able to access private facilities.

Although financially unrewarding, care of the marginalised and the poor is squarely the responsibility of the government in a democracy that values justice. Foisting the responsibility on the private sector is a callous abdication of this duty, and betrayal of the trust of the least-empowered citizens.

Driven by profit

The private healthcare establishment, with the exception of not-for-profit or mission hospitals, is mostly driven by profits, and would arguably not exist without it. This has a place in the network of healthcare resources, but it cannot be expected to do the welfare work of the government. In fact, the track record of public-private arrangements has been dismal.

Market-driven institutions have not responded favourably to price caps on devices and surgical procedures, and the number of operation procedures like hysterectomies and cataracts suddenly increased when they were covered by government health schemes. Hospitals have been made to wait for months to receive dues from patients covered by government programmes. The law prohibits private hospitals from denying emergency care, but the government is silent on who should pick up the tab if that patient is uninsured and cannot afford to pay!

Despite promises of health insurance policies that will cover weaker sections, and several false starts, 80% of the population remains uninsured, according to the Central Bureau of Health Intelligence. Reams of paper and planning are spent on Sustainable Development Goals in Health, but these will pass us by if there is no political will for implementation, as have other laudable targets like ‘Health for All by Year 2000.’

Privatisation of healthcare in the US has not worked. Instead, there are other models of the public health system, such as in Cuba and Sri Lanka, that we could adopt and learn from. Given the size of the problem and complexity of the need, the formula to provide for health needs of all will only emerge from a concerted effort to remove inequalities, motivated by the intention to serve.

Doctors have to advocate against commercialisation of healthcare that could alienate millions in this country. It is sad that the Gorakhpur tragedy was necessary to highlight this problem and for voices to be raised against the unjust neglect of the public health system, but let’s hope it is the turning point.

(The writer is adjunct professor, Division of Health and Humanities, St Johns Research Institute, Bengaluru)