People over Profit

“The time to make health and healthcare a fundamental right is now!” was the slogan of India’s third National Health Assembly, held in Raipur, Chhattisgarh, in September. It declares that health is no more a service delivery issue, but rather involves the politics of rights. The assembly was a congregation of more than 2,000 people from all over the country.

Under the aegis of Jan Swasthya Abhiyan (JSA), it became a platform of collective health activism for trade unions, NGOs, government health workers, academia, patient network groups, community-based organisations and others. It has immense significance in the current scenario to understand how well the peoples’ experience with regard to health is in sync with the government’s priorities and policy decisions.

The assembly distinguishes healthcare from health. Health is the manifestation of the ‘state of being’ — which is a continuous process of negotiation with the State-facilitated politics, market-determined economy and contextually processed social events. Healthcare is the space to negotiate with the events of service provision. In other words, healthcare deals with the diseased, whereas health deals with the disease itself!

The health of indigenous people is at great risk because of curtailed autonomy on natural resources (primarily, river-forest-land). People are dismayed by the government’s practice of giving forest land to corporates for mining and natural resource extraction businesses at the cost of creating health hazards. Experiences from Chhattisgarh’s mining areas show that mine water pollutes agricultural land, village ponds and even drinking water sources.

The state of healthy life is becoming irredeemable because of the government’s apathy in taking action against the corporates’ profit maximisation practice. Hence, the struggles are fought by the people alone — in Kodaikanal, on mercury contamination among the factory workers and adjacent communities; for the compensation of Silicosis victims in Gujarat and other states, etc. These have happened because of continuous dilution in labour laws, relaxation of environmental rules which eventually impact on the workers’ occupational health and long-term health menaces for the community.

Corporate invasion is similarly damaging the avenues of healthcare, too. The assembly recounted the experience of a bereaved father who is fighting a legal battle with a Gurgaon-based corporate hospital. The man was billed Rs 18 lakh for 15 days of in-patient treatment for Dengue, while the result of the treatment was the death of his seven-year-old daughter, due to alleged medical negligence. Concerns were raised over the growing presence of private players in public policy-making spaces.

For example, the Karnataka Private Medical Establishment (Amendment) Act, 2017, is not effective enough because of the pressure from the private hospital lobby, which was part of the amendment review committee. Due to the absence of ethical and legal regulatory framework, the entire care-business of the private health sector is financially exploitative of the people, and thus limits access to care.

The government’s decision to include private players in public service provision is restricting services that would be otherwise available to the people. The lack of investment in the public system, especially in infrastructure and equipment, unavailability of skilled health workers, shortage of drugs and diagnostics procedures, have led to public-private partnerships (PPP). However, the experiences from Karnataka, Bihar, Chhattisgarh, Rajasthan and others show that due to lack of profit and business, private sector inclusion at primary and secondary levels are not successful.

Similarly, the strategy of private sector participation in tertiary care, where the government purchases services through private hospitals for a select population (strategic purchase) is under doubt. Indeed, poor people are getting some benefit out of that strategy, but the question is about financial viability.

India’s present-day health policy is fashioned only in terms of medical care. Apart from the national disease control/eradication (such as TB, HIV/AIDS, Malaria, etc) and family planning programmes, the entire health policy is focused on the curative model of universal health coverage. Since the provision of public service is staggering in scale, the government takes recourse to strategic purchase and PPP.

The idea is, let the government run the preventable, communicable diseases and routine vaccination programmes, the curative part can be done through PPP and strategic purchase. This, while the government continuously ignores the health service organisational challenges, the growing discontent amongst grass-roots level health workers over salary issues, failures in technological standardisation, the lack of skilled medical manpower, infrastructure bottlenecks and adequate budgetary support for the public system.

The policy outlook is in complete mismatch with the peoples’ experience in health and healthcare. The policy priority of health is reduced to medical care by ignoring the larger political, economic and social dimensions of health. The government’s macro-economic policy to include private sector has two impacts on the health and healthcare of people.

First, the health service is enormously commercialised. Second, the operation of private players in other sectors, such as mining, food processing, heavy and small-scale industry are equally worrisome for people. In the name of ease of doing business, nobody knows the extent of health hazards that are being accumulated by society.

The existing health policy position is unable to understand these complexities, hence the need to make health and healthcare a fundamental right under the Constitution. Under Ayushman Bharat, it is evident that the government is prioritising private sector profit over people’s health. The peoples’ assembly is a counter resistance to that preference.

(The writer is a PhD student at the Centre for Social Medicine and Community Health, JNU)