Public health services will have to be the backbone of any system that guarantees access to quality health care services to all citizens of the country. For this to happen, public health services need to be expanded and strengthened to ensure that it becomes the principal provider of health care services the country. At the same time public services have to be accountable to communities and people they serve. The presence of a strong and reliable public health system also puts a check on the unregulated growth of the private sector and helps in preventing unethical practices in the private sector.
It is being argued within sections of the Government that the only remedy is to hand over health care to private providers and especially to the large corporatised private sector. The supporters of privatisation base their positions not on facts but on an ideological logic that public services are inherently inefficient. To the contrary, corporatization and privatization is a remedy worse than the disease.
Greater public investment (at least up to 5% of GDP from the present measly 1%) and continuous and significant addition of human resources are needed. In addition, the strengthening of public health systems requires major institutional capacity building at all levels of the system.
Regulate the Private Sector
India’s Health Care System is one of the most privatized in the world. Thanks to the policy of the government to encourage the growth of the private sector, especially since the 1990s, the share of private sector in various components of health care in India today is as follows:
Medical graduates 90% Medical colleges 30%
Post-graduate doctors 95% Manufacture of medicines 99%
Outpatient care 80% Manufacture of medical 100%
Indoor patients 40% Devices
In the approach to the huge private medical sector, two choices lie before us. Either public resources would be made to serve private benefit, OR private resources would be made to serve public benefit. Today a dominant strand in the establishment is advocating the former approach under the garb of publicly funded health insurance schemes and different forms of ‘Public-Private partnerships’. In all these models public funds would be handed over to the private medical sector without any effective regulation, accountability or rationalisation of this sector, and in a manner that would further weaken the public health system.
We need to develop an alternative approach of using sections of private resources for public benefit. This would involve in-sourcing of certain kinds of private providers (including not for profit providers) in a manner that would strengthen and complement the public health system instead of weakening it, by utilising such providers where and if necessary and under certain terms, conditions. A pre-requisite for any engagement with the private sector is comprehensive regulation of the private medical sector in India is absolutely essential.
Health Insurance: Who Benefits?
The health insurance model (like the national Rashtriya Swasthya Bima Yojana and state schemes such as the Arogyasri in A.P.) was introduced to protect people from the catastrophic impact of health care expenditure, especially among the poor and the vulnerable. While such benefits would have accrued to a small number of beneficiaries genuinely requiring hospital care, by and large the schemes are inimical to the development and sustenance of a robust public health system. The Ministry of Labour, which administers the RSBY scheme, would like to promote the scheme as pro-worker and pro-poor. This is a gross travesty of the actual situation. The only guarantor of secure access to quality health care is a well resourced and accountable public health system. The working of the insurance schemes should be comprehensively enquired into, especially the very serious charges against private hospitals that they are attempting to ‘milk’ the scheme by resorting to a range of unethical practices. The working people of this country deserve much better, and trade unions and peoples organisations need to be involved in a thorough scrutiny of the RSBY and other like schemes.
Ensuring Access to Medicines for All
50% to 80% of the Indian population are not able to access all the medicines that they need. Given that India today is the 3rd largest producer of drugs (by volume) in the world and exports medicines to over 200 countries, this is clearly an unacceptable situation.
The Government, a few months back, had announced a “free medicines” scheme, under which all essential medicines would be available free of cost in all public facilities. Unfortunately the same Government has now started backtracking from a promise made by the Prime Minister himself. For a successful operation of this scheme across the nation, state level experiences where this scheme is already functional should be taken into cognizance. Noteworthy among these experiences are those of Tamilnadu Medical Services Corporation (TNMSC) which has developed transparent norms for drug procurement and distribution for public sector facilities.
There are an estimated 60,000 to 80,000 brands of various drugs available in the Indian market, a majority of which are either hazardous, or irrational or useless resulting from the license provided by drug regulatory agencies to produce hundreds of combination products (which combine two or more drugs). We need immediate and sustained steps to stop the manufacture and sale of all irrational medicines and the operationalisation of regulatory mechanisms for rational use of medicines.
Since 1970, the Government has endeavored to regulate the prices of some drugs through successive Drug Price Control Orders (DPCO). However, the number of drugs under control has come down from 342 to just 74 in the DPCO of 1995 (which is still under operation). Due to the almost total decontrol of drug prices, over-pricing is rampant in the country with wide variation in the prices of drugs sold in retail and those sold in bulk through tenders to institutions ranging from around 100% to 5600%. Recently the Group of Ministers (headed by Sri Sharad Pawar), tasked to decide on the modalities of drug price control, has recommended a ‘market based’ mechanism to control drug prices of all essential drugs (in violation of the opinion of the honourable Supreme Court). This legitimizes the rampant over-pricing of drugs by companies, prevalent today. All essential drugs (348 at present) including their combinations and dosage forms should be placed under price control based on a cost based pricing formula.
The change in the Indian Patent Act in 2005 took away a valuable tool available with Indian companies. There have been several positive judgments pronounced recently that have made use of the health safeguards in the Indian law. These include the issuing of the first compulsory license (i.e. a license to an Indian company to produce a patented drug manufactured by a foreign company) for an anti-cancer drug (sorafenib) and reversal of the first drug patent since 2005 (issued for a drug for Hepatitis-C – peg-interferon). In spite of these victories many new drugs are now being granted patents and are way out of the reach of almost all Indians. Multinational corporations continue to try to challenge the positive parts of the Indian law – the Swiss company, Novartis, is still continuing its challenge to a key portion of India’s law in the Supreme Court. More stringent Patent rules are being demanded of us by the European Union and the US, either as autonomous measures or through Free Trade Agreements. The Government stand firm in defence of health safeguards in the Indian Patent Act and take active measures to ensure that Patents are not a barrier to medicines’ access.
Prioritise Needs of the most Vulnerable
The transformation of the Health system needs to be carried out in a manner that prioritises the needs of sections with special health needs and populations which are vulnerable or marginalised in various ways. We know well that women, children and elderly people suffer disproportionately from denial of health rights due to combination of special health needs and negative influence of social hierarchies and power relationships. Persons living with HIV/AIDS and people with mental health problems today suffer serious discrimination, which compounds their health problems and leads to their health rights being violated in various ways. Dalit and Adivasi communities have historically suffered from major social exclusion which reflects in continued denial of their health rights. Migrants, unorganised sector workers, people living in situations of displacement and conflict, persons of different sexual orientation are often placed in situations of extreme marginalisation and require special measures to ensure protection of their health rights.