Medical Services, Medical Technology and Privatisation
Item
- Title
- Medical Services, Medical Technology and Privatisation
- Creator
- Ravi Duggal
- Date
- 1989
- extracted text
-
'COMMUNITY HtA
B A-J
47/1, (First FloorJSt. Marksf'aacJ
BANGALG fE - 5S0 GUI
R0•- AD PAP SR
XV ANNUAL MEET OF MEDICO FREIND CIRCLE
- Technology in Health Care : Issues and
Perspective
Medical services, Medical Technology and Privatisation
- Ravi Duggal.
The growth and development of private capital, especially
monopoly capital, has an umbilical connection with the State.
Without the latter's assistance capital accumulation would not have
reached its stage of monopolistic concentration, what in radical
political economics is referred to as imperialism.
Monopoly capitalism implies complex social division of work that
is reflected in a general trend towards specialisation; health
services are no exception to this and that brings about costlier
personnel reproduction (Breilh, 1981). High technology and more
efficient managerial and administrative practices-, especially since
the late seventies, have given capitalism/imperialism a new lease .
of life.
In the field of health and'medidine "new medical technology" and
"community medicine" (it may appear contradictory to the former)
have provided a new strength for private capital to flourish in
an area where- State intervention has historically a dominant force.
It is in this context that the issue of privatisation emerges.
We raise this issue because there is concrete evidence of the
State’s support and encouragement of the private health sector
(similar to many other sectors of the economy).
Defining Privatisation;
At the outset we would like to clarify thqt privatisation does
not mean or refer to the existence or growth of a dominant private
sector. As indicated earlier it refers to the relationship
(especially the changing process) of the private sector with the
public sector. Thus privatisation is a process, It is a process
that has been going on for a long time and has accelerated in
recent years due to certain developments in health.sector globally.
Privatisation may be best explained through the forms it takes:
a) Divestiture (transfer of ownership): This involves the selling
put of public provision to the private sector. Isolated cases
of such privatisation may be cited from the past but this form
°f privatisation is still in an infantile stage in India. In
U.K. and France this -is becoming the dominant form of privatisation
and in the years to coma it could become a major trend globally.
L
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b)
Contracting/Leasing:
sj. nas This is a very common form of
privatisation that exists globally. It is a dominant form in the
service sector of the economy and is widely practiced in the U.S.A.
In the health sector certain hospital functions, construction,
activity, purchasing, programme management and implementation,
leasing out for a short period etc... are the common types of this
form of privatisation which is auite rampant in India, both in the
health sector end outside it.
c)
Source of Income: Privatising the source of income like, 'fee
for services’, permitting private practice etc. in the public
hospitals and health centres has been a dominant trend globally
since the late seventies. This form of privatisation is already
becoming a major trend in India.
d)
Strengthening the Private Sector: This form of privatisation
is the historically dominant form. Its main characteristic is
that public resources are used for the development, growth and
strengthening of the private sector - the public sector provides
inputs (medical education, soft loans, tax concessions and
'.subsidies, social and economic infrastructure etc.) and the
profits are appropriated by the private sector.
There is also another emergent trend,, which however cannot be
labelled as privatisation. The trend is one of increasing
corporate control of the health services sector.. This has been
aided largely by the new sophisticated medical technology and a
more efficient management of resources which has made .the.
operation of private health' services more profitable.. This trend
is bound to make major changes in the future in private practice
of medicine because the medical practitioner in all probability
will be reduced to being an employee (albeit well paid and
pampered) rather than an independent professional. One may call
this precess ’corporatisation5.
Thus privatisation' broadly is a process whereby public provision
is transfered (in whatever manner or form) to the private sector.
This amounts to, on the one hand increased profitability and
concentration of private capital and on the other a more expensive
and difficult acess health care delivery system for the consumer
because services availability gets related to the proportion of
"
one's income.
The Historical Context of Privatisation in India:
After Independence from colonialism, inspite of the analysis of.
India's health situation and recommendations of the Bhore
Committee Report, the government preferred to let the private
sector domineer in the provision of health care services. The
Bhore Committee Report clearly favoured the establishment of a
broad based intag?.ated national health system that would be
equally accessible to the entire population, irrespective of their
ability to- pay.
1
.The Indian State and the bourgeosie rejected the Bhore Committee’s,
recommendations and preferred a system of health care services
where he-1th ere and medicine would be commodities. The private
health sector geared and flourished, with adequate State patronage,
to provide curative services which is the primary need/demand of
the population -no the State was left with the responsibility of
public health -nd health care services for the periphery. The
State w~s --Iso made to provide the infrastructure-medical
education and research, bulk drugs, tax rebates and subsidies as a suppe-t to ve private health sector.
tice developed as the core of the health
ttally strengthening the enclave sector, then
- h-". rorinb.ery as opportunities for
. . 'I.
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3
expropriation of surplus, by providing health services, increased
due to the expansion of the socio-economic infrastructure through
public funded programmes. Today three fourths of the health
cnrv. is catered to by the private sector.
India is even today largely a subsistence economy. The poor
majority is placed at the mercy of the private health sector to
meet their health care needs because of the lack of adequate (free)
and easily accessible government health services. The government
has failed to develop a proper health infrastructure that could
meet the needs/demands of the majority underdeveloped population
of the country. On the contrary the government has supported the
expansion and strengthening of the private health sector. The
result is that the health care sector remains underprivileged
for the majority of the population whereas a small elite group
(enclave sector)
enjoys special treatment.
In spite of this appaling situation the government is talking of
privatisation of health services. The National Health Policy of
1983 clearly speaks in favour of privatisation;
’ The policy
envisages a very constructive and supportive relationship between
... the public and the private health sectors in the area of health
by providing a corrective _to_ re-establish the position of the
, private healxin™ec”tur’ ”
With a view to reducing government
expenditure a..d fully util icing untapped resources, planned
programmes may
d-vised, related to local requirements and
potent!als to encourage the establishment of practioe' by private
■ medical professionals',. increased investment by non-government
agencies in est .‘-lishing curative centres and by offering
organised logi •„-t .cal fir? a no la.', and technical support to voluntary
agencies in the health. field., *
(GOT, 1983).
Thus., historically.the private sector has been the major provider
of health car?, services in India. Over the years it has been
; nurtured and sctengrhened*by State interventions and today large
. scale privatisation of public health services is in the offing.
Why privatisation is becoming an issue today is because the forms
it is taking is moving away from the traditional patterns of
privatisation i,e. it is changing from State support to'more direct
forms,
The State and Privatisation;
As pointed out earlier, State support of the private health sector
is the historically dominant form of privatisation in India. What
are the areas of Stqte intervention ?
a) Medical Ed-c--tion is almost wholly a State financed activity.
The 1.,- j^r beneric lory of this is the trained doctor who practices
-medicine pri vu-■'.y« Between 2/3rds and 3/4ths of the trained
alloyaias
■* . the private health sector. Though they are
trained a~ P rlic expenses, their return to society is negligible
be; ran rites ii
tiica engage in health care as a business activity*
Also ; subs.
— ’proportion migrate to developed countries and
joni^ising r_n tr
.leer's health care development.
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b) The government provides concessions and subsidies to private
medical professionals and hospitals to sot
practice and
hospitals. It provides incentives, tax hoi id-its su.-'t’.as to
private industry (pharmaceutical, medical equl ?: r *•) . It
manufactures and supplies raw material (bulk d .i ;• = )
• p.-lvat^
formulation units at subsidised rates/low cost. It
exemptions in taxes and duties in importing medical, umliwst and
drugs, especially the highly expensive new medical ti1ob),;gz.
c)
The government has allowed a highly profitable p,<:ty_ahe hospital
______
„ as trusts
_____ which
___ I._______
I „ _ vfrom
i
a r. e
sector_________
to function
are exempt
they don't contribute to the State exchequer even though the/ charge
patients exorbitantly.
d)
The government has permitted non-government organ.:.?.! fleas (NGOs)
to run its programmes (contracted out) in”selectee <
have provided NGOs financial support. This has beer- ‘t
g.in
rural areas where ineffective public health service.-" ’keen set
up. The result has been that the government's own s-.mean have
suffered a further loss of credibility thus creating ;. Justification
for future privatisation.
■r
e) The government has pioneered introduction of allopathic medici^
in untouched areas thus creating a basis for the entry of privbte
medical services in these areas. The setting up of PHCs, for ■
instance, in backward areas and provision of other supportive
infrastructure has provided both an entry point and incentives to
private practitioners and hospitals to set up their services.
f)
Construction of hospitals and' health centres are generally
contracted out -co private persons. The latter make a lot of
money in the construction process but most of the hospitals and
health centres, except in selected urban centres, that have come
up through substantial public investment do not function adequately
to meet the demands of the population.
g) ____
________________________
_______________________
______
Medical
Research and Pharmaceutical
Research and' Development
is largely carried out in public institutions but the major
beneficiaries are private sector institutions. Development of
drugs, medical and surgical techniques etc. are generally
pioneered in public institutions but commercialisation,. - marketting
and profit appropriation is left to the private sector.
h)
In recent years the government health- services have introduced
*fee-for-service s1 at its health facilities. This amounts to
privatisation of public services as utilization of the latter
would now depend on the av ailability of purchasing power.
Increasing private sources of income ef publicly owned services
would convert them into elitist institutions. In fact it is well
known that specialist facilities in public teaching hospitals
and other well known public hospitals are monopolised by
influential persons.
i)
Th'- government has allowed the private health sector to
/
proliferate uncontrolled. Neither the government nor the Medical
Council of Indi- have any control over unqualified, unethical,
irrational for-profit practice of medicine. Even doctors working
in public institutions who are paid a non-practicing allowance
(even this is questionable) run a successful private practice with
the full knowledge of the concerned authority and no action is
taken.
The above are saac illustrations about linkage between the
private and pu.olic sectors, Historical evidence does show that
the State sector has contributed to a strengthening of the private
health s-cror ir. a significant way. In this light the recent
5
trends in privatisation, which involve more di rec*. emetic-' lilcdivestiture and leasing out or privatising th.. .soiA-fcahntcmc
of public institutions raise serious questionof the health sector and even more so about th' Vxrsv -/ucy'Ornf.y ©f
the underprivileged and underserved population h oi- • v<iIk6je_
affected by it.
J
New Medical Technology and Privatisation;
We have stated earlier that the new high technology
with more efficient managerial and administrative
accelerating the process of privatisation.
ed eng
is
By its very nature the new genre technologies (espa'cr'cA^.y Df the
electronic and computer aided variety) has made cooc<&rtYc,cHa)
of monopoly capital even more simpler and the control caxsj'sjr.
This is true for all sectors of the economy but more so 'fox medicine.
The new medical technology (NMT) has opened new avenues of corporate
investment that is going to bring out far reaching changes in .the
structure of health care delivery. NMT has brought health care
delivery to the doorsteps of monopoly capital. The various forms
of privatisation are early signs, and corporatisation the virus
that helps complete the cycle.
•In a country like India where basic health care is still a dream
for the masses, the fast paced'introduction and proliferation
of NMT is only strengthening unequal health care distribution.
NMT and privatisation go hand in hand. Corporatisation follows
and adds strength to it.
Historically the introduction of modern medicine, its technology
and practices have been characterised by an enclave sector patterns
of development. During the. colonial period modern health,care was
available/accessible to those in civil and military services. ■
Introduction to the periphery was largely restricted to setting
up of civil hospitals at the district level which had very
restricted access. Provincial governments did make some efforts
in setting up dispensaries in 'mofussil areas* but they were too
few to have had any impact. In fact it was the missionaries who
. made successful attempts at introducing modern medicine in quite
a few remote and difficult access areas. In the post-independence
period, the State undertook the responsibility of providing
health care to the periphery but the development has been very
gradual to the extent that even today there is only one 6 bedded
PHC with two doctors and about 8-10 paramedics placed at sub
centres for about one lakh population, (in 1946 Bhore Committee
had. recommended a 75 bedded primary unit with 6 doctors, 6 public ••
health nurses, 6 mid-wives and 66 other paramedic and noh-tiealth
supportive staff for a 10., 000 to 2 0,000 population, supported by a
650 bedded secondary unit serving 500,000 population with 140
medical officers of a wide variety of specialists and the secondary
unit will in turn be supported by a 2500 bedded hospital with 269
doctors serving a 3 million population)
(GOI, 1946) . In the
public sector hospital services are only available at the district
level through a 101 to 200 bedded civil hospital for 2 to 3 million
popul '.cion.
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The above description clearly shows that the proliferation of
modern medicine through public sector has been a slow precess.
It’s access is very dispersed. On one hand the private
even though of questionable quality, piggybacking >n tr;e L vl.to,
i. If: •
sector, has sunk deeper roots and is more easily •vr'-jstfi.
(physically) to the population - only the access u..'
1 - to
purchasing power. A strong curative medical can; ;■/>*..7, . s had
been suggested by the Bhore Committee, has never
■’.’lic'c-id
by the State for the mass of unorganised popular:, :y 1 o i■' ■■■ i ■ u.lphery.
However, in major industrial centres and cities tl»a public iiealth
care facilities are relatively far better developed ■;.*■;
better
utilised. This unequal development clearly subs tn. rt ■ a tea v.ia> enclave
sector patterns of development of the health sectc;\
I
The same holds good for the NMT. The difference between
and
introduction and development of modern medical, servic-’3 is only
academic. In the case of the latter, the public swjt.r
the
groundwork of introduction of modern medicine (of course
missionaries had already done it in a few areas much e--c'1 icr.; on
a wide scale in the periphery and the private sector f.>>. ;rwed and
established themselves - it is very clearly established- that the
public health services in the periphery are only an appeasement
and not a well grounded and proper health care service that meet
the needs of the proper health care services of the population.
w
.In the case of NMT it is the private sector that is introducing
the technology but again with the assistance (tax subsidies, duty
exemptions etc.) of the State. The NMT is very- expensive to use
and thus has restricted access to an insignificantly small proportion
- of the population. But given the nature of private medical
practices in India with its system of kickbacks an overuse/misuse
of NMT:’ is taking place and its use proliferating to groups of
population who even find preceding medical technologies an extreme
financial burden to use. And NMT is the forerunner of corporatisatior
Another import.* nt development that has diverted the development of a
proper medical care system is the community health or medicine model
exported to underdeveloped countries by~ideologues' of imperialism...
‘ Talking.of community medicine in a class, society is absurd because
a community in such a society does not exist - ’it appears only as
a mystifying label placed on poor peasants, urban subproletarians
and the family of workers, and the ultimate intention of such
community services is not to provide the people with the best
possible care but to install a cheap invisible structure of
"concession" and "repression" through medicine* .(Breilh, 1981).
Community medicine as a concept has existed for a long time but it
was demonstrated in India by the John Hopkins’ project at Narangwal,
Punjab, in the late sixties under the leadership of Carl Taylor
who had earlier been associated with community development projects
in India. For capitalism the community medicine type of low cost
technology serves as an instrument of redistribution and helps
provide health services (albeit of an inferior kind) to a wide area
and p. 'illation (in periphery) with a negligible investment (of . course)
by the State) that appears as a special concession and demonstrates
the humanitarian concerns of the State (Ibid).
It nay *lso be hoterP that tx.i.; mac el of health care has been
prem t . v
och vely i’ InclL' with the collaboration of a host of
NGOs. ’ (•)£.£ ocjcu'va Shwas s trong public-private linkages and indicates
a ur.igue t'tfhni
pa v.vct-ioc'.’Hon because resources used by NGOs are
inV'-ricJ'fy c-£ QC'j&ir.yAsi.nt, i.jr they are not imperialist.
Thus, the lack oj*pyoperly organised basic health care/medical care
servir.es
tn®> VYwsggus, the emergence of NMT that contributes to
furthers
avt| the model of community medicines- that reeks of -
7
double standards and ofcourse institutionalises an unequal health/
medical care service, all are indicative of the vested interests
that are served in the process of providing of health cere airl
the development (rather underdevelopment) of the health sector in
India.
CONCLUSIONS:
The NMT has provided a firm footing for the growth of monopoly
capital in the health sector. Since historically the health sector
has had large scale public investments, monopoly capital cun only
survive and grow further through the process of privatisation.
In India privatisation has always existed; only presently the forms
are changing in keeping with trends the world over.
Privatisation, if furthered in India is going to have drastic
consequences. The health sector in India, unlike those in developed
countries, is inadequate and underdeveloped and it is highly
unequally distributed. If steps are not taken to arrost its growth
it will generate further inequality. The developed countries already
have well developed health care systems which are either national
systems or insurance based, or a combination of the two. privatisatiof
in those countries will not have as serious a consequence as in
underdeveloped countries .because the former have a well .organised
workforce which demands health as a right
whether the government ,
provides it or it pays the private sector to provide it. One thing
must be made clear, that the State health expenditures will not
decline either in developed or underdeveloped countries because of
privatisation - the difference will be that the state will contribute
more to the private sector :
Thus a demand for a national health service in India and other
underdeveloped countries bgpomos even more urgent because of
•privatisation.
Arguments in favour of privatisation stress the importance of cost
containment and cost-efficiency in health care delivery. The
privatisation lobby promises more efficient services that would not
cost the State much; fees payable by the patient are supposed to
act as disincentives for 'overutilising' health services. Their
arguments are based on the rollpwing principles - The individual is responsible for his/her own health.
- Access to unlimited free health care is a privilege, and not a right
- There must be on unitary health care delivery system.
- The individual, rather than the institution should be subsidised.
- User charges should be levied.
- Medical aid schemes should be restructured, over—usage of health
services should be curbed, and a more market-oriented health care
deljv..ry system should be developed (Critical Health, 1987)
If one lucks closely at these arguments and principles it becomes
clear that the privatisation lobby is not interested in meeting
health enru needs hut in serving vested interests such as private
hosyi” . 1c nt. practitioners and the pharmaceutical and the medical
cqui
industry .. Also.' privatisation will make access to health
care cape.".’’ent v? buying cau-city of the individual. This would
mean ir p,u ion' I boy. you ;■ at get good health care, but if
lucky y-u may h.-r^ access to third rate indigent health aid
pacxng_s or
: • y health care.
i
For t?;_.
rails I State, privatisation is a welcome step, because
health far |.jecomo Kfghly political and privatisation could help
dc=yoi iHVs.c (Jt- cwvdl Ybaerate the state from this responsibility.
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Thus rivatisation will help the state to break its umbilical
conn ztion with the private sector (if not that of its protector)
and leave the masses at the mercy of the whiirs of the market..
All these manoeuvres of capitalism have thus to be arrested and
the demand for health as a right and a national, health service has
to be pushed vigorously as an answer to privatisation for the
sake of "Health for all”.
REFERENCES:
*
Breilh J., 1981; Community Medicine under Imperialisms A New
Medical Police ? in Imperialism, Health and Medicine
By Vicente Navarro (ed), Baywood, K.Y.
*
Critical Health 1987: "Privatisation : Health at a Price" in
Critical Health Number 19, April 1997.
*
GOI, 1946 (Whore Committee): Health Survey and Development
Committee, GOI Press , New Delhi.
* GOI,
1983:
National Health Policy, NHRW, New Delhi.
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