MFCM090: A critique to the background paper 'Medical Services, Medical Technology and Privatisation' of the mfc annual meet, January 27-29, 1989.pdf

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A critique to the background paper 'Medical
Services, Medical Technology and Privatisation'

of the MEG annual meet, January 27-29, 1989.
By; Sujit K. Das, P.K. Sarkar, Smarajit Jana
and Dipankar Sengupta.
COMMUNITY HEALTH CELL
47/1,
(First Floor)St. Marks Road
1. General comments;
BANGALORE-560 001
The characterisation, offered in the background paper (BP)

of the development of health care services in India, appears to be one
sided and often myopic. Such one-sided approach has inevitably led to
self-contradictions on important matters. Through certain sweeping

observations, the BP wants to establish that the entire trend of post­
independence development of health care service is towards development o£

of a strong and dominant private sector in health service. Such an

assertion is only possible if one ignores the massive post-independence
development of State health care service. The BP appears to have done
just that. We are, however, of the opinion that the actual development
of state services ought to be taken into consideration if one ventures
into an objective assessment of reality. In the field of public health,,
public sector is not only dominant but one can very well characterise

it as monopolistic, the private sector is virtually absent. In the
field of medical care, the massive network of State services composed
of 1 lakh stibcentres, 15000 PHCs, 26000 dispensaries, 4200 hospitals

with 4.2 lakh beds present a gigantic edifice which the private sector
(excluding the individual medical practitioners) will take decades to
match.
Analysing the pattern of budgetary allocation of the

Government, the BP observes that a major part of the allocation on
health sector is actually spent to provide infrastructure and subsidy
to the private sector. In doing so, the BP gives the impression that

this budgetary policy is peculiar to the health sector alone. But it

is not so. In almost all developmental and service sectors including
industry, agriculture, power, education etc., this is the dominant
trend, health is no exception. The BP1s exposition is true that State
financed medical education predominantly serves private sector; but
same is the purpose of all State-financed education.

The BP refrains from dealing with a major issue of the
subject under discussion i.e. Centre Vs. Province. Unless the consti­

tutional obligations and political imperatives of Centre and provinces
are known and their respective roles are taken into consideration,
these will be misplaced accusations, particularly in the perspective
of the emergence of non-congress and left governments. Medicare and
public health measures are the exclusive responsibility of the provin­
ces; medical education for the most part is run by the provinces. In
contd. ...

= 2 =

this context, it should be known that the central government has reco­

mmended banning of private practice for all govt, employed doctors in­
cluding medical teachers but it is yet to be implemented by all prov­

inces; even the Left Front Government in West Bengal has not accepted
it. Another significant recommendation of the Centre is to stop free
distribution of drugs from the State hospitals to the affluent section

of population; this also has been rejected by the provincial govern­
ments including the Left Front in West Bengal.

The theory that extension of public sector to the unreach­

ed areas is actually the harbinger of private sector to those areas
for commercial exploitation, is difficult to sustain. In the remote
areas, the private sector is virtually non-existent (We, of course,

are talking about modern medicine); in the enlightened rural areas,

the private sector is as yet under-developed; in the cities, maffusil

town and industrial - commercial centres, the private sector is domi­
nant. This is because, the private sector does not move into a' place

where there is little to exploit for profit and this applies to all
commodities, not peculiar to medical service alone. It is rather a
credit to the State that people in the periphery, where commodity medi­
care is absent or poorly organised, receive some amount of medicare

through State Service. In any case, what's wrong with extension of free

State medicare to the unreached areas? Even if it is inadequate and
even if the private sector is carried on its piggyback? One cannot
ignore the service, however inadequate it may be, rendered by the
State machinery to the indigent population through its massive network.

It ought to be emphasized that private sector has never rendered such
service and will never do so. We ask again - what's wrong with that?
In the process of analysing the health scene with such
one-sided approach, the BP is enmeshed in a major self-contradiction.
The BP repeatedly asserts that the private medicare sector as well as
the New Medical Technology (NMT) serves only an elite section (enclave
sector); it is not accessible to majority impoverished population. If
that is so, why quarrel with private sector and NMT? But the BP still

picks up quarrel with the private sector and NMT with a complaint that
the latter is putting obstacles on the path of the poor's access to
State free medicare.
The BP, nevertheless, has made a lucid exposition of the
process of privatisation and presented the actual health xxd need of

the population in an unambiguous manner in the context of the ensuing
trend of introduction of NMT and corporatisation in medicare service.
In calling for a solution to the problem, the BP, however, raises
innocuous demands. This critique will concentrate on formulating concontd. ...

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crete demands for solving the problem in the Context of present real­

ity. One aspect of the BP is really praiseworthy that the Bp has not

followed the sterotyped line of a section of the radicals who invari­
ably prescribe revolution and socialism as panacea to meet all the
problems.
2. Few specific comments:

(a) NMT : NMT should primarily be evaluated on the basis of

its efficacy and medical desirability, which the BP has not done. If

NMT is found to be based on sound scientific principles, medically
efficacious and hence desirable, then the question is - how to incor­

porate it into the peoples medicare service. If not, then the primary

duty is to attack it on this ground, besides other factors.
(b) The BP observes - "The Indian State

preferred a

system of health care services where health care and medicare would

be commodities,

..4

the State was left with the responsibility of

public health and health care services for the periphery"

(Page 2). in

the context of reality, how can one reconcile with such observation?
It is for everyone to see that, before independence^ medicare (not
health care) .was sold as a commodity almost Universally. After inde­
pendence, State offered free-medicare which provided an alternative

to the indigent population who could not afford to purchase the commo­

dity in the market. The preference of the State policy is therefore,
may be interpreted as to develop a counter-force against the commodity
trend. Further, it is not true that the State service is restricted
to the 'periphery'. On the contrary, about 3/4th of the State medicare
expenditure is allocated to the central urban areas.

(c) Construction work (para f, page 4): True, construction
work of hospitals and health centres benefits private sector, but such
is the case for all governjnental construction work and in comparison,
the health sector job is rather insif; insignificant.
(d) Research (para g, page 4); It is doubtful how far the
private sector profits from research done in public sector for the

simple reason that the amount of profitable medical research in public
sector appears to be negligible.
(e) We do not agree with the observation "In the public

sector hospital services are only available at the district level
through a 100 to 200 bedded civil hospital for 2 to 3 million popula­

tion"

(Page 5, last sentence). Our experience tells us that hospital

service is available at all levels including the rural health centres.
(f) There are a number of observations in the BP whose mean­

ing or implications are not clear to us, e.g. 'The NMT
is going
to bring out far reaching changes in the structure of health care
delivery1 ■ (Page 5) , 'NMT and privatisation go hand in hand* (Page 5),
contd. .

= 4 =
'private sector, has sunk deeper roots and is more easily accessible
(physically) to the population' (page 6), 'The difference between NMT
and introduction and development of modern medical service is only
academic' (page 6) etc. Instead of making comments on such observa­
tions, we propose to deal with those in the next section.

3. Our analysis of the situation;
We are constrained to make our analysis very very briefly and .
present only the essentials, being aware of the fact that a little bit
of elaboration would have been helpful. In the pre-independence period,
the private sector was overwhelmingly dominant. Since independence,
public sector made tremendous xtxdxz strides in quantity, quality and
geographical spread, particularly in the rural India. In comparison,
private sector lagged behind i.e. could not keep pace with the public
b
sector. Though the public sector was corjtrained to deliver public
health almost exclusively, it had to contribute in the delivery of
medicare service to its fullest extent, so much so- that the rural
health centres, which are assigned chiefly to look after public health,
were compelled to engage their utmost efforts towards delivery of medi­
care. Introduction of NMT has all along been the business of the public
sector, the private sector followed behind with a long time-gap. That
was why, the public sector used to attract talents of the medical
profession and the costly NMT of the public sector was largely consumed/cornered by the stronger section of the society. In fact, a belief­
trend has steadily developed that better and sophisticated medicare is
available in the public sector. In this regard, we agree with the
observation of the National Health Policy document of the GOI that the
Government' sjjspecially those residing in the urban areas ... at the
cost of providing comprehensive primary health care services to the
entire population' (page 4.2).

1

Politics of medicare;
Indian post-independence welfare State embarked on a costly
modern medicare programme with the intention of acquiring people's
appreciation thereby enhancing its own pro-people image, and this
programme actually brought good dividends for quite a length of time.
But later, the ungrateful masses of impoverished citizens, instead of
remaining for-ever-grateful for free medicare, started claiming free
medicare as their right and even voiced such demand through various
ways including agitations. Frequent assaults on hospital employees and
disruption of hospital services often emerged as law and order problem.
It became the common practice of the candidates for election to promise

3.1.

contd. .

= 5 =
the electorate their utmost efforts, if elected, to establish a hos­
pital in the constituency or to improve the services of the already
existing one. The demand for State medicare became irresistible but
in an exploitative economic order, the ruling classes cannot concede
basic medicare free to the indigent population; if it does, expendi­
ture on medicare will perforce increase several-fold and in that case
capital accumulation will suffer, the pleasure of profit-making will
disappear. The ruling classes soon realised that free-medicare, which
once helped them in battle of ballot-box, now turned into a boomerang;
failure of the State in providing medicare became a political problem
for the Government.
The problem is not peculiar to India. It has created crisis
in almost all countries following capitalist mode of development,
particularly in a few advanced capitalist countries. This internation­
al crisis has forced the international ruling classes to search for
global solution; a number of formulas have been advocated, the major
one being 'Health for All by 2000 A.D.' under the aegis of WHO. This
formula calls for reduction of expenditure on medicare, more emphasis
on public health and personal care, and of course, community medicine a populist panacea. For the Third World countries like India, this
WHO cake has been topped with several progressive attractive icings
e.g. alien modern medicare be supplanted by glorious indigenous tradi­
tional medicare which is compatible with people's culture, introduc­
tion of traditional medicine will help combat cultural imperialism
and resist the exploitation of the giant medical industry of the
international capital, increase community's control and self-reliance
etc. Predictably, the Indian State gleefully grabbed this formula.
Because, as rightly pointed out in the BP "Community medicine type of
low cost technology serves as an instrument of redistribution and
helps to provide health services (albeit of inferior kind) to a wide
area and population (in periphery) with a negligible investment (of
course by the State) that appears as a special concession and demon­
strates the humanitarian concerns of the State" (page 6). Further,
the explicit ideology in 'Health for All' calls for personal enter­
prise of the individual and absolves the embarrassed welfare State of
its committed responsibility of providing medicare to all citizens.
This alternative medicare programme has been prescribed pointedly for
the poor only, the affluent is condemned to modern medicare including
NMT. But lately, the State service is found to be unable to meet the
demands of the affluent also; the demands of the strong affluent lobby
can hardly be ignored. Hence privatisation, which will offer access
almost exclusively for the affluent.
contd. .

= 6 =

4. Conclusion and demands

It is thus obvious that the problem of people's medicare is
essentially the problem of access and distribution. Neither NMT which
may be desirable, nor the development of the private sector which is
inaccessible to the indigent, are the real constraints. The point is how to make State medicare accessible to the poor and how to effect an
equitable distribution. In this context, 'national health service', as
demanded by the BP, is a little bit vague, perhaps utopian and defini­
tely difficult to achieve in the prevailing economic-political set up;
one may also point out that national health service does not preclude
existence of a private sector, as we find in the U.K. In any case,
'medicare for all' or for that matter 'anything for all' is essentia­
lly a bourgeois demand. Bourgeois ideology has taught us the concept
of equality and set up the objectives of achieving everything for all
food for all, education for all, democracy for all, justice for all,
what not. The actual practice of discrimination, deprivation and ex­
ploitation is concealed under these unexceptionable democratic humani­
tarian slogans. The actual practice has put insurmountable barriers to
access thereby negating the very essence of these slogans. One can
combat this discriminatory practice only with a counter-discriminatory
practice, raising class-slogans. The deceptive slogan 'Health for All'
be abandoned and counter-slogan should be 'Medicare for the poor'. We
suggest the following demands:1. State medicare be exclusively reserved for the people liv­
ing below the Poverty Line or some such other income demarcating level.
2. Affluent section be left under care of private sector.
3. Middle income group be organised under insurance scheme
with State assistance.
4. Employers should provide medicare to the employees.
The above demands are discriminatory in nature but it is
counter-discrimination in favour of the under-privileged. The point
is - whatever may be the State policy towards privatisation, State
must provide for modern medicare including desirable NMT to the indi­
gent citizens; unless the entry of the privileged section to the State
service is prohibited, access of the under-privileged cannot be ensur­
ed.

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