Analytical Monthly Review, published in Kharagpur, West Bengal, India, is a sister edition of Monthly Review. Below is the editorial in its June 2015 issue. — Ed.
The essence of “free market” ideology is exposed clearly when the health of the human body is at issue. When outcomes are determined on the basis of the given distribution of wealth, that is, on allocating scarce items to those who can pay the most, then medicine becomes the means by which the rich will live and the poor will die. The clearest example, so clear in fact that all but the most demented avoid its advocacy, is the “free market” trade in bodily organs. Despite its outlawry in the Transplantation of Human Organs Act in 1994, everyone knows that the practice continues, and the media continually rediscovers the fact. See, for example, the illegal practice openly described as a “demand and supply problem” in “Why Organ Trafficking Thrives in India”, Livemint, May 28, 2015, or the 2014 CNN report on Nepalese kidney traffickers bringing their impoverished “donors” to India, or the 2013 Telegraph report of the murder of a schoolgirl in an Indian hospital to harvest her organs.
One step removed from “harvesting” the body parts of the poor for transplantation into the bodies of the rich, but seemingly lawful, is the recruitment of the poor in India as the subjects of clinical trials for untested medicines and medical practices, trials that as conducted in India often would not be permitted in the nations where the tested medicines are intended to be sold. A report published in the Times of India says: “Despite clinical trials coming under scrutiny in various courts, little has changed on the ground. At least 370 deaths have been reported during clinical trials in India since February 2013, but compensation has been paid in only 21 cases, according to government data. The amount ranged from Rs 4 lakh to Rs 40 lakh, a senior official told TOI.”
The next step in this process is the glorification of the rapid, dare we say cancerous, growth of a private medical system providing its services to the minority who can afford them. The Draft National Health Policy 2015 shamelessly boasts of “the emergence of a robust [private] health care industry growing at 15% compound annual growth rate (CAGR). This represents twice the rate of growth in all services and thrice the national economic growth rate” (page 3). And the role of the neoliberal regime, under both coalitions, is undisguised: “Engaging and supporting the growth of the health care industry has been an important element of public policy. The private health care industry is valued at $40 billion and is projected to grow to $280 billion by 2020 as per market sources. The current growth rate of this perennially and most rapidly growing area of the economy, the healthcare industry, at 14% is projected to be 21% in the next decade. Even during the global recession of 2008, this sector remained relatively recession-proof” (page 9). Nor is there any hesitation about the dominating role in this process of imperial monopoly capital: “Indeed in one year alone 2012-13 . . . as per market sources the private health care industry attracted over 2 billion dollars of FDI much of it as venture capital. For International Finance Corporation, the section of the World Bank investing in private sector, the Indian private health care industry is the second highest destination for its global investments in health” (page 9).
In step with continual and intentional neglect of the public health system, private capital has massively invaded the health sector — not only as big corporate chains of hospitals but also as nursing homes, polyclinics, and diagnostic centres in almost every town of India. Anyone can get a feel of this from the advertisements in almost all forms of media at all levels — local, regional and national. The present draft is open about the process and its cause. It states: “The private sector growth cannot be seen merely as a consequence of limited public sector investment. The Government has had an active policy in the last 25 years of building a positive economic climate for the health care industry. Amongst these measures are lower direct taxes; higher depreciation in medical equipment; Income Tax exemptions for 5 years for rural hospitals; custom duty exemptions for imported equipment that are lifesaving; Income Tax exemption for Health Insurance; and active engagement through publicly financed health insurance which now covers almost 27% of the population. Further forms of assistance are preferential and subsidized allocation of land that has been acquired under the public acquisitions Act, and the subsidized education for medical, nursing and other paramedical professional[s] graduating from government institutions and who constitute a significant proportion of the human resources that work for the private sector; and the provision for 100% FDI” (page 9).
These excerpts from Draft National Health Policy 2015 are sufficient to gauge the essence of the policy, i.e. making health a tool that, while providing the latest medical benefits to those with money to pay, will open the previously public sphere to corporate neo-liberal looting. The entire approach represents an extension of the fragmented individualist world view that underlies neoliberalism down into the practice of medicine, with detrimental results even to those able to afford its latest advances. As Jill A. Fisher elaborated in the article “Coming Soon to a Physician Near You: Medical Neoliberalism and Pharmaceutical Clinical Trials,” “on the institutional level, medical neoliberalism is characterized by a commodification of health that transforms individuals from patients to consumers. . . . [O]n the cultural level, through the process of making health care a commodity medical neoliberalism also commodifies the body itself. Medical neoliberalism fragments the body by homing in on specific problem areas with or within the body to the detriment of holistic analysis. The implication of this fragmentation is that body parts are seen in terms of the products designed to maintain, cure, or enhance them. Potential dangers of this consumerist mode of fragmentation are new perceptions of disability and the rise of ‘technoluxe’ and transhumanist models of medicine in which the focus is no longer on health per se but on enhancement of the body.”
But the ugly truth of a damaged medicine, available only to those with money to afford it, has to be masked with some sugar coated promises for the consumption of the public — hence the coinage of the term “Universal Health Care” with PPP as the main plank. The whole system is proposed to be based on insurance — either public or private. And “as part of reorienting public hospitals, it is proposed that rather than being viewed as providers of free healthcare, they shall be viewed as part of a ‘tax financed single payer healthcare system’ wherein they shall be remunerated through prepayment akin to commercial insurance — a method that has been deemed ‘cost effective’ in providing for the healthcare needs of the population” (Mohan Rao, Prachin Godajkar, Rama Baru, Ramila Bisht, Ritu Priya Mehrotra, Rajib Dasgupta, Sunita Reddy, and Vikas Bajpai, “Draft National Health Policy 2015: A Public Health Analysis,” Economic & Political Weekly 50.17, April 25, 2015).
In fact the policy is a web of hypocritical verbiage to hide two contradictions: (1) irreconcilable contradiction between the private sector health care, with corporatised tertiary care hospitals as its highest form, and the public sector health care (including all primary, secondary and tertiary care institutions) to serve the health care needs of all the people — or, in essence, the motive of “profit maximisation” of the private sector, and the “need to serve all irrespective of the ability to pay” of the public sector; (2) contradiction between the health care needs of the affluent sections and those of the masses, that is, class interests in health care provisioning (ibid). The motive behind the “Universal Heath Care with PPP” slogan becomes clear from IMF’s own analysis of the origin of PPPs in health care: “PPPs began to emerge significantly as a means of obtaining private sector capital and management expertise for infrastructure investment, both to carry on where privatization had left off and as an alternative where there had been obstacles to privatization. After a modest start, a wave of PPPs is now beginning to sweep the world.”
Imrana Qadeer exposes the hypocrisy: “[R]ecommendations for UHC . . . entail further abdication of the State’s responsibility in health care with the emphasis shifting from public provisioning of services to merely ensuring universal access to services. Acts of commission (recommendations for public private partnership [PPPs], definition and provision of an essential health package to vulnerable populations to ensure universal access to care) and omission (silence maintained on tertiary care) will eventually strengthen the private and corporate sector at the cost of the public health care services and access to care for the marginalized. Thus, the current UHC strategy uses equity as a tool for promoting the private sector in medical care rather than health for all.” (“Universal Health Care in India: Panacea for Whom?” Indian Journal of Public Health 57.4, Oct-Dec 2013:225-30).
For the sake of debate on health security for the poor it is argued that insurance schemes are introduced to take care of the treatment of the poor, such as the Rashtriya Swasthya Bima Yojana (RSBY) at the national level, the Yeshasvini scheme in Karnataka, Kudumbasree in Kerala, and the Aarogyasri (Rajiv Aarogyasri Community Health Insurance Scheme — RACHI) in Andhra Pradesh that was launched to extend coverage to workers in the informal sector. But in a study, “Aarogyasri Scheme in Andhra Pradesh, India: Some Critical Reflections,” published in Social Change 43.2 (2013): 245-261 by Sunita Reddy and Immaculate Mary, facts were presented that reveal the truth:
- The Aarogyasri scheme started in 2007 as a political move, and is continuing and praised as one of the most effective ways of treating tertiary, curative, largely surgeries and therapies for BPL [Below Poverty Line] population and is completely sponsored by the state.
- Media reports indicate that there is a widespread culture of irrational investigations, unnecessary surgical procedures, excessive influence of pharmaceutical companies on prescribing doctors through medical representatives, inflation of hospitalisation bills, holding patients for longer periods to claim higher reimbursement, etc, in various hospitals. These unethical practices had become so rampant that in 2011 the state government stopped payments and launched punitive action against 66 hospitals for committing irregularities while offering treatment to patients under the Aarogyasri health insurance scheme.
- Aarogyasri in AP shows that the corporate hospitals handle the biggest share of the catastrophic illness cases but that there is no provision for out-patient treatment of everyday illnesses that affect the working capacity of the patient. The focus on tertiary health care to the exclusion of all other forms of medical assistance leads to an inefficient medical care model with a low level of real impact on meeting the needs of health care and the health of the population.
- After 18 months of implementation of the RACHI scheme, it was noted that Rs 274 crores went to private hospitals and the share of the government hospital in the scheme was only Rs 34 crores. Of the Rs 274 crores spent on the scheme, Rs 135 crores went to cardiac surgeries alone (The Hindu, 2008a).
- Of the total Rs 4,729 crores claimed, the corporate/private hospitals have the highest share of almost 77.3 per cent, that is, Rs 3,656 crores and the share of the government hospitals is only Rs 1,073 crores.
- The Planning Commission observed that these insurance schemes are turning out to be a ‘cash cow’ for the corporate hospitals. Even though this scheme helped some poor families to undergo surgeries, the fact is that the private hospitals were making money through excessive reimbursement by the state government (Times of India, 2011).
- Contrary to the core ethical principles for the partnerships, beneficence (joint gains), in this case the state is bearing the whole cost, and equity is defeated, where there are no fair returns in proportion to investment, instead over-medicalisation and unnecessary surgeries are being carried out. Control is in the hands of corporate/private hospitals which lobby for the schemes continuation and inclusion of [the] maximum number of surgeries. This has only served the corporate/private hospitals and resulted in complete neglect of primary and secondary care.
The claim of a legal provision of “health care for all” is a fraud. The phenomenon of non-compliance by many corporate hospitals of their obligation to treat poor patients free of charge despite availing of huge public subsidies has been well documented.
In fact structural adjustment programs in all sectors are gathering steam — recently published “Interim Report of the Committee for Mobilization of Resources for Major Railway Projects and Restructuring of Railway Ministry and Railway Board” is an addition to this for the privatization in the garb of PPP model. Each individual policy proposal by the government is intertwined with neo-liberal policy framework. It is time not only to expose, but rather to incriminate, the ruling classes for the unbearable misery faced by a huge section of Indian population. The outcome of this process, so visibly under way, is clear. A “first world” population, comfortable and relatively long-lived and healthy, surrounded by the great mass of the miserable, short-lived and sick, whose bodies are “harvested” and subjected to “clinical testing” that should not ethically be performed even on rodents. And this “free market” paradise described, for those who will believe anything, as “Universal Health Care.”