Under the shadow of the Charter of the United Nations (1945) and the Universal Declaration of Human Rights (1948), countries are obliged to guarantee the right to health. The 1946 Constitution of the World Health Organisation (WHO) defines health as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’. These modern standards do not guarantee that everyone will be healthy, but that they have access to medical care as well as adequate food, clothing, housing, and necessary social services. The World Bank and the WHO recently found that, for at least 800 million people, 10% of their household budgets were spent on health expenditures; at least 100 million people fell into extreme poverty because of high medical expenses. Strikingly, this study found that half of the world’s population lacks essential health services.
Indian government data reports that the cost of out-of-pocket health care is among the highest in the world. For the average Indian, 67.78% of health care costs are out-of-pocket, which compares unfavourably to the global average of 18.2%. Each year, 57 million Indians are pushed into poverty due to such medical costs. The largest single item of these costs is for the purchase of medicines. Over the decades, the Indian government has demonstrated its unwillingness to provide the necessary resources to solve this health care cost crisis. India’s per capita health care expenditure over the past decade is dwarfed by the amount spent in other countries.
The Indian Communist movement–a hundred years old this year–has experimented with various forms of people’s polyclinics (PPCs), clinics that provide free or reduced-cost health care to anyone. The epicentre of this experimentation has been in the Telugu-speaking region of India–including the present-day state of Andhra Pradesh and Telangana (current population of 85 million people). Our Tricontinental: Institute for Social Research Dossier no. 25 focuses on the history of polyclinics in this region.
Communists and Health
Centuries of landlordism and colonial rule have degraded the conditions of life for the vast majority of those who live in South Asia. Despite high-minded claims that the colonial rulers had come to ‘civilise’ the population, when the British left India in 1947, hunger, disease, and illiteracy continued to negatively impact the people. When the communist movement developed a hundred years ago, it had to take seriously both the question of immediate relief–such as against disease, hunger, and illiteracy aggravated by centuries of colonial rule–and of political power–through organising agricultural worker and peasant unions, working-class unions, and political parties. Demands for land reform and higher wages came alongside concrete programmes to address questions of famine and epidemics.
During World War II, many parts of India suffered from terrible famine–partly due to the colonial neglect of agrarian infrastructure and partly due to the removal of grain from the subcontinent in order to feed European troops. Millions perished in the famine of 1943, mostly in Bengal but also in the Telugu-speaking region. In this latter region, communists took the initiative and collected funds to open gruel (porridge) centres. The Communist Party of India (CPI), under the leadership of P. Sundarayya, mobilised activists and volunteers to repair the canal system that had been completely neglected by the colonial authorities. As a result of the disrepair of the canals, enormous tracts of fertile land lay uncultivated, which contributed to the shortage of food grains. The communists manually desilted the canal system of the River Krishna and made important repairs to irrigate the fields.
At the same time, the CPI began to provide health care in villages, where people died at a young age due to easily preventable and treatable health problems. In the 1930s, Sundarayya started a small dispensary in his village. The dispensary provided basic first aid treatment–such as cleaning and dressing wounds–as well as medicines for common diseases. Patients who needed more elaborate treatment were sent along to clinics where they saw qualified physicians. Sundarayya, from his personal experience, felt that the communist movement should encourage and inspire physicians to serve in rural areas, where health care access is minimal. He asked his youngest brother, Ramachandra Reddy, to study medicine in order to provide health care to the peasantry and working class.
The Initial Phase
Dr. Ramachandra Reddy–who was known as Dr. Ram–articulated the principles for the people’s polyclinic (‘Praja Vaidyasala’). The point of such a clinic or hospital would be to treat anyone who needed health care; the clinic would not be concerned if the patient could not afford to pay for the treatment or the medicines (although those who could afford to pay would be asked to do so). Dr. Ram opened a practice in Nellore in the 1940s. He did not have any money to start a clinic, since he–like his brother Sundarayya–had given all his money to the Communist Party. Their older brother, Venkata Ramana Reddy, gave him Rs. 5000 to start the clinic. Dr. Ram worked with Dr. Suguna and Dr. Somayya as well as with Rahim, a compounder or hospital assistant, at this first people’s clinic. If Dr. Ram saw a sick person–especially those who were gravely ill–he would bring them to the clinic on a cycle rickshaw and treat them.
During World War II, the British colonial government in India demanded that doctors enlist for the war effort. Doctors Ram, Suguna, and Somayya went to Madras (now Chennai) to register their names for military service. In 1942, the British colonial government called upon Dr. Suguna and Dr. Somayya to serve in the military. They did not take Dr. Ram–most likely because he was a communist and his brother, Sundarayya, was one of the country’s leading communists. Dr. Ram worked in Stanley Hospital (Madras), where he trained to be a master surgeon and where he played an active part in the freedom movement. In 1943, Dr. Ram went to famine-affected Bengal to work in the relief effort.
The Telangana armed struggle began under the leadership of the communists soon after the end of World War II; it would run from 1946 to 1951. The Telangana region was not formally under British colonial rule but was a princely state under the rule of the Nizams; the British colonial rulers had suzerainty over the Nizams, who paid tribute to the British (the Nizams, thanks to the Golconda diamond mines, became amongst the richest people on earth). The peasants, the agricultural workers, and the rural poor in Telangana suffered under the oppressive yoke of the landlords. Under the leadership of the Communist Party, they took up arms against the regime of the Nizams and the landlords.
Dr. Ram got involved in the armed struggle from 1946. He oversaw the logistics for the CPI, though he would not take up arms, as this went against his oath as a doctor not to take the life of a human being. He provided crucial medical services to underground activists. Dr. Ram became known as a communist doctor, alongside his friends, including Dr. Ramadas, who went into the forests to treat the injured fighters. During this period, the Nellore People’s Polyclinic was often forced to shut down temporarily since its doctors were providing medical help in the armed struggle.
British colonialism left behind a health system in ruins. In 1951, the doctor-to-population ratio was very low–only 50,000 doctors in a country of 360 million–or one doctor for every 7,200 people. Matters are better today, with one doctor for every 1,457 people, although this is below the WHO recommendation of one doctor per thousand people; there are immense regional and class variations that are hidden by this ratio. The bourgeois-landlord State–which has failed to make health care a priority for the country – is to blame for this reality. Nonetheless, the country did drive an agenda to create public rural health care facilities called Primary Health Centres (PHCs). By 1955, there were only 77 PHCs; by 2011, this number had grown to 23,887, intended to serve a population of 1.3 billion. These PHCs face a shortage of doctors, many of whom are not motivated to work in rural areas (where 68% of the population lives). Rural health care provision–including through the Indian government’s flagship National Rural Health Mission (launched in 2013)–is essential in a country like India, where the rural poor cannot afford to travel to urban areas for medical care
In the 1950s, Dr. Ram helped create a programme to train health care volunteers. Epidemics such as cholera, which has claimed thousands of lives, could be easily overcome by providing primary health care. The rural poor suffer terribly from such epidemics, and they suffer even more deeply due to the State’s active disregard for their fate. When cholera or any other epidemic visits the neighbourhoods of the Dalits (formerly referred to as ‘untouchables’), they are ostracized even further by other communities, and they are forbidden to leave their part of the village (including to go to the weekly village market). This not only leads to high death rates, but also economic destruction. The problems, therefore, are not just medical but also social. Dr. Ram recognised that 90% of the diseases that impacted the rural poor did not require the services of a medical doctor; primary health care and social campaigns against the caste system, for instance, would be sufficient in many cases. From that perspective, Dr. Ram worked to build a movement called First Aiders.
Activists of the Communist Party, youth from the villages, and teachers joined the First Aiders movement. Dr. Ram trained batches of fifteen to twenty volunteers for a period of four weeks at the Nellore People’s Polyclinic. The trainees worked in the clinic during the day to gain a practical understanding of medical issues, including how to diagnose ailments, how to dispense medicines, and how to give injections; in the evenings, the trainees were taught the theory of medicine, including a basic understanding of the aetiology of diseases. The trainees were also provided with food and lodging.
Dr. Ram and his team trained about three thousand first aiders, many of whom went to villages and began to provide first aid treatment. Those days, injections in urban areas cost Rs. 1, which was unaffordable for the rural masses. The first aiders provided villagers with injections that cost them only 25p–a quarter of the cost in urban areas. If there was a particularly serious medical problem, the first aiders would refer the patient to a specialist. The first aider volunteers played a major role in preventing cholera epidemics in the Nellore district.
Dr. Rajeshwar Rao, the current administrative head of the hospital, told Tricontinental: Institute for Social Research that there has recently been an expansion of the first aiders training programme into the tribal areas of Andhra Pradesh. In these areas, there are frequent health crises due to epidemics. The first batch of student volunteers from the tribal areas will join in February 2020 and work for three months; they will bring a set of measures to help prevent epidemics and tend to those who have been impacted by the long-term health crisis in the region.
The Permanent Setup
Until 1953, Dr. Ram ran the hospital by himself. That year, a trust was set up to guide the hospital and Dr. Sesha Reddy, Dr. Ram’s nephew, joined the Nellore People’s Polyclinic. After finishing his medical degree, Dr. Reddy joined the Communist Party as a full-time activist. The Communist Party of India (Marxist) or CPI(M), which emerged out of the CPI in 1964, underscored the value of his work as a doctor, advising him to practise his political activity through his medical work rather than give up medicine to become a full-time activist. Being a people’s doctor is revolutionary activity, Sundarayya told him.
It was Dr. Reddy who institutionalised the Nellore People’s Polyclinic. Dr. Geyanand, one of the doctors who had trained at the Nellore People’s Polyclinic in the 1980s, refers to the polyclinic as a unique experiment–nothing like this polyclinic exists in the country. It is a politically active institution, which often intervenes in social troubles in Nellore. Highly respected by the people of Nellore, the Polyclinic has the moral stature to calm socially toxic tensions. The Nellore People’s Polyclinic is particularly known for its work on communal harmony. Dr. Ram and his hospital assistant Rahim were known as the ‘Ram-Rahim duo’, with Ram being from a Hindu background and Rahim from a Muslim one.
Just a Basic Medical Degree
The polyclinic in Nellore began as a small clinic in a thatched house with just three doctors. Today, it has grown to be a hospital with sixty doctors and two hundred and fifty beds for inpatients that is governed by a trust of twenty-five members. After Dr. Ram’s death in 1967, the hospital was renamed to honour him. The first new hospital complex was built in 1984 and inaugurated by the CPI(M) leader Harkishan Singh Surjeet.
Since its inception, making modern medicine available to the poor at affordable prices has been the guiding motto of the Nellore People’s Polyclinic. In the Indian context, it was decided that a basic medical degree (MBBS)–typically a five-year programme–is sufficient to treat almost all of the diseases and ailments that affect the majority of the people. The Nellore People’s Polyclinic began a three-year training course for those who had finished their MBBS degree, who it then trains to become general practitioners. The Polyclinic trains these doctors in basic procedures in all areas of medical specialisation so that they can provide some of the medical care needed by patients that is otherwise only provided by specialty doctors (such as child delivery). This three-year course was not devised by medical schools–it emerged out of the concrete practice of the Nellore People’s Polyclinic.
The training programme prepares doctors to practice in remote, rural areas, where doctors have to provide health care across a range of specialisations–often by themselves. These doctors learn to perform anaesthesia, emergency medicine, and cardiac care, as well as a range of surgeries and dental care. Almost all medical problems can be treated by these doctors who have no formal training in specialised medical fields beyond the MBBS. This initiative is particularly important in areas where there is a shortage of specialised doctors being trained at formal medical colleges. To assist the doctors, the Nellore People’s Polyclinic trains health volunteers, many of whom are activists from the left movement. These volunteers go through a two to three-month course in which they learn to administer first aid in rural areas.
Since its founding, the Nellore People’s Polyclinic has trained over five hundred such doctors who now provide health care across the Telugu-speaking region, and who–over the past several decades–have played a key role in providing health care to people who have been impacted by natural calamities (such as cyclones) and health epidemics; doctors from the Nellore People’s Polyclinic are often the first to go and set up medical centres at relief camps. As part of the attempt to tackle the broad problems impacting human health, including psychological ailments, the doctors work to counter superstitions and pseudo-religious gurus who manipulate people into using non-medical products. It was out of this experience that the Jana Vignana Vedika (JVV), or People’s Knowledge Platform, emerged in 1989, a movement that seeks to advance scientific thinking and fight against superstitions that have a detrimental impact on people’s health.
The idea of treating not only the individual human body, but also evaluating the impact of the patient’s broader environment, came to the forefront during the late 1980s. It became clear that the social crisis of unemployment and poverty, as well as the provision of cheap alcohol (arrack), had created the conditions for high alcohol consumption, which in turn had led to its own terrifying social and health crisis. This included rising rates of domestic violence and alcohol-related diseases. Women from rural areas took to the streets to demand that the government ban liquor in the state, which led to the anti-arrack movement. The Nellore People’s Polyclinic, as a result, had been treating patients with several alcohol and domestic violence related issues, which drew the Polyclinic to the forefront of the movement. The Polyclinic’s role in the anti-arrack movement is a demonstration of the need for doctors to be part of public campaigns not only against the symptoms of the disease (alcoholism), but also against the root causes: unemployment, poverty, and the profitability of selling alcohol.
A Thousand Patients a Day
Today, the Nellore People’s Polyclinic treats 312,000 patients annually, which works out to about a thousand patients a day. The outpatient department is open from 8am to 5pm, while the emergency ward is open twenty-four hours a day, six days a week (the hospital closes only on Sundays). Patients who need treatment can register for a lifelong membership scheme which costs Rs. 20, in addition to a consultation fee of Rs. 50, which is valid for a month. There are thirteen outpatient departments, five gynaecological departments, and one surgical department, all managed by the senior doctors. There are eighteen units for inpatients, each headed by a senior doctor who is assisted by two junior doctors.
The Nellore People’s Polyclinic takes its expertise into the field through the mobile health camps every two months. The hospital holds these camps on Sunday to provide free consultations to people who cannot come to the clinic; these patients are also able to get medicines for chronic diseases such as diabetes, hypertension, and epilepsy for Rs. 200–a fraction of the market cost. Blood sugar tests are done at the camp for the nominal fee of Rs. 10.
The Polyclinic recently wrapped up a three-year rural health programme that took place in four villages that surround Nellore. These villages and their hinterlands do not have a primary health centre. Over the course of three years, a team from the clinic made up of a doctor and a nurse visited these four villages every day and provided treatment to anyone who approached them. In the evenings, the team organised meetings every day where audio-visual presentations were shared with the villagers on such basic health problems as snake and scorpion bites, gastroenteritis, and the social impact of tobacco and alcohol. The clinic also shared information on nutrition and distributed seeds for the cultivation of green leafy vegetables.
The hospital has a fully functional laboratory that provides test results on the day of the test itself. It also has a digital X-ray machine that was donated by the state-run Life Insurance Corporation of India, four electro-cardiogram machines, and two operation theatres. When a patient gets the results of their tests, they are expected to visit their doctor to talk about them, a process that educates the patients in the practices of modern medicine.
The doctors largely manage the Nellore People’s Polyclinic. There are sixty doctors and four hundred and forty-four supporting staff. The hospital is financed by the income it generates through the payments made by the patients. Despite charging 40% less than the private hospitals in Nellore, this people’s hospital is able to function at a high level and is able to pay salaries (including a bonus of one month’s salary) to its workers that are on par with those of major corporate hospitals, a practice unique to people’s polyclinics. Not only does the clinic provide services to the general population; it has also become a centre of training.
Dr. B. Rajeshwara Rao, the current administrative head of the Nellore People’s Polyclinic, joined the clinic in 1989. He studied for his MBBS in Kurnool Medical College–a hub of the progressive doctors’ movement–where he was active in the left student movement. In 2000, the Nellore People’s Polyclinic opened the Dr. P. V. Ramachandra Reddy People’s Polyclinic School of Nursing, where one hundred and twenty students are enrolled in the three-year course. Those who come from families of industrial workers and agricultural workers, from the urban and rural poor, and from socially oppressed families are able to study and live at the school without payment; the hospital helps fund their education through various government schemes
The Proliferation of Polyclinics
Many doctors who trained at the Nellore People’s Polyclinic have gone back to their home districts and set up polyclinics of their own. At one point in time there existed more than one hundred such polyclinics. Even though these clinics are private initiatives, they provide low cost health services to the people. These polyclinics are found in Anantapur, Zaheerabad, Hyderabad, and elsewhere. The Communist Party of India (Marxist) has also established additional people’s hospitals in the area.
Praja Vaidyasala (Anantapur)
Doctors P. Prasoona and M. Geyanand left the doors of the Nellore People’s Polyclinic in 1990, went home to Anantapur, and set up the Praja Vaidyasala (‘People’s Clinic’). Both doctors studied for their MBBS at Kurnool Medical College, where they became active in the left student movement. Dr. Prasoona’s father, who was in the left movement, worked as a compounder at the Nellore People’s Polyclinic; it was her father who inspired her to pursue her medical degree and join the People’s Polyclinic to deepen her commitment to people’s medicine. Dr. Geyanand was initiated into the left movement as a student.
The couple set up their first clinic in a stone building that had previously been an oil mill. Although people tried to discourage them from starting a polyclinic of their own with merely MBBS degrees, they were fully prepared both politically and medically with their three-year training at the Nellore People’s Polyclinic. Their clinic offers a health care card system that covers the cost of consultations for a month, which cost Rs. 5 at the time the clinic was opened. Over the last thirty years, the consultation fees have increased to Rs. 50–a nominally low fee. If this is unaffordable for the patient, however, they can pay a reduced fee of Rs. 10, and students who live in hostels can see a doctor for no charge if they cannot afford to pay for the consultation. The clinic is particularly considerate to migrant labourers, who are especially prone to being discriminated against by private hospitals.
The Anantapur clinic trains first aiders, drawing from the experience of its Nellore parent. Roughly one hundred young people have gone through the three-year first aid training. The doctors say that this training programme is valuable not only for the trainees but also for the hospital, which is able to readily access trained staff as a result. These trained first aiders become Rural Medical Practitioners (RMPs), who provide basic medical care in areas where no medical facilities are available.
Now, with the growth of private, corporate hospitals, the RMPs are not seen as viable alternatives because of their lower level of training compared to speciality doctors; people prefer to go to the hospitals even if they are more expensive. The corporate hospitals take advantage of the RMPs to bring them patients. As Doctors Prasoona and Geyanand point out, the people’s polyclinics remain relevant, especially as the growth of the private, corporate hospitals has increased the burden of health care costs on the poor. Private hospitals push patients to get a range of medical tests, which are often unnecessary. But this is how corporate hospitals make money.
People who come to the clinics do so because they trust the institution and the doctors. They know that these polyclinics do not make them incur unnecessary costs; if there are costs, they are kept down to the bare minimum. In corporate hospitals and imaging centres, an ultrasound costs Rs. 700, of which Rs. 300 are siphoned off as a ‘commission’ by the doctor who recommends the scan, who gets yet another cut for other medical investigations. The patients from the Anantapur People’s Polyclinic used to be charged only Rs. 400, since the doctors do not take any commission. Now that the clinic has an ultrasound scanner of its own, they charge only Rs. 300–less than half of the fee that private hospitals charge. The members of the Indian Medical Association in Anantapur have held up the people-centred approach of Doctors Prasoona and Geyanand as a model to be commended and replicated.
However, Doctors Prasoona and Geyanand feel that it is not going to be easy to replicate the people’s polyclinics in the future. Patients have begun to prefer to go to specialist doctors in the large corporate hospitals, whose advertising campaigns create immense aspirations and whose ability to become the conduit of government funds attracts poor patients. Doctors Prasoona and Geyanand feel that individual polyclinics are not the way of the future; what is needed instead, they suggest, is a cooperative model that links all polyclinics started by the doctors trained at the Nellore People’s Polyclinic. This network would then develop minimum standard protocols for the medical and political operation of the polyclinics. There is also a need for the polyclinics to develop links to specialists who can provide affordable services to the people via the polyclinics when necessary.
A key element of the people’s polyclinic model is its politics. The doctors who work in these kinds of polyclinics are not motivated by money, but by their political understanding of society and of the class realities of illness and healing. Both Dr. Prasoona and Dr. Geyanand are associated with the left movement, whose orientation provides them with the determination to maintain and expand the people’s polyclinic movement. Dr. Prasoona contested in and won local body elections as a candidate of the CPI(M); in 2011, Dr. Geyanand was elected as a member of the legislative council for the graduates constituency in Anantapur as an independent candidate supported by CPI(M) and CPI. Both doctors are members of the Jana Vignana Vedika (JVV).
The JVV, alongside other organisations, has played an active role in mobilising large numbers of people in the district to establish a government medical college in the town. The college was established in 2000 as a result of these struggles. When the government planned to reduce funding to the college and raise the user fees, their policy was met with protest. These mobilisations, in which the JVV participated, stayed the hand of the government: the funding structure for the government medical college in Anantapur went unchanged. Government medical colleges in other districts that refused to join the agitation, however, were underfunded and struggled to survive. It is social struggle and the people-centred politics of polyclinics that saved the government medical college in Anantapur, and it is this politics that inspires and directs the work of the polyclinic.
Pragati Nursing Home (Zaheerabad)
Dr. K. Shiva Babu started the Pragati Nursing Home in 2004. In the 1990s, Dr. Babu was active in the left-led student movement at Guntur Medical College, where he was a convenor of the joint action committee that fought against medical colleges charging a capitation fee. After he got his MBBS, Dr. Babu trained at the Nellore PPC from 1996 to 1999. The trade union movement had begun to grow in Zaheerabad, one hundred kilometres outside of the state’s capital of Hyderabad, where the CPI(M) felt that there needed to be physicians to assist the workers. Dr. Babu and Dr. K. Vijayalaxmi decided to set up their clinic in Zaheerabad. They see about eighty patients per day, a number that has begun to expand as the town grows.
Dr. Babu told Tricontinental: Institute for Social Research that the People’s Polyclinic model remains relevant despite the challenges. Millions of Indians in rural and semi-urban areas do not have access to affordable, quality medical care. Doctors who are trained in traditional medical colleges do not have a holistic view of health and are often driven by specialisation and by profit. They are trained to order routine tests and they come to a diagnosis based on the results, often missing other key factors like the patient’s health history, access to nutrition, and emotional well-being. Doctors who are trained at the Peoples’ Polyclinic in Nellore, however, are exposed to link between socio-biological factors and illness. Doctors at the Polyclinic are trained to seek out patterns and–based on these patterns–are able to make a comprehensive diagnosis without unnecessary expensive investigations. The doctors are able to discern these patterns due to their experience and clinical work gained at the Nellore People’s Polyclinic. Trainee doctors learn from their seniors to also look for the social nature of sickness. This holistic assessment is possible largely because of their political view of health and wellness. These are not individual concepts; rather, they are embedded in class and social hierarchy. It helps that the doctors are regularly involved in public campaigns on health issues in the Zaheerabad area, which enables them to gain direct knowledge about the social conditions of life and their impact on health. These campaigns are also conducted by the JVV, which goes to the people to teach them about the dangers of communicable diseases and the benefits of hygiene and nutrition.
The People’s Hospital (Pragati Nagar, Hyderabad)
In the 1990s, the employees of Hyderabad Allwyn Limited, the government-owned factory that made buses and ballot boxes, were in the CPI(M)-affiliated trade union, the Centre of Indian Trade Unions (CITU). The union members decided to open community housing and created a collective called the People’s Progress Trust. The Trust developed a housing colony called Pragati Nagar (‘Progress Colony’). They began a non-profit school in the colony and hoped to set up a hospital. Allwyn closed down in 1999, but the residential colony remains intact.
In 2011, the Trust gathered donations and then took out a bank loan to set up a multi-speciality hospital called the People’s Hospital. The hospital is a charitable organisation whose trustees are associated with the state’s communist movement. R. Sri Ramulu, a CPI(M) member and the executive director of the hospital, told us that the hospital–which has one hundred beds and twelve full-time doctors–functions with the funds that it can raise through medical charges. Despite its reliance upon fees, the hospital is able to provide treatment at low costs. Every day, an average of two hundred and fifty patients come to the hospital as outpatients. Even for speciality treatment, the People’s Hospital charges half of what a corporate hospital charges; here an outpatient is charged Rs. 200 to see a speciality doctor. If a patient goes to any other corporate hospital the consultation fee is around Rs. 500. For inpatients, the costs are 60% less than what corporate hospitals charge.
Praja Vaidyasalas (People’s Hospitals)
The Communist Party of India (Marxist) runs a series of people’s clinics across the state of Telangana, which are managed by a network of progressive doctors. The Party raises funds through different trusts in order to maintain these clinics. The Party and the Jana Vignana Vedika work to provide low-cost medical treatment and low-cost medicines. This approach was developed by Dr. Gopalam Shivannarayana of the JVV.
In Khammam, a district in Telangana where the CPI(M) has a strong presence, the Party organises four medical camps each month. In these camps, doctors provide consultations and medicines, often for chronic conditions such as diabetes and hypertension–both increasingly common diseases even in rural areas. The cost for an entire month is a very low Rs. 100, even though the cost of medicines on the open market ranges from Rs. 1500 to Rs. 3000. The CPI(M) arranges for low-cost generic medicines to be made available. Each month, about two thousand people visit these medical camps. Each patient is treated for Rs. 1,200 annually, rather than the Rs. 27,000 that they would have to spend at a private hospital; these camps reduce the cost of medicines and treatment by 97%.
Bonthu Rammohan, a CPI(M) leader in the area, says that it is very important to take care of the health needs of the people. The Party found that people in villages were not aware of the harmful effects of diabetes, which had caused many to begin to lose limbs and their eyesight and to suffer from kidney failure. The Party began to hold camps to distribute pamphlets on the dangers of diabetes and how to prevent and treat diabetes. The work of the camps began to expand to take up other health issues as well. What was done at Khammam was then replicated in Nalgonda, where the CPI(M) set up an outpatient department and a monthly medical camp.
The Party decided that it had to directly tackle the high price of medicines. Nandyala Narasimha Reddy, who is in charge of health issues in the Telangana State Committee of the CPI(M), said that the Party has decided to establish a generic medical shop in each district of the state. The Party set up a wholesale medical shop in Hyderabad that delivers medicines to the district shops, which can keep a share of the sales to fund their shops. Nalgonda district has four generic medical shops.
Alternatives Are Possible
The Nellore People’s Polyclinic has operated for seventy-five years; in these years its doctors and staff have found that it remains as necessary now as it did when it first began. Over these decades, neither the Indian government nor the government of Andhra Pradesh–and now Telangana–have addressed the need to reconstruct the entire health system in order to benefit the majority of the population. Government health infrastructure is weak, its hospitals are understaffed, and its equipment is falling apart. The sad state of government health care provides justification for the ruling class agenda to privatise health care. By starving its own health system of money, the government makes the point that its health system is inefficient and that the government should work instead to use public finances to build up a private health care system. This is exactly the opposite of the agenda of the People’s Polyclinic.
The use of public funds to aid private hospitals is a central mechanism for privatising the health care system. Some state governments–including in Andhra Pradesh and Telangana–are under an obligation to finance medical treatment for families whose incomes are below the poverty line. The funds for these schemes have been diverted from payments for medical treatment in general to payments for hospitalisation, mainly for surgeries of various kinds and for tertiary care. Poor families get admitted into private hospitals, which bill the government for all of their expenses; but this government reimbursement only comes if the patient is admitted into the hospital–not if they are an outpatient. For the purpose of accessing these government insurance funds, private hospitals admit patients for health problems that do not require surgery or hospitalisation.
As a result, precious government resources are diverted to these private hospitals from the public health care system, which provides essential primary and secondary health care at a much lower cost. Only 10% to 20% of all health needs require tertiary care or surgical intervention; the bulk of medical problems can be treated by primary and secondary care, which are underfunded as a result. The problem is particularly severe in regions that are economically distressed, notably in tribal areas; in these areas, private hospitals are absent, so government money for health care does not reach the people, who are now forced to either quietly suffer their illnesses or travel over unaffordable distances in search of medical care. This diversion of funds into insurance schemes for private hospitals weakens the public health care system. A large part of health care is now being unfunded; the lack of funds to this sector could result in the rise of epidemics and other preventable health care crises.
Polyclinics, which emphasise primary and secondary care, offer a sharp alternative to private hospitals and point to the need to strengthen these fields rather than siphon money into more profitable surgeries and tertiary care. The point of running the polyclinics is not to extend charity to the public, but to demonstrate an alternative approach to the provision of health care that centres people over profit. Already, the existence of the People’s Polyclinic puts pressure on the private hospitals in Nellore city, which cater to the surrounding region. Importantly, the polyclinics limit the medical costs that are charged not only in their pharmacies, hospitals, and camps, but also in the private hospitals which are forced to keep their costs lower in order to compete with the People’s Polyclinic. The lower cost and the excellent healthcare provided by the People’s Polyclinic therefore draws in a large number of patients. As a result, the private (corporate) hospitals cannot charge exorbitant costs, which is their objective. People are able to see the difference between the polyclinics and the corporate health care institutions. The existence and the success of the polyclinics gives people the idea that an alternative to the capitalist system of health care delivery is not only possible; it is realistic and necessary.
Doctors who work at the people’s polyclinics understand that their work is political. Through their practice, they help shape people’s ideas about the left movement and the possibilities of socialist health care, and they bring people closer to the movement. Robust communist values become material forces in the practise of these clinics.