Speaking for Ourselves 221
Public health in private hands? A note on the Public
Health Foundation of India
MOHAN RAO, K. R. NAYAR
We live in a world of profound, and growing, inequalities.
Changes in the global economy over the past three decades
have been accompanied by dramatic reversals of health gains
made in the post-Second World War period. While some countries
have witnessed stagnation in health indices, others have
seen dramatic declines. At the same time, what is termed
the health divide—between rich nations and poor nations,
and between the rich and poor within countries—is
increasing remarkably. Thus, for example, the gap in the
under-5 death rate, considered a sensitive indicator of
social and economic development, has widened between the
rich countries and the poor. The under-5 death rate gap
increased from a ratio of 7.8 in 1978 to 12.5 in 1998.
Similarly, the death rate ratio in the age group 5–14
years also increased from 3.8 in 1950 to 7 in 1990.
It is widely accepted that these widening health inequalities
are the consequence of the imposition of the World Bank
and International Monetary Fund (IMF)-led policies of structural
adjustment and the accompanying health sector reforms around
the globe. Over the same period, the role of the WHO has
shrunk, with the World Bank increasingly setting the agenda
for health. World Bank loans for one disease alone, malaria,
exceed the entire budget of the WHO.
In addition to reducing state commitment to health, typically,
these health prescriptions of the World Bank are committed
to methodological individualism and to behaviourism; they
do not recognize the structural factors that govern and
contour the health or ecology of disease. As a result,
interventions tend to be disjointed (oral rehydration solution
[ORS] for diarrhoea rather than emphasizing on water supply
and sanitation; focusing on anaemia in pregnancy, but not
anaemia in the general population), and of a technical
nature—what is referred to as the biomedical approach
in public health. This has led to the growth of disease-centric
vertical programmes. Globally—and reflected even
in India’s National Health Policy 2002—it is
recognized that one of the failures of health sector development
in the past has been due to such vertical programme approaches.
Assuming there is a grave fiscal crisis—which still
seems to allow for subsidies to be given to the rich in
a variety of areas—these prescriptions typically
include fee for services. Again, the global experience
has been that this excludes the poor from access to health
services. Indeed, it is this explicit recognition that
has led countries such as Zambia to do away with this policy
prescription. What the package of prescriptions tends to
do is to wrench apart comprehensive public healthcare,
entrust profitable sectors of it to the private sector
and enjoin the state to subsidize a minimum clinical package,
which typically involves family planning.
The global experience with this approach to health sector
development has been dismal, and not just in poor countries.
In Russia, following the neo-liberal changes in the economy
and the accompanying health sector reforms, between 1991
and 1994, life expectancy among men decreased by close
to 7 years, from 63.6 to 57.5 years; among women the decline
was close to 3 years, from 74.4 to 71.1 years. Such a decline
in life expectations in populations not at war or suffering
the onslaught of that other horse of the apocalypse, famine,
is historically unprecedented. Accompanying the collapse
of under-funded systems of healthcare, a booming private
health system has emerged, along with a resurgence of old
communicable diseases and hunger. Indeed, even in the USA,
data on life expectancy by race, a crude indicator of inequality,
shows increasing divergence between whites and blacks beginning
in the Reagan years. The most telling data are from the
UK that reveal increasing mortality differentials by class.
The Black Report showed a substantial increase in mortality
differentials by social class; the mortality rates among
unskilled working-class men in 1981 were higher than they
had ever been in the twentieth century, deteriorating after
1971.
This is despite the fact that developed countries spend
much more on health than India does, not only in absolute
per capita terms but also as shares of national income
or public budgets. The UK spends 6% of its budget on health,
India now less than 1%. In contrast, the USA spends 12%
of its budget on health. The UK relies on universal coverage
and a state-supported and -led National Health Service.
It has better health indices than the USA despite spending
less on health. In the USA, for instance, about 40 million
people obtain no health coverage. Infant mortality rates
(IMRs) and under-5 mortality rates (U5MR) are significantly
higher than in the UK. This calls for re-thinking of some
neo-liberal shibboleths such as the supposed inefficiency
of the public sector and the greater efficiency of market-driven
private behaviour. Sri Lanka offers an excellent example
of state-led quality healthcare provision. In Sri Lanka,
about 97% of inpatient care and 83% of outpatient care
is in the public sector, where they have also integrated
the so-called indigenous systems of medicine.
India is yet to achieve the National Health Policy 1983
target of reducing the IMR to less than 60 per 1000 live
births. More serious is the fact that the rate of decline
in the IMR, which was significant in the 1970s and 1980s,
has markedly decelerated in the 1990s. The percentage decline
in IMR between 1971 and 1981 was 14.7; between 1981 and
1991 it was even greater at 27.3. However, in the period
1991–99, there has been a stagnation, with the rate
of decline in the IMR at 10%. Similarly, while there has
been a decline in the U5MR, the pace of decline has come
down and the U5MR is currently hovering around 95. During
1971–81, the percentage decline was 20.6. The decline
was much sharper during the 1980s, with a percentage decline
of 35.7. However, during the 1990s, with the onset of policies
of liberalization, the rate of decline fell to 15.1.1
Other changes have been equally important. Interregional,
rural–urban, gender and economic class differentials
in access to healthcare in India are well documented. But
since the onset of liberalization policies, these have
widened considerably. The decline in public investments
was matched by growing subsidies to the private sector
in healthcare in a variety of ways.2 State support for
private healthcare grew with the initiation of private–public
partnerships that took a variety of forms. At the same
time, there were far-reaching changes in drug policies.
Thus India—earlier characterized by relatively low
costs of drugs and pharmaceuticals, along with major indigenous
production of drugs—has witnessed a greater concentration
of drug production, a larger role for multinationals, a
higher proportion of imported drugs and unbelievably steep
rises in the costs of drugs.3 Concurrently, marked shifts
have occurred in healthcare utilization. Among people who
sought outpatient services in 1995–96, more than
80% did so in the private sector, a sharp increase in even
the poorer states of the country.4 In 1995–96, 55%
and 57% of people in rural and urban areas, respectively,
were hospitalized in the private sector compared to 40%
in 1986–87. The National Sample Survey (NSS) data
indicate greater inequality in the use of health facilities
by economic class gradients. In rural areas the class gradient
in inpatient use of public hospitals—which was insignificant
in the mid-1980s—turned statistically significant
in the mid-1990s. In urban areas, inequality in the use
of public facilities did not worsen significantly, but
inequality in the use of private facilities did. The steep
fall in rural hospitalization rates, along with increasing
use by the better-off indicates that the poor are being
squeezed out. Fee-for-services is undoubtedly one important
mechanism that has succeeded in doing this. In other words,
World Bank policies on health, contained in the influential
World development report 1993 succeeded in doing exactly
the opposite of what was ostensibly its raison d’être: reduce the utilization of public services by the better-off
to increase access
to the poor.
Costs of both outpatient and inpatient care have increased
sharply in both rural and urban areas, compared to the
mid-1980s. Private outpatient costs increased by 142% as
against 77% in the public sector in rural areas. In urban
areas, private outpatient costs increased by 150% compared
to 124% in the public sector. The increase in costs in
inpatient care is even more striking: average costs rose
by 436% in rural and 320% in urban areas.4 Thus, it is
not surprising that, as the National Health Policy 2002
notes, medical expenditure has emerged as one of the leading
causes of indebtedness.5 At the same time, the proportion
of people not availing any type of medical care due to
financial reasons between 1986–87 and 1995–96
increased from 10% to 21% in urban areas, and from 15%
to 24% in rural areas.6
What we need is state-led support to primary healthcare
in all its dimensions. Efforts to do so through the National
Rural Health Mission appear diminished in vision, and totally
lack a systemic perspective. It is also seriously underfunded.
Thus, the need is to concentrate on strengthening the entire
primary healthcare (PHC) system—which includes efficient
referral systems to secondary and tertiary levels of care.
State governments are facing huge financial problems in
doing so. There are massive shortages of human resources
such as public health nurses, auxiliary nurse–midwives,
male multipurpose workers, etc. not to mention specialists.
This is especially the case in states with poor health
indices. Given the low financial outlays, a large part
of the health budget goes towards salaries. Without resources,
time, support staff and drugs to provide effective public
healthcare, doctors lose motivation and seek alternative
work. In this situation the PHC system offers little other
than family planning and oral polio vaccination, driving
people, the poor included, into the private sector. In
this situation of state-led collapse of the public health
structure, community initiatives are both inadequate and
regressive. Accredited social health activists (ASHAs)
cannot function in a dysfunctional healthcare system. A
further drain on public resources is through knee-jerk
initiatives such as increasing public–private partnerships
(PPP) or ‘NGOization’.
It is against this backdrop that the effort to create a
Public Health Foundation of India (PHFI) needs to be critically
examined. This is apparently an autonomous institution
with 15% of funds from the government and the rest from
other sources. State governments are expected to provide
land and other infrastructure facilities. The PHFI will
create 5 new institutions for training in public health,
commencing initially with 2 schools. We understand that
recruitment of faculty has already commenced in schools
of public health in the USA (the last date for applications
was 9 March 2006, as per a circular to Deans and Assistant
Deans of schools of public health in the USA; the PHFI
was inaugurated on 28 March 2006).
There are a number of issues with regard to the new-found
love for world-class ‘India-centric, India-relevant
and tailored to India’ public health. It is apparent
that dual systems of healthcare will now extend to dual
systems of training in public health. This includes possibly
dual salary structures, leading to internal brain drain.
The question that needs to be seriously considered is the
system of public health that is now being considered worthy
of emulation. As we noted earlier, one model of healthcare
that should not to be emulated is the American model. It
is not only much more expensive, but also leaves out substantial
sections of the population. Indeed, it would not be an
exaggeration to state that the aim of the American system
of public health is the creation of markets in healthcare.
Under the influence of such a system, the global industry
in health has increased from US$ 396 billion in 1976 to
US$ 786 billion in 1990.
It is in this context that one should examine the role
of the Harvard School of Public Health, indeed, the American
system of public health schools, in shaping public health
education and research in India and in many other developing
countries, including China. Scholars such as Hugh Leavell,
Benjamin Paul, John Gordon, Carl Taylor, Theodore Ingalls,
James Simmons and John Wyon, collectively known as the ‘Harvard
group’, were instrumental in shaping the population
control agenda with a neo-Malthusian bias in the early
1960s. The damage this has caused to health sector development
in India is well known. Their enthnocentrism was evident
when one of their influential studies concluded: ‘Westerners
have strong feelings about the value of children not shared
by Punjabi villagers.’7
However, perhaps more important is the shaping of the curriculum
of Preventive and Social Medicine by scholars such as Carl
Taylor who chaired the Department of Preventive and Social
Medicine (PSM) of the Christian Medical College in Ludhiana.
No doubt, at that time as well, the curriculum was India-relevant
as it was based on the well-known ‘internship studies’ undertaken
by the Harvard group. The approach was strikingly similar
to colonial anthropology, that of studying the ‘natives’.8 A
survey undertaken in 1959 of the teaching of PSM revealed
that rural internship programmes were in serious trouble.
It was found that rural health centres for training interns
had evolved without proper planning. The major problems
were inadequate staffing, equipment and accommodation.
There was widespread apathy among the interns regarding
the purpose of the programme. Following this, a project
on rural orientation of physicians was undertaken on a
request from the Minister of Health, Government of India
by the PSM Department of the Ludhiana Medical College under
the leadership of Carl Taylor. The project was funded through
a PL-480 grant from the Bureau of Educational and Cultural
Affairs of the United States Department of State. The study
reinforced the internship approach by expanding the practical
training over 4 levels of facilities: teaching hospitals,
average district hospitals, teaching health centres and
average health centres, and suggested the philosophy of ‘medical
colleges without walls’. Despite such heavy foreign
funding and American ‘wheat’ funding, the quality
of public health teaching could not be salvaged.
The intervention of the Medical Council of India (MCI)
and recommendations of the Srivastava Committee led to
further shifts in the teaching of public health in medical
colleges. The important shift was the introduction of the
Reorientation of Medical Education (ROME) scheme in 1977.
The objectives of the ROME scheme were to involve medical
colleges in direct delivery of health services to the rural
population as well as expose students to the rural environment.
Some foreign governments even donated huge mobile clinics
for rural areas under the programme, which of course did
not serve the purpose since these large vans could not
traverse narrow, unpaved rural roads. The ROME scheme was
implemented initially in 25 medical colleges and was extended
to all the medical colleges recognized by the MCI. It can
now be safely asserted that the present poor state of PSM
education in medical colleges in India and the failure
to produce a ‘managerial physician’ could be
attributed to the original sin committed in the 1950s.
Further cosmetic changes did not succeed due to the poorly
envisioned curriculum that continued to remain unattractive.
It is evident that without strengthening the existing public
health teaching in medical colleges—there are 120
of them throughout the country at present—it will
be impossible to create a ‘managerial physician’ who
needs to provide effective leadership in the health services
system. An elite-oriented public health education on such
a large scale and in a vertical fashion may not achieve
such an objective.
It appears that planners in India seek to bring back this
variety of American-exported public health. Once famously
described as a-theoretical, a-political and a-historical,
this is now touted as a model for ‘high impact public
health research’. It is also not accidental that
many American and European schools of public
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health (based on the so-called ‘hygiene’ and ‘tropical’ medicine
models) that have been cornering international research
funds for ‘sanitizing’ and intellectually ‘colonizing’ many
African countries are looking for new markets for their
knowledge.
The PHFI initiative also aims to create
a capacity to train 10 000 people per year in public health
by offering long
and short term programmes with multiple degrees such as
certificates, diplomas, masters, doctorates, etc. Is this
what India actually needs? If we look at the manpower requirement
in rural primary healthcare, it becomes evident that most
shortages are those of ‘low-level’ primary
care staff such as nurses and male health workers (Table
I). Can such high-profile institutes provide the personnel
needed to manage primary healthcare services? There is
no doubt that the duality in public health education will
breed elitism and produce an unfit and unwanted class of
professionals. What it will also do is produce public health
staff for the First World, at a cheaper price. Currently
4000–5000 doctors trained at public expense emigrate
every year, at an estimated cost of US$ 160 million to
the Indian exchequer.9
It is also necessary to mention the role of private foundation
funding in this whole process. For instance, the Bill and
Melinda Gates Foundation is a major partner in PHFI. The ‘grand
challenges’ proposed by the Gates Foundation have
turned critical challenges in public health into a narrowly
conceived understanding of health as the product of technical
interventions
divorced from the economic, social and epidemiological
contexts.10 Six of the 14 grand challenges in public health
relate to vaccine development. It is possible that such
a narrow technology-driven vision of public health will
be the paradigmatic basis of the grand new public health
in future. Should such a public health orientation set
standards and determine the accreditation of public health
education in India as has been proposed through the PHFI?
When the market starts dominating the discourse of public
health, it will only undermine academic autonomy as is
already the case in management education.11 Indeed, it
will create a discipline based on the rules and games of
the market including profits and student-customers who
can buy such an education.
A further substantial part of the PHFI’s budget is
to come from unspecified private sector contributions.
This is even more undesirable as it will distort public
health priorities even further towards profitable interventions
alone. Examples are legion of private sector funding skewing
research agendas and findings. Thus, for instance, the
ban on routine inclusion of antibiotics in animal feed
in order to reduce antibiotic resistance in the general
human population, effected in England after the outbreak
of bovine spongiform encephalitis (mad cow disease), has
been bitterly contested by public health scientists in
the USA on the basis of research funded by the animal foods
industry.12
It is not our argument that public health training does
not need strengthening or that institutionalized education
in this matter is not necessary. Both are very important.
However, before we set up new institutions at great cost—whatever
the source of funds—we must examine what ails the
existing system. India already has institutions such as
the National Institute of Health and Family Welfare, the
National Tuberculosis Institute, the All India Institute
of Hygiene and Public Health and so forth—some of
which did remarkable public health work in the past. There
are, however, problems with many of these institutions,
such as lack of funds, lack of autonomy and so on, which
need to be dealt with. Without doing so, to start new institutions
is not only undesirable, but in a situation of fund constraint,
also hugely wasteful economically.
ACKNOWLEDGEMENTS
Our grateful thanks to Jayati Ghosh for her comments. She
is, however, not to be besmirched by the weaknesses of
our arguments—or infelicities in them.
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