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Case for nationalising India's healthcare system amidst 'strong' private control

Counterview Desk
A draft discussion note, prepared by Dr Maya Valecha, a Gujarat-based gynecologist and activist, sent to the People's Union for Civil Liberties (PUCL) as also a large number of activists, academics and professionals as an email alert, is all set to create a flutter among policy experts for its strong insistence on nationalizing India’s healthcare system.
The note has been prepared following well-known film-maker activist KP Sasi reacting to it, stating that he does not know whether there should be a demand for nationalization at this moment, or whether it should be a demand for 'strengthening the public health care system and implementing tighter control of the private sector'.
Reproduced below is Dr Valecha’s note and KP Sasi’s reaction.

Dr Valecha’s note:

As is thoroughly exposed during this corona time, not only the fact that private sector healthcare service is of no use when it comes to the health care of vast majority of poor people during normal time but during a health crisis it was of no use also to the minority of rich people from whom it earned exorbitantly all along.
It was only our government hospitals which were neglected in the era of privatization, that came to the rescue of We the People of India.
About 80% of the patients prior to lockdown were going to private healthcare especially because in the era of privatization governments neglected funding government hospitals. There have been instances when prestigious government hospitals with attached medical college, would not have even proper ECG machine. Patients are advised routinely to get medical tests and medicine from outside. From equipments to staff to drugs government hospitals always faced shortages.
Private doctors in even otherwise normal times charged heavily and large scale malpractice in terms of unnecessary investigations, drugs and surgeries is an open secret. We keep on getting reports in between and label it as some bad apples in the basket. With five star corporate hospitals on one hand to substandard small private hospitals, patients were suffering financially and in terms of healthcare.
But the corona has exposed the whole system fully. As soon as the lockdown was declared private hospitals shut down their shutters. They stop seeing or admitting even the non-Corona patients. And even the ambulance service which is 10 times more in private sector in most cities than government ambulances, stopped functioning. When they were forced to open for Covid patients we know how heavily they charged. Instances were reported when non-Covid patients were treated after bargaining for heavy charge to give treatment. So the greed for money was exposed like any other business.
Government hospitals were overburdened because of this and admitting mild patients of corona and institutional quarantine even of asymptomatic corona positive persons. Obviously some medical and other care was diverted for even asymptomatic persons. And with extra procedures for crematoriums and the patients who were dying all spread over the city, now dying only in government hospitals we saw piling up of dead bodies.
Let us all accept in spite of all this it was the government facilities created mainly after Independence till 1990s that is standing as our backbone in this crisis.The lesson that We The People of India have learnt from this is that health is such a sensitive and important part of our life that we cannot neglect it with private and public sectors running parallel. We have seen that in such a situation with number of factors playing part the public sector is neglected and private sector becomes more and more commercial. In the end public interest is not served. Some Charity Hospitals giving good services can always be integrated in the public health infrastructure created.
The pharma industry is an integral part of healthcare system. Not only for availability of medicine at affordable prices but also orientation of researches as per the need of the people. There are examples. Once BCG vaccine has been introduced in Universal Programme, further evaluation of its effectiveness, need to develop any other variety is never examined.
And we have more than 1,400 people dying of tuberculosis daily. In case of oral pulse polio in spite of knowledge that it was causing harm, it took years to change it. And though injectable polio vaccine is the safest for children, just because it is costlier oral doses are universalized.
So when we demand nationalization of healthcare, pharma industry is included, to have the optimum, need based production and availability of medicines.
There is need for immediate takeover of private hospitals with reasonable compensation. Small clinics can be converted to govt mohalla clinics
What we need is one robust national healthcare system where all the resources of our country are channelized for the best care of our people. Of course the government will have to spend more. And for that government will have to tax rich people. For years they are given all tax benefits, subsidies, tax free periods, tax cuts, bailouts and host of other advantages. Superrich tax is one such but even otherwise tax slabs are too low for rich.
Lives of the people are far more important than the extra luxurious life for few. It is the experience world over that wherever the healthcare is nationalized with good governance, on one hand unnecessary investigations, medicines and surgeries are avoided but when required, it is always available.
For that we demand following:
  • Immediate takeover of all private hospitals with reasonable compensation at depreciated value of assets. Small clinics can be converted to government mohalla clinics.
  • Strengthen and expand the already existing chain of government health infrastructure from sub-centres in villages, primary healthcare centres, community healthcare centres to district level hospitals and multi-specialty hospitals. 
  • Enough doctors, nurses and other paramedical staff should be available at all the levels. A compulsory village level service is a must for all doctors before post graduation and then in rotation as per the need. Let us remember the resources of the country and poor patients are used for training the doctors. 
  • Let us pay a dignified handsome salary to doctors as well as all other medical staff. Class 1 salary and then as the experience and degree goes higher, the way IAS officers are given, they can go higher in the ladder. 
  • The most important part is the direct democratic control of people to oversee the functioning of healthcare system. 
  • A committee of hospital administration, doctors’ representative, other paramedical staff’s representatives and people’s representatives elected directly for this should be formed to solve day to day problems. 
  • The hospitals have to hold a public meeting every month to hear the suggestions, complains of people apart from complain and suggestion boxes. The boxes should also be opened in these meetings. 
  • Every patient should be offered a survey form (digital for those who can), about their experience after each visit the way many banks and other companies are doing it to improve performance. 
  • A strong suggestion is made to teach different practices of medicine, that is allopathy, homeopathy, ayurved and others at undergraduate level to all students and only at specialization level they do separate training. That way the best practices of all can be used for patients. Instead of mutually exclusive all these should become complementary. Today, the patient who is the least knowledgeable decides which practice she should choose for a particular sickness. 
  • Environment science and how different pathogens are entering from wild animals to human should become important part of curriculum. 
A wide spread demand from people to force the government to do all this and take the lives of people seriously is the only way to a secure future.

KP Sasi’s view:

I totally agree with you that this is the right time to demand the strengthening of the public health care system, when the private sector has proven to be a failure, especially for the poor, in dealing with health care during the Carona crisis.
I still do not know whether the demand should be for nationalization at this moment or whether it should be a demand for 'strengthening the public health care system and implementing tighter control of the private sector'.
Because the private sector of health care is already a reality today and how do we deal with such a reality needs further discussions. There should also be more vigilance and control on the research conducted on health by the private companies, since most of them are oriented towards increasing their profits, rather than contributing to the health of the people.
KP Sasi
The linkages between the private pharmaceutical companies and private hospitals cannot be ignored since both of them function within the framework of profits rather than service. In between, we also have a large number of charitable hospitals and some of them are also doing much better work than the Government hospitals. This would add to the confusion in order to take a non-compromising stand on this issue.
On the other hand, India does not even spend a small fraction of money spent on armaments. This certainly is a major contradiction. War becomes the priority than providing life to people to such an extent that even the language of health care seemed to change during the Carona days. The government was speaking about `war on Carona'.
It is high time that a more united and stronger resistance is generated against the manner in which health is treated as an industry rather than service. Only when the public sector is active, the people of this country can demand health as a `right' rather than as a `commodity'.
In the above context, strengthening of the public health care system is definitely an urgent need. During the Covid-19 days, better results were found in places where better public health care system was functioning. Kerala is an example.

Comments

Maya Valecha said…
As I have already mentioned partly in the draft, because of the existing political system dependent for funds, private players' pressure remains on the government not to spend on public hospitals. Also when we have so much health infrastructure existing, built by public money that is loans from banks, why more resources should be spent on creating a parallel system? If a private system exists, doctors may not join government hospitals. Today many existing posts remain vacant. We doctors not only use government facilities during our training but use the poor patients. One patient being examined by 10 to 15 students, remain surrounded by medicos discussing about you in a language not understood by you, even if it is painful, is not a small price they pay. People of our country deserve better. Yes private practice is a reality and something which was known all along is exposed what that reality is. The real percentage of rotten apples in the basket is known now. So I again urge for nationalization and not just strengthening public healthcare. That anyway will have to be done.
K.P. Sasi said…
It is certainly very ideal situation, where health becomes a right of the citizens and responsibility of the State. But under the present scenerio, where both the private and public sector in health cannot meet the requirements, how do we deal with this mess? Private sector works for money and the public sector is not just bothered in many situations leave alone the fact that it is not equipped. Apart from this, a lot of our health care is catered through indigenous means in the rural areas. How do we classify them. How about an Ayurvedic doctor who practices with three or four beds in a rural area? There are many Adivasi areas in India where they do not need both private sector and public sector to take care of their health. They use their own indigenous health care. If you bring all such health care systems under public sector, it would mean another health crisis in India. Further, politically speaking, we have already experienced the problems of capitalist control of health care as well as absolute control of the State over individuals. Compassion is not something that is usually taught in our medical colleges to become a doctor. It has to be evolved culturally. Therefore, it would also be good to talk about community control of health care, where the patients are also understood as human beings apart from a professional clinical approach - whether it is state controlled or corporate controlled.
Maya Valecha said…
Let us understand each issue point by point.
First of all I must thank you for initiating this mind churning discussion. It’s your response that has started discussion.
Let me make it clear right in the beginning that what is being proposed right now is that the huge resources of our country, material and human in private hands specially in allopathy, to be taken serve the public interest, because that resource is built by public money in the form of loans and used for many unnecessary investigations, drugs and surgeries.
What to do with good charity hospitals should be left to the people of that area. If people are happy with them, let them be. And whenever required they should be given more help and funds. They are a miniscule of the whole healthcare apparatus.
Big Ayurvedic and Homeopathy hospitals would come in the category of speciality or superspeciality hospitals, I am not sure how many but quite a lot of them would be government run even today. For that, basic doctors should know and understand these practices as scientific. Existing small private practitioners of indigenous medicines can be provided separate OPD at all levels of government hospitals, subcenters in villages, PHC to District level hospitals.
That is why I have suggested the need to learn all, allopathy, ayurved, and homeopathy, even Unani at undergraduate level by all students and do specialization in any of them at post graduate level. Today majority of the allopathic doctors do not recognize other branches as even scientific. Monetary interests play a major role in spreading this myth. This is in spite of AAYUSH department.
Right now Ayurvedic and Homeopathy students are given basic knowledge of Allopathy. Majority of them work in allopathic private nursing homes in the initial years. (There, the private allopathy doctors don’t mind using them as they have to pay less but on every other platform they don’t recognize them.)
Maya Valecha said…
Today the patient who has no knowledge of any branch decides where to go as trial and error method or out of economic compulsion and availability. Instead, if all doctors have basic knowledge of all the ‘pathies’, they can guide the patient as per the requirement. The way yoga, Acupuncture are being adopted by physiotherapists, other branches of medicine should be given equal status.
But still let us be very clear, charity came in existence because the government abdicated its duty to provide healthcare to all, remote areas included. Some of them might be running very good but I have worked for three months in a very old charity hospital in the heart of the city where primary instruments for a gynecological inspection were not there in the OPD and the table also not suited to gynecological examination. Because I was young at that time some thought that because I am inexperienced I need more instruments! Many Charity hospitals feel funds crunch. And if they are not part of the robust healthcare system, how to monitor the standard there, is an issue. Poor patients going there would not understand this.
Also the way even poor feel empowered and understand their right in a government hospital, they would not demand in a charity hospital. Those who want to do charity can provide services in the government hospital, with their name on the board there. Drugs bill, payment of staff, anything they want to, after such ill-managed hospitals because of fund crunch are taken over by govermnet. But a uniform high standard treatment for all is the goal, and not different standard for poor and rich.
Demilitarization? yes. These days I am putting on all social media platforms whenever I get a chance, “People of China and India should pressurize their governments to stop all fighting. We want peace. All ice laden ecofragile region, full of glaciers be declared as No Wo/man’s Land. Let us remember poet Atal Behari Vajpayee’s poem, “Hum Jung Na Hone Denge”. Because the war or war- like situation is the ground for arms purchase and commission.
I agree Nationalization in Cuba came with revolution but even under the pressure of socialist countries nationalization was done in many capitalist countries and was running fine till 1990. After that, during liberalization this weakening of government institution started. But they are still much better.
Maya Valecha said…
I would like to have revolution today but we don’t have an organization strong enough and thereby people ready to bring revolution. Our immediate demands should be such that it explains the need for revolution in long term. So if demand does not include the need to use private resource it will not educate people further.
Politics and healthcare are not two different entities. Not only the fact that politics is economics by other means, but BJP is having their doctors’ cell. The way women’s cell is to fulfill women’s demands, this works to fulfill their demand. Majority of private doctors are BJP members in Gujarat. Will they advise to strengthen the public sector? Other parties I don’t know.
After independence, like all other sectors, it was the government who was running hospitals in India and we already have a prescribed structure of primary, secondary and tertiary healthcare structure. The best equipments and best brains were supposed to be in government hospitals at that time. But like in every other field with the rise of private sector the public sector is neglected, big private sharks would not let the public institutions survive. All debates are managed with the intention to decrease government spending.
It works at many levels. Apart from policy levels, drugs meant for government hospitals being diverted to private hands (stolen), because private avenue to sell is available, a big anesthesia trolley being stolen from a hospital attached to a medical college. Who can use it?
Now comes compassion. There is a book named ‘Spirit Level’, the authors have done 40 years study of mainly developed countries (because of reliable data available) and concluded that empathy, trust towards fellow citizens is more where the inequality is less. Many other things were studied crime rates to teen pregnancy to death penalty.
I just recently met a doctor who has studied her medicine in China. Among other things I specifically asked about the behavior of doctors and other staff towards patients and she described it to be polite, human, full of empathy. So nationalized does not mean bad. They were crowded but neat and clean, patients being guided well and so on. She has finished her studies in 2013. Once the attraction of vulgar money earning is gone more people with service orientation would come to medicine. Also there will be superviosion.
Maya Valecha said…
I have particularly described in the draft how it would not be bureaucracy but people’s democratic local control along with medical staff that will govern the hospital. When we create a strong public opinion and then a movement, people will be well aware to do that.
Totally agree about health, environment and economics. I have mentioned even to include environmental science in medical education and beware of the corona and other pathogens have their origin in climate change, deforestation.
Let me tell one last thing that with this primary draft I am getting huge positive response on WhatsApp, Twitter and emails. Facebook just started. May add Instagram. The group here has people from different states and Hindi translation is already done. Gujarati and Tamil are about to get finished. A person in Mumbai just after reading it on site has offered to translate in Marathi. It’s not just the middle class. The staff here in a housekeeping contract is from UP, Bihar, Bengal and they all read it and say, “Sahi Aavaz Uthai Hai” I tell them to send the same to their native. Whatsapp has changed the world. My contacts from slum work have gone back to their native. I started sending to them from yesterday and awaiting response.
Two offers for arranging webinars one from Indore and one from Pune are in the pipeline. Local webinars in Gujarat are on. So people are ready. Some who were pucca Bhakts so far have responded positively.
Your publishing at Counterview.net has definitely helped.
Unknown said…
It is high time ..we need more reliable and affordable govt healthcare system and it is our fundamental right to have it.
Som Derashri said…
While I agree for nationalization of the healthcare services, the root cause is that we have limited the number of doctors that we produce in our country. This creates artificial shortage of doctors and makes the private collages charge exorbitant fees(running in crores as donations). This lures the new doctors to recover their investment in education by any means. Most doctors collect fees in cash & do not declare their actual income in collusion with their smart CAs' and do not pay right income tax. For a population of 130 crores, at the WHO recommended rate of 1:1000 we need at least 13 lakhs doctors. Before nationalisation of hospitals, the medical education has to be open by de-limiting the number of seats for doctors. With abundance of doctors, the health services in villages will also improve as many doctors will be available to provide treatment to rural, poor & needy patients at their door steps.
We are also loosing a lot of medical students to other countries where the medical education is much cheaper. We could on the contrary be a doctors hub, just like the IT hub to provide doctors to world over.
seeniwasan said…
While I agree for nationalization of the healthcare services, the root cause is that we have limited the number of doctors that we produce in our country.
best liver transplant hospital in india
Anonymous said…
Yes of course it's there in the article to increase doctors and other staff in the government hospitals. But without nationalization, even the existing number of doctors don't go to government hospitals and want to earn in private. There can be many reasons for that also. But improving condition of government hospitals will solve that. Allocating more funds, taxing super rich, all should go along with.

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