Speaking for Myself

Macroeconomics or microeconomics of health [PDF]

N. H. ANTIA

India neither requires another study nor a new approach for achieving ‘Health for All’ its citizens. The solution propagated by Jeffrey Sachs, as well as by the WHO and World Bank, is to impose another westernized, science-based approach on countries with entirely different medical, sociocultural, economic and political problems, most of which are a result of continued poverty amid islands of affluence.1 This macro-approach can hardly be expected to solve the problems of these countries. Increased financial inputs into the same system that has failed to deliver the goods for over 50 years can only further confuse the issue. This approach has already converted ‘health’ into another marketable medical commodity in an area where consumer resistance is at its lowest. The answer does not lie in propagating health insurance after creating an unnecessary increase in health costs, but in stemming the influence of a globalized market economy, which is the source of the majority of our problems.
   The answer lies in addressing the basic needs of the majority rather than pandering to the exotic needs of the affluent few. Many of these ‘needs’ are unnecessarily generated. The ‘trickle down’ effect of an increased gross domestic product (GDP) in a country where there is no colony to exploit except our own poor has invariably resulted in a ‘trickle up’ effect where the rich have become richer and the poor poorer. Five-star hospitals, which serve the affluent few to the middle class and even the poor, meet the demand for such unnecessarily expensive services. Under the guise of a demand, the ‘latest that emerges from the West is the best’, regardless of the actual need, cost or appropriateness.
   Since 1947, we have sought to develop India by opting for a large-scale, western-type, urban industrial, techno-managerial approach to alleviate the problems of poverty. A decentralized form of socioeconomic development as advocated by Mahatma Gandhi would not only have been more in keeping with the social and economic problems of our people but also in tune with the health culture and needs of the vast majority, with their age-old philosophy concerning health and health practices as well as acceptance of unavoidable suffering and the inevitability of death. In this yearning for the latest that is emerging from the West, we have not only neglected the most relevant aspects of our own systems of healthcare, but also failed to utilize the readily available and highly cost-effective aspects of western medical science and technology for the communicable diseases that still plague our poor.
   The answer lies in blending all relevant knowledge, systems and technologies from all available sources to develop an integrated form of healthcare to serve the needs of our people. Western science based on the Cartesian biomechanical concept of life is becoming increasingly expensive and is being aggressively promoted by its market-driven forces, regardless of cost or appropriateness. Unfortunately, this dominates the present ‘health’ scene as seen in our westernized medical colleges, hospitals and among specialists where cure and profit, not service and caring, are the goals. In this, the health of our people is the major casualty.
   Even after gaining Independence we have denigrated our own systems and looked to the West for answers to our country’s entirely different social and economic problems. The integrated approach of WHO to health as presented at Alma Ata in 1978 by its then Director General Dr Halfdan Mahler, was soon converted into a series of vertical programmes based on the techno-managerial approach to solve individual problems and diseases. This was accepted unquestioningly by the health ministries of newly independent countries, including India, especially when promoted with monetary and other inducements. This has dominated the health scene of our country.
   The Bretton Woods twins (World Bank and International Monetary Fund), after getting us into a debt trap, now demand a reduction in our country’s public health expenditure, which serves the majority who are poor, to 0.9% of the GDP.3 At the same time they demand that we give free rein to the private sector, which accounts for 4.1% of our GDP, for those who can pay or can be induced to pay for the increasingly expensive services under the guise that cost be equated with efficiency and effectiveness. This has resulted in the mushrooming of five-star hospitals and nursing homes operated by CEOs and superspecialists, which exist cheek by jowl with the degrading poverty and grime of urban slums.
   Despite producing 1.4 million doctors, the majority of them are reluctant to serve even at primary health centres (PHC), leave aside live and serve in the 650 000 villages where 70% of our people reside. The pharmaceutical and medical instrumentation industries, enjoying government support, have only added to the escalating cost of medical care. This has not spared even the poorest.
   As a result, the rich are dangerously overmedicated and the middle class pauperized when they fall ill. This form of curative medicine, under the guise of health, is now a major cause of indebtedness of the poor, next only to dowry. As predicted by Ivan Illich, this form of medicine poses a new health hazard under the populist slogan of ‘Health for All’.
   Soon after the Alma Ata conference, a joint panel of the Indian Council of Social Science Research (ICSSR) under the leadership of the late J. P. Naik and the Indian Council of Medical Research (ICMR) under the chairmanship of the late Professor V. Ramalingaswami, was appointed to study the problems of both health and medical care of our people to help evolve a viable alternative. Its path-breaking report of 1981, ‘Health for All: An alternative strategy’ was submitted after a detailed study of the problem over a period of 3 years. This still remains a landmark document for providing healthcare to all Indians in a practical, humane, readily accessible, affordable and highly cost-effective manner utilizing the available knowledge and technology from all sources. The recommendation of this report could also be applicable to other need-based countries of the South Asian region.
   This report, which was presented to a Parliamentary subcommittee, has unfortunately not been implemented to date. This demonstrates the dominance of the western bias not only among the medical profession but also among our elite and leaders who determine our nation’s policies. Hence, there is no check on what is now one of the fastest growing businesses in the world. It is also a measure of the lack of concern for human values in an increasingly violent and dehumanized world.
   Hence, it is necessary that the new policy to ensure ‘Health for All’, which is being advocated by the World Bank under the umbrella of macroeconomics, should be considered in the context of the prevailing socioeconomic and health problems that concern the vast majority, rather than a mere macroeconomic exercise where the private sector is given free rein and for which vast loans will be readily provided by the World Bank. This will only accentuate the existing problems. Similar loans, when provided to the public health sector and operated by the same inefficient bureaucracy, can only lead to further indebtedness and demand for more loans.
   There is ample evidence that a decentralized, people-oriented, people-based and people-operated healthcare system as recommended by the ICSSR/ICMR report can provide appropriate Health for All citizens. This has also been demonstrated by China, Sri Lanka, Costa Rica, Chile under Allende and by our own state of Kerala. Such a decentralized, people-based system has the capability to provide accessible, humane, accountable and cost-effective healthcare to all citizens when devoid of the profit motive, frills and influence of unregulated market forces. The above experiences, together with those of a number of voluntary organizations in India, have demonstrated that good healthcare is feasible for all at a remarkably low cost, while inappropriate healthcare provided as marketable curative medicine can be unaffordably expensive.
   Personal experience over three decades has demonstrated that even semi-literate village women have both self-interest as well as the capability to attend to a majority of preventive, promotive and even curative health and medical problems if provided with appropriate knowledge and technology from all available sources and systems of healthcare. This has the advantage of availability, communication skills, intimate knowledge of the community and accountability to her own people in an effective manner. Support for a few problems that require added knowledge, skills and facilities can also be made available close to where they live. Fear of pain, suffering and death is often employed as a means for denying self-reliance and creating a feeling of dependency on the public and private sectors, both of which have failed to deliver services at a cost that is accessible and affordable.
   The answer lies in providing primacy to the people’s own sector to the extent possible as indicated by the ICSSR/ICMR report with the public and private sectors providing support. Panchayati Raj now offers an opportunity for implementing such a decentralized people-based and people-operated healthcare system on a nationwide scale.
   In conclusion, I would like to state that health is primarily a function of the individual, family and local community and hence a microeconomic, not a macroeconomic, function that can be undertaken by the people themselves with graded professional support, which has to be under their control. Communicable diseases as well as most vertical national programmes such as those for family planning also lend themselves admirably to the people’s own efforts in such an integrated system.
   This was dramatically demonstrated for cholera, smallpox, plague and malaria during the first two decades after Independence, utilizing the same knowledge and technology which till then had been restricted to the British cantonments. This was achieved by mobilizing the vast energy of a liberated people aided by limited public health professional support; not in the reverse as it is at present.
   It is unfortunate that people have been dissuaded rather than persuaded to attend to their own health problems to the extent that this is feasible. Healthcare has been converted into a large-scale macrobusiness and the health industry into a marketable commodity at the highest price that it can command. A lucrative trade in human suffering!