medico345- friend347 circle bulletin

February - July 2011

Towards a Regulatory Framework for Private Providers in UHC-Anant Phadke and Abhay Shukla1

1. The Broader Canvas of Regulation of MedicalPractice in UHC

The UHC (Universal Health Care) system would be anational system predominantly based on public funds.Therefore it will have to be an appropriately regulatedsystem - both its private and public componentsincluded, although the concrete mechanisms ofregulation of these two components might differ incertain aspects. Regulation of that portion of the privatehealth care which would become part of UHC wouldthus be part of the overall regulation of the system ofUniversal Health Care India, so that the private healthcare component of UHC would also follow the basiclogic of the UHC, while retaining its 'private' character.Even that private care which is out side the UHC willhave to be subject to some regulation so that it worksin tandem with the UHC system; at least it should notwork at cross purposes. It should also be noted thatthere is a definite need to move towards a more people-oriented and participatory system of governance ofthe entire health system, which would be stronglyreflected in the forms of regulation for UHC.

The objectives of this regulation would be consistentwith the objectives of the UHC and would be threefold:

1. To ensure provision of UHC to all residents inIndia. This care will have to be rationally andethically sound, humane and appropriate. Theseand other desirable dimensions of health carein UHC have been ingrained in the 'coreprinciples of UHC' and need not be repeated here.

2. To provide job satisfaction and honourableconditions to all health care providers.

3. To promote democratic relations amongstvarious stake-holders in the UHC - the medicalpersonnel, bureaucrats, managers, policy-makers, patients, and society at large.

Society should reach at the earliest, a stage in whichall stake-holders are on equal footing and inherentvulnerability of patients with respect to health careproviders is adequately addressed.

Taking a look at the overall canvas of regulation, wemay note that a Health care system involves -

1.1 A set of relationships amongst various stakeholders that need to be regulated-a. Doctors working at various levels, in

various capacitiesb. Paramedics of various kinds and levelsc. Hospital and health system administrators,

managersd. Policy makerse. Patients and citizensf. Pharma-industry and other medical

industry

1.2 A range of activities including -

g. Education, training of medical personnel

h. Continuing Medical Education

i. Clinical and non-clinical health care withits components like rationality, ethics,observance of patients' rights, planning,research, etc.

The relationships and activities mentioned above willhave to be regulated with the help of following measures-

Appropriate constitutional changes and legalenactments

Enabling National Policy to concretize thepolitical commitment to UHC

1 Based on the discussion among certain HLEG members,

PHFI members and civil society representatives on Jan 15,2011 at Mumbai. This note is an improved, expanded versionof our note for this Jan 15 meeting. Attempt has been made toincorporate various valuable suggestions from theparticipants. Email ids: <anant.phadke@gmail.com>,<abhayshukla1@gmail.com>.

2 mfc bulletin/February - July 2011Appropriate regulatory agencies/structuresadequately supported by financial andappropriate human power resources

Multi-stakeholder mechanisms and processesin which patients' and other civil societyorganizations too would have an important spaceand role to play - processes like peer review,monitoring, redressal and periodic review

Though the pace of progress as regards these measuresmay vary, all these measures are essential and shouldwork in tandem with each other, and the success ofUHC would depend upon this holistic progress.

The above would be the overall broader canvas ofregulation for all the components of the UHC, bothPublic and Private. Out this broad canvas, this shortnote would focus only on a sub-set of relations andactivities - namely, those which constitute provisioningof medical care by private providers in UHC. However,it is to be noted that if the rest of the canvas is notaddressed, it will adversely affect this regulationproportionately. Thus for example in a situation wherehigh-fee based private colleges or irrationalities andexploitation by pharma industry, or inadequate supplyof trained nurses and sub-standard private nursingcolleges in the context of paucity of qualified nursescontinue, the private medical sector would not providegood quality medical care in the UHC system.

Thus even if focus our attention on a sub-set of thebroader canvas, this broader canvas has to be kept atthe back of our mind during this small exercise also.

2. Towards a Regulatory Framework for PrivateProviders in UHC

2. 1. Background

On the one hand, private medical care is widely accessedby people and sections of private providers in Indiahave shown their capacity to provide technicallycompetent, quality care, on the other hand it suffersfrom serious problems and has the following features:

Very large, predominant, highly stratified privatemedical sector (ranging from rural 'informal'providers to corporate hospitals)Complete lack of regulation of medical practicesleading to -Large scale irrationality,Massive wastage due to excessive medicationsand interventionsFrequent exploitation of patientsViolation of patients' rightsComplete failure of self-regulation by IMA, etc.,and by MCI

In combination with this situation, there is weak and

inadequate public health provisioning which is unableto significantly influence private care towards fulfillingsocial goals.

In UHC, this background will have to be changed by:

Comprehensive and effective regulation of theentire health care sector, including the privatesector. Certain regulations would be applicableacross the board for all health care providers(related to physical and humanpower standards,patient rights, equity in distribution) while somefurther regulations would be enforced regardingproviders involved in the UHC system(guidelines and protocols for rational care, normson costs of care) although even the latterregulations would be expected to have aprogressive, system-wide effect.

Considerable strengthening and improving thePublic Health System so that it would becomethe backbone of the UHC, and would lead thePrivate Health Care within the UHC system, inmany respects.

Due emphasis in UHC policy towards enhancingutilisation of public facilities.

2.2. ‘Insourcing' of Private Providers or 'PPP'?

Involvement of the private providers in UHC wouldbe more in the form of 'insourcing' and 'expansionof the public system' unlike the typical 'PPP' in whichthere is mostly 'contracting out to private providers'.This 'contracting out' means the concerned privatemedical care provider does not organically becomepart of the UHC.

This is especially relevant since the experience so farin India points out to the following risks associatedwith most current 'PPPs' in India:

Continued and even intensified irrationalmedical practicesUnjustifiably high costs being offloaded ontothe public systemLack of quality care, standardizationDual charging (charging from both public systemand also illegal charging from users)Shunting off 'difficult cases' and focusing ontreating 'profitable cases'Collusion between certain public health staff andprivate providers, to channelise patients frompublic facilities to 'preferred' private hospitals

Given this background, the policy for interactionbetween the public UHC system and private providersshould ensure that:

There should be preference to in-sourcing ofPrivate Health Care into the publicly organised

mfc bulletin/February - July 2011 3UHC system, rather than outsourcing anddilution of public control - the latter is typicalof existing PPPs.

Appropriate, comprehensive regulation of thePrivate Providers would be an essential pre-condition for such 'insourcing'.

This insourcing into the UHC should strengthenand not weaken socialization of health care;utilization of existing Public Health Facilitiesshould increase and not decrease due to thisinsourcing. This interaction should expand pro-poor investment and expand services in thehealth sector - not substitute public sector byprivate sector

Private facilities involved in UHC would besubject to similar transparency andaccountability conditions as the public system- such as RTI, community based monitoring, etc.

Rights of staff in private facilities as regardswages and working conditions must be protected

Effective participatory monitoring and redressalmechanisms must be in place to ensure thatstipulated regulations are being followed

2.3. Domains of Regulation

Key areas requiring regulation would include thefollowing:a. Standardization of structures and human-power

to ensure quality of careb. Protecting patients rightsc. Equalizing accessibility/distribution of

establishmentsd. Standardization and rationalisation of process

of care based on standard protocolse. Rationalizing costs of care

Of these major domains of regulation, areas (a), (b) and(c) above would need to be regulated for the entirehealth care sector, including private providers who donot participate in UHC. However (d) and (e) wouldmainly apply to health care providers within the UHCsystem, yet even these regulations would progressivelyhave a broader, 'induction' effect on providers outsidethe UHC system.

2. 4. Measures for Regulation

Appropriate regulation of Private Medical Care inUHC would require the following measures keepingin mind the changed background mentioned above:

2.4.1 Formation of adequate law/reformulation ofexisting law through multi-stakeholder(including citizens') participation

Multi-stakeholder process for law formulationto take into account the concerns of variousstakeholders so that no serious lacunae remain;for example the current Clinical EstablishmentsRegistration Act does not have provisions forpatients rights or ensuring public healthobligations of private providers.

Rules under the act should be formedimmediately after the enactment, so thatimplementation is not delayed.

Observance of patients' rights must be includedin minimum process standards.

Rules should include specifying a decentralisedframework of implementation by an autonomousregulatory authority

Rules should include specify multi-stakeholderbodies (including civil society organizationsworking for Patient's Rights) in promoting andmonitoring the regulatory work

2.4.2 Policy and Regulatory Structures toImplement the Law

Appropriate agencies/structures would be required,which must be adequately supported by resources, tooperationalise regulation and standardisation. Thesebodies would be in two parallel streams:

1. Health care authorities at various levels, whichwould be offices with full time, professional staffentrusted with direct implementation of regulation

2. Health boards or councils at various levels,which would be multi-stakeholder bodies withvariety of representatives, meeting periodically

Healthcare Authority (full time, paid Health Boards/Councils (multi-stakeholderprofessionals for execution of body with appropriate decision making,regulation mechanism) monitoring powers and functions)

National level National Healthcare Authority National Health Board

State level State Healthcare Authority State Health Board

District level District Healthcare Authority District Health Council

Block/City level Block / City Healthcare Authority Block/City Health Council

4 mfc bulletin/February - July 2011and carrying out broader planning, decisionmaking, standard setting and monitoring ofregulation.

2.4.3 Health Boards and Councils

National and State level boards would havemulti-stakeholder composition led by PublicHealth Authorities and including electedrepresentatives, medical profession and healthcare providers, and civil society organisations.The State Boards would be the autonomousapex bodies in respective states who will shapethe concrete policy directives and standards forthe respective states, in the light of the Policyand standards framed by the National Board andby the Health Ministry.

The State Boards would also formulate policydirectives for implementation and overalloversight.

The State and National Boards would besupported by adequate, appropriate staff andadequate funds

At district, block and city level also there willbe multi-stake holder 'Health Councils'(consisting of health officials, representatives ofproviders, health care employees, elected /panchayat representatives and community/citizens' representatives) who would giveoversight to the regulatory process, would takelocal policy decisions for execution at locallevel, and would monitor implementationaspects

Monitoring by Health councils would bedovetailed with existing participatorymonitoring mechanisms like Community-BasedMonitoring with clear space also fororganizations of patients/health interest groups

National and State health boards would alsocarry out periodic reviews to make progressiveimprovements in the UHC system. These reviewstoo would have to be multi-stake holderaccompanied by with feedback and involvementof the general public and civil societyorganisations.

2.4.4. Healthcare Authorities

To ensure proper implementation, the executivewing of the regulatory process would be anAutonomous Public Authority in each state /district / block city, supported by appropriate,adequate staff and funds

Fees collected from Private Providers would beused to augment the budget of this authorityand should not be spent on other budget items

2.5 Mechanisms/Processes for Regulation

These processes may be of three types:

i) There would be enabling mechanisms to fosterdelivery of rational, ethical, appropriate care:

Appropriate orientation of students in medicalcolleges, specifically about rational, ethicalpractice and patients rights, political economyof health care etc.

Continuing Medical Education of doctors andother health care providers

Elimination of unethical promotion andmarketing by pharma and other health carerelated industries

ii) There will be binding norms like setting ofstandards which will restrict the scope ofirrational, insensitive care:

Preparing Indian, local minimum standards forstructures, processes about

Quality, rationality and costs of care,

Observance of Patients' Rights

Standard protocols to be evolved by State andNational level boards with involvement ofprofessional organizations

System of regular audit of prescriptions andinpatient records, death audit and other peerreview processes,

Clear norms for payment and quality/rationality of care, (There may be a tendencynot to economize while preparing standards,even when commercial interests are absent)

Certificate of need would be needed forlicensing of all new establishments accordingto norms and presence of existing facilities ina particular area (block / town). This wouldpromote more equitable distribution of healthcare facilities.

iii) To ensure adherence to binding norms, there willbe 'external inspection and direct monitoringmechanisms' to ensure the observance ofstandards for structures, processes and outcomesof health care -

Inspectors of the Local Supervisory Authoritywould monitor observance of standards throughchecking of records and by visiting the healthcare facilities

Participatory monitoring (on the lines ofCommunity Based Monitoring) by HealthCouncils

2.6 Redressal Mechanisms

" User friendly, independent, redressal mechanism

mfc bulletin/February - July 2011 5at local level would be needed. This mechanismwill have to be made widely known.

One option may be of 'Grievance redressal cells'with Ombudsperson type functions, supportedby small teams/civil society organisations tocarry out enquiries and inspections, supportedby public funds.

Maximum possible transparency would have tobe ingrained in all the above mechanisms. Thiscan be done by extensive dissemination of allimportant information through web basedinformation centres.

The overall objective of such a regulatory systemwould be to move towards progressivesocialization of the entire health care system,including private providers who are involvedin the UHC system. The direction would be tosystematically develop participatorygovernance (including professional regulatorsbut not confined to top-down, bureaucraticregulation) including elements of self and socialregulation, towards an accountable andeffective system for Universal Health Care.

Annexure

Standard Charter of Patients' Rights in ProposedRules under BNHRA 2005 (amended)

Section 16, Rule 14

Standard Charter of Patients' Rights

1) No person suffering from HIV may be denied careonly on the basis of the HIV status, provided the curativeor diagnostic care is available at the Nursing Home.Not having a Voluntary Testing and Counseling Centrecannot become grounds to refuse care. For managementof patients who is HIV positive, the nursing home wouldfollow guidelines circulated from time to time by NACO(National AIDS Control Organization)

2) Every nursing home shall maintain an inspection bookand a complaint register (for the patients' party), whichshall be produced before the LSA as and when required.

3) All nursing homes must adopt a Standard Charter ofPatient's Rights, observe it and orient their staff forthe same. This Standard Charter of Patient's Rightswould include that -

A) The patients and/or Person authorized by patient shouldreceive:

The relevant information about the nature, cause, likelyoutcome of the present illness.

The relevant information about the proposed care, theexpected results, possible and the expected costscomplications.

Patient and all nursing homes must adopt a StandardCharter of Patient's Rights, observe it and orient theirstaff for the same. This Standard Charter of Patient's

Rights would include that-

B) Patient and/or person authorized by patient has a rightto have:

An access to his/her clinical records at all times duringadmission to Nursing Home

Photocopy should be available within 24 hrs whenadmitted to Nursing Home or within 72 hrs of makingan application after discharge or death after paying feesfor photocopy.

A discharge summary at the time of discharge, whichshould contain:

The reasons for admission, significant clinical findingsand results of investigations, diagnosis, treatment andthe patient's condition at the time of discharge.

Follow-up advice, medication and other instructionsand when and how to obtain urgent care when neededin an easily understandable manner.

In case of death, the summary of the case should alsoinclude the cause of death.

C) Treating patient information as confidential.

D) Patient has a right to personal dignity and privacyduring examination, procedures 24 and treatment.

E) Patient and family rights include informed consent beforeanesthesia, blood and blood product transfusions andany invasive/high risk procedures/treatment. Informedconsent includes information in a language and mannerthat the patient can understand, on risks, benefits,alternatives if any and as to who will perform therequisite procedure. Information and consent beforeany research protocol is initiated (see below).

F) Patient and family rights include information on howto voice a complaint. Appropriate procedure forgrievance redressal must be put in place by the hospital.

G) Rights of women as patients:

Privacy during examination. In case of examinationby male doctor, a female attendant must be present.

Right to confidentiality of reports and information notto be disclosed to any person other than one who isauthorized by the patient

Confidentiality of HIV positive patients

H) Patient has the right to seek second opinion. All medicaland diagnostic reports must be made available to thepatient or authorized person to facilitate second opinion.

I) Non-discrimination on the basis of HIV status:

Patients and families should be informed about the aboverights in a format and language, that they can understand

Patients and family are informed about the financialimplications when there is a change in the patientcondition or treatment setting.

J) In case of Nursing Homes undertaking clinical research:

Documented policies and procedures should guide allresearch activities in compliance with national (ICMR)and international guidelines

6 mfc bulletin/February - July 2011

Moving Towards a System for UAHC in IndiaModified broad understanding, some learnings and areas for further work

based on MFC discussions during Jan-8-7, 2011

The Context: Model of development and SocialDeterminants of Health

Due to inequitable and pathological modelof development, traditional patterns ofmorbidi ty cont inue ( infect ions,malnutr i t ion, high chi ld and maternalmortality etc.)

In addition, new morbidities, addictions,mental health problems, accidents etc. areadding to burden of ill health

Need to comprehensively address model ofdevelopment and social determinants ofhealth to minimise ill health and promotehealth; would be integrated with the UAHChealth care system

UAHC: the Broad Direction

In a framework of rights and equity, need toensure required health services to all; careshould be provided at lowest possible leveland in closest possible manner

Address the entire health system in integratedmanner

Considerable strengthening and expansionof Public health system with reorganisationand people-orientation; PHS as backboneand pivot of UAHC

Regulation and some degree of socialorientation of elements of the private sectorwhile bringing them in to serve UAHC

Expanding the ambit of 'public' to includesocialised providers serving public healthsystem and goals

This would require large scale health systemchanges - a major socio-political process

Provisioning: Patterns of Care

Promotion of self-care and home care -system is geared in this direction

Promote choice of systems, AYUSH to occupysignificant position; option of training of

integrated doctors

Taking into account people's own knowledgeand skills, healthy local traditions whiledeveloping system

Significant role to CHWs and paramedics,moving from doctor centred to health teammodel

Need to discuss updated and modified PHCapproach

Moving Towards a Different Model

With a core of strengthened and expandedPublic health system, involves regulation,incorporation and public orientation of non-public providers

A system for UAHC is qualitatively differentfrom generalising current 'PPPs'; insteadpublic insourcing of private providers

Three level option in order of preference -a. Public b. NGO/Charitable/Trust c. Forprofit private

State specific models necessary to movetowards UAHC

Effective social and legal regulation is anabsolute precondition for involvement ofnon-public providers in UAHC.

Provisioning - Primary Level Care

For primary level care, with expansion andstrengthening of public provisioning andinsourcing of non-public resources it couldbecome dominant provider in foreseeablefuture

Health team based on CHWs, paramedics,AYUSH and allopathic doctors

Recognise and address great diversity inpresence and type of private sector indifferent areas

Private doctors could be brought into systemas 'Family practitioners' with regulation andoverall public management

mfc bulletin/February - July 2011 7Urban areas would require distinct contextspecific models

Provisioning - Secondary and Tertiary LevelCare

Strengthening of existing public facilitiesincluding insourcing specialists

Pooling and coordinating all public facilities(ESI, CGHS, Railways, Army, PSU facilitiesetc.) to expand base

Overall need for greater attention to solvingdysfunctionalities of present PHS oftenrelated to over-centralisation of decisionmaking, corrupt ion, s luggish f low offinances, understaffing and lack of largescale new permanent appointments, poormanagement skills etc. etc.

Financing

Tax based financing as the plank forsupporting the UAHC system

Various calculations show 3-5% of GDP maybe required to support UAHC in India - butexisting calculations need more discussionand working out

Equitable allocation of resources combinedwith decentralised management

No user fees, co-payment etc.

Governance and Regulation

People-centered governance and orientationof entire health system

Decentralised planning and decision makingwith involvement of various communityrepresentatives, organisations along withPRI and elected representatives

Community based monitoring and system ofHealth councils at various levels

Mult i -s takeholder bodies includingcommunity representatives, providers, healthcare workers and public officials

Need for large scale transparency and

accountability

Governance and regulation

Need for comprehensive regulation of entirehealth system with participation of civilsociety organisations

Need to decisively confront the medicalprofession on unethical and irrat ionalpractice.

Create common standards for private sectorand public sector.

Governance and Regulation

Conflict of interest - the primary provideralso being the regulator.

Community monitoring vs. professionalautonomy - need for balance.

Organizational dynamics, insti tutionaldynamics in the health system need to beaddressed

Changing roles, perception of roles withinhealth team.

Need for huge investment in regulatorybodies, more human resources, capability toeffectively regulate.

Need for a framework law to supportregulation and ensure rights

NO SUBSTITUTE FOR COMMUNITYMOBILIZATION AND SOCIO-POLITICALMOVEMENT

Placing Politics at the Centre

Whether, How and in What form India wouldmove towards UAHC is essentially a socio-political process

While debating and resolving gray areas anddifferences, we need to present broadcontours for wider social debate andmobilisation

Reversing neo-liberal logic and replacingit by social logic in the health sector

8 mfc bulletin/February - July 2011

Some Non-Negotiables on the Road to a UHC System

Need to comprehensively address model of development and social determinants of health

to minimise ill health and promote health; would be integrated with the UAHC health caresystem

Genuine universality: breaking through 'BPL fixation' - bringing in the privileged classes,

encompassing the not-so-poor and 'APL', reaching out to the marginalised; public packagewould be same for all

Spectrum of health care to start from self and home care, include CHWs, paramedics, AYUSH

and other primary doctors and specialised providers; moving from doctor centered to health

team model

Significant expansion and strengthening of public health provisioning in both rural and urban

areas; public health system as pivot and backbone of UAHC system

Significantly increased tax based public health finances: tax based funding would be the

basic plank of financing and should be adequate to meet needs of comprehensive UAHC

UAHC system involves making all state facilities (Incl. ESI, Railways etc.) fully public, wherever

required bringing private providers under public system, in framework of UAHC logic and

socialisation of health system

Legal and operational regulation of costs and standardisation, rationalisation of private healthcare with patients rights as precondition for engagement with private sector. Publicly defined

principles and mechanisms to govern all facilities under UAHC

Adopting a health system-wide approach with bodies managing the entire health system

People centered and participatory planning and monitoring with decentralised framework of

decision making

Process Related Suggestions

Convening a larger conference with representation of all concerned stakeholders (incl. socialmovements and concerned trade unions, charitable and private sector providers)

Exploring with some interested state governments about state level models

Ongoing dialogue with civil society platforms including MFC

Being aware of possibility of dilution, distortion or selective reading of report - should be

addressed in report itself stating that this is an integrated package which stands or falls asa whole, not a cafeteria for 'pick and choose'

Some Concerns about the Politics of UAHC

What is the underlying political logic and direction regarding UAHC?

What is level of willingness to reshape the entire health system in direction of socialisedsystem vs. continuation and generalisation of outsourcing type PPPs?

Is there political will to significantly raise levels of public health financing?

What is the role of private sector lobby, CII and FICCI, private insurance lobby?

mfc bulletin/February - July 2011 9

UAHC with 'Community Participation' Or 'People Centre-stage'?Implications for Governance, Provisioning and Financing

-Ritu Priya

In our people-oriented model for universal access tohealth care (UAHC), is the vision one of people's roleas 'participation' in pre-designed services, or shouldthe model itself keep 'people centre-stage'? This isthe central issue for governance being addressed inthis paper.

Some Considerations for an 'Indian Model ofUAHC'

UAHC is the latest initiative in a series of endeavoursthat is meant to help India and other low and middleincome countries break out of the prevailingsituation of distress due to lack of access to qualityhealth care when there is a felt need for it. Beingin agreement with several of the issues taken up inthe concept note for the MFC meet, I would like totake the discussion forward on two points: One relatesto the intent stated in the note that it attempts tobreak the myth of the TINA syndrome; that ThereIs No Alternative to privatisation of health care andthe health service system working on commercialprinciples, since the state cannot provide universalaccess to health care. The second is about themeaning of 'commodification' in health.

1. The TINA Syndrome and an AlternativeDiscourse for UAHC

As stated in the concept note for this meet, "Theidea of this whole exercise is not just the developmentof a model but of creating an alternative people-oriented discourse in the present claustrophobicatmosphere of "TINA" and problematic 'PPPs'when it comes to 'development'." (Shukla et al, 2010)

My contention is that we have the opportunity atthis point of time to do much more 'alternate' thinkingand model building than in the model proposed fordiscussion. In fact the world is almost looking toIndia to generate a bolder alternative, since it is a'felt need' of all countries and India has historicallygiven pluralist alternative visions to the world inseveral areas, including in public health. We mustaddress the challenge to the maximum possible.

The TINA syndrome to be broken in health caretoday is not so much about the desirability of UAHCas a responsibility of the state, as it is about 'how'the state is to ensure UAHC. There is a globaldiscourse pushing for publically funded UAHC inall countries, as much with the intent of people'swellbeing as with the intent of ensuring financialreturns of the highest order on investments in healthcare and allied industries. Recognising the positivepotential of this trend, we need to bring all thesynergies together and use all spaces possible forthe former objective. The TINA syndrome beingpropagated is that it is only through public financingand private provisioning that UAHC is possible withefficiency and quality and therefore is the desirableprinciple for building health systems with UAHC.The predominant discussions and the model beingproposed across the world demonstrate a remarkablesimilarity across very different contexts revealingsome common characteristics that fall well withinthe neo-liberal paradigm: they are highlymedicalised and doctor-centred, commodify health,and propose social insurance and purchase ofservices as the means to UAHC. What is the 'alternatediscourse' that our 'model in the making' presents?

There is another perspective available to build amodel for UAHC, as being articulated in thediscussions on 'revitalising Primary Health Care',which though weaker in their salience and visibility,are also alive and kicking in the global discourse.We will have to consciously chose which one weadopt as our framework for UAHC -- one that iscurrently being most widely propagatedinternationally in the neo-liberal paradigm or theother which espouses the spirit of the Primary HealthCare approach and is closest to the 'MFC perspective'available in the statement in the MFC website.Features of the two are tabulated here after analysisof recent documents on UAHC and RevitalisingPHC. It should be recognised that suchcharacterisation is always fraught with ideal typereductionism, and there will in reality be an overlapof the two. *Background Paper for MFC Annual Meet, Jan 7-9, 2011,

Nagpur. Author's email: <ritu_priya_jnu@yahoo.com >

10 mfc bulletin/February - July 2011

No. Current Dominant UAHC Discourse & Proposed Alternative Discourse of UAHC withProposed Models in the Neo-liberal PHC Approach/MFC PerspectiveParadigm

1. Medicalised perspective Socio-biological perspective and multi-dimensionalapproach to dealing with health

2. Doctor-centred People as primary actors for health; providers assupports.

Doctors and other providers equally important inappropriate roles

3. Top down Bottom up

4. Commodification of health (purchasing People empowering; addresses the knowledgeof services) hierarchy in health

5. Financing through social insurance/ Financing through tax revenue based budgetaryprivate insurance/cess/tax revenues allocations /health cess

6. PPP under a private sector framework PPP under a public service framework

7. Efficient, feasible and effective services Cost effective and safe health care under thefrom institutional and clinical perspectives. context specific people's life conditions.

8. Universalist and singular technological Context specific and pluralist technological contentcontent that reinforces bio-medical of services that is appropriate, cost-effective andhegemony. The system that is exorbitantly deliverable at the closest point possible.expensive and with ever-escalating costsis sought to be made 'affordable'.

9. Community participation is an externally Community participation is more than 'communitygenerated involvement of people in monitoring', it is inherent in the structures andservices planned top down as ritualistic content of provisioning, financing and governance.committee members or as users.

10. Governance mechanisms being proposed Structures of deliberative democracy have to be(such as the National Health Authority) actively nurtured and mechanisms for assessmentare more corporate compatible than and articulation of people's felt needs have to beconducive to people's control or made central to the policies and implementation.political control.

11. Despite cost-cutting exercises, The only inherently non-commercial healthincrementally escalating costs due to interventions are home remedies and communitystructures that are promoting profit-based services of local health care providers. Besidesprovisioning and defensive practice by helping in cutting costs, they keep the possibilitydoctors (as in the USA), and high levels of a different vision alive. The danger of accessingof iatrogenesis despite systems for medical help later than desirable has to be dealtreporting of side-effects. with by a simultaneous strengthening of services to

ensure access to primary and referral levels withquality. In addition, primary level workers whocould facilitate self-care should also giveinformation and skills about when to seekprofessional help.

12. Addressing the social determinants of Possibility of inter-sectoral coordination andhealth is not a concern of the institution addressing the social determinants of health liesbased medical care service systems and only in public systems with community leveltherefore are ignored, an issue of concern mechanisms.in contexts such as ours where water,sanitation and nutrition have yet to beaddressed.

Features of Two Frameworks for Developing Systems of Universal Access to Health Care

mfc bulletin/February - July 2011 11While we adopt one of these frameworks, componentsof the other will continue to be elements within it.It seems safe to assume that MFC's predilection willbe for the second approach. While adopting it, wecannot afford to be romantic about public systemsor community initiative, and must recognise theimportance of examining the experiences ofimplementing the first approach and learnings ofanalyses from its perspective, drawing upon the lessonswherever relevant, to be placed within the secondframework. In fact there is no country among the lowand middle income countries that has demonstratedthe feasibility exclusively of the first or second design.Brazil and Thailand offer some degree of success andexamining the relevance of these models for Indiashows that an eclectic mix of the two has worked toan extent. Experience of these two countries also showsthat Social Insurance is inadequate in 'developing'country settings and tax based financing is essential.But they go further, demonstrating that comprehensiveservices with strengthening of community level andoutreach initiatives is crucial for UAHC among themost marginalised. Between them, Brazil is the moremedicalised (urbanised as well) but it has evolved someform of deliberative democracy (would it be difficultto replicate or sustain as some analyses suggest?).Thailand's is a more rooted rural-based model thoughwith less procedural democracy.

2. Defining 'commodification' in health andthereby the content of 'health care'

Moving away from the definition given in the conceptnote, it is proposed that commodification is not onlyabout public and private provisioning, or paymentand non-payment at point of service, it is about howwe conceptualise health care. Is health care only aboutsomething to be 'delivered' so that technology andservices by experts have to be purchased, whether bygovernments or by individual households? In whichcase does it not remain a commodity?

Definitions of health care given in recent publicationsview it as only professional services, or even as 'goodsand services'.

"The prevention, treatment, and management of illnessand the preservation of mental and physical well-being through the services offered by the medical andallied health professions" (The American HeritageMedical Dictionary).

Health care embraces all the goods and servicesdesigned to promote health, including preventive,curative and palliative interventions, whetherdirected to individuals or to populations" (WHO,

2000).

In some instances there is a further shift, from 'universalhealth care' to 'universal health coverage' and thenseemlessly on to 'universal health insurance' (asobserved, for instance, from documents related to theMontreux symposium and in the Lancet)!

An alternative people-centred discourse has to gobeyond this kind of definition and the following maybe more useful from the Primary Health Care/MFCPerspective:

'Health care is a continuum from everyday activitiesand self-care by people to primary, secondary andtertiary levels of care provided by those withspecialised knowledge about health who support theindividual/community appropriately as and whennecessary.'

This definition significantly changes the contours,content and functional design of a system for UAHCfrom that being widely propagated through the currentdiscourse that views health care as only 'services tobe delivered'. The two perspectives may accommodatethe same services, but the functional quality andculture of health care they generate could bedramatically different. Can we develop this alternativediscourse that goes beyond the professionals andmedical institutions to a wider imagination that buildson and furthers the strengths of 'ordinary' people ?

If people are doing it themselves, why do we thenhave to think about self-care in a system for universal'access'? It is important because even self-care requirescertain pre-requisites for it to be accessible to people,it requires the knowledge, the confidence to use theknowledge on one's own and the material inputsrequired for it. Depending on their orientation to theissue, health professionals can dissuade people fromself-care or facilitate effective and rational self-care."Supporting self-care is about increasing people'sconfidence and self-esteem, enabling them to takedecisions about the sensible care of their health, andavoiding triggering health problems. Although manypeople are already practising self-care to some extent,there is a great deal more that they can do, and doit more effectively. The key is having health and socialcare professionals enthusiastically supporting self-care." (Chambers et al, 2006)

Widening the boundaries of 'health care' to includeself-care would change the meaning of 'participation'and the 'culture of citizen's participation' that theconcept note refers to. If people's felt needs are givencentrality, it takes us beyond mechanical 'communityparticipation' to a more organic basis for the

12 mfc bulletin/February - July 2011community's active involvement in health care. It alsorequires an active change in the approach of cliniciansand other health care providers, to what the patientsand communities can and should be supported to do.

A separate note attempts to illustrate this approachby outlining the principles and possible model ofevidence-based health service development withUAHC -- 'Conceptualising UAHC Bottom-up:Implications for Provisioning and Financing'. Someimplications for governance are being discussed inthe next part of this note.

II

Implications for Governance

A distinction has to be made between 'governance'and 'management'. In the present mainstreamdiscourse there is much discussion about governance,but the content is almost entirely about managementissues.

Governance is about setting down of the vision andobjectives, the policy, principles and priorities of anyinstitution or organised system. Management is aboutoperationalisation of the principles to address thepriorities set out in the governance exercise. Thiswould require another set of policy/principle/priorityissues/indicators to be decided for the more operationaldimensions. For instance, financing such that thereshould be no out of pocket payment at the point ofservice is a governance issue, while working out ofthe mode of payment and the accounting systems toensure this is more of a management exercise. Bothare important and overlapping.

One of the primary governance issues is the processto be adopted for planning of the health services.Is it to be a top down process of building health servicestructures, giving primacy to the institutions andtechnologies, or is it to be a bottom-up process startingfrom the people's knowledge and possibilities of'empowerment'? What are the decision-makingstructures and who gets primacy? Is it to be only aboutgiving them membership in structures that functionsuch that it becomes ritualistic 'communityparticipation'? For instance, as one of several membersof the RKS which is otherwise composed of and headedby officials who not only do not value their opinionsbut actually find it a 'problem'? Or is it also possibleto give them power by giving weight to theirperceptions and priorities, for example by designingsome indicators used for assessing quality based oncommunity understanding. The process would thenhave to be based on both, official policy and planninggiving consideration to people's 'felt needs' and

demand (as expressed through the findings of studieson people's perceptions and health seeking behavioursand through community monitoring) as well as ondirect participatory decision making.

Empowerment comes by valuing their valid healthknowledge and allowing their critical thinking to begiven weight in official decisions, rather than onlyby giving them the capacity to buy commodifiedhealth care.

A second issue of vision and policy is about assigningroles to the public and private sector in UAHC. Thenon-fragmented, unified approach to the entire healthservice system requires that public, private, NGO,community action for health -- all be consideredtogether. In a market economy, regulation of the privatesector can only be through the market principle ofcompetition and the public sector must be strengthenedto provide it in the people's interest. The issue is ofprimacy to the public services framework under whichall providers should become part of a unified system,or should the private sector framework be the unifyingframe? The Primary Health Care approach suggests apublic services-cum-community action framework. Tomove towards giving concrete shape to such an approachin health services development and management, anoutline is given below.

The Planning Paradigm & Health CareDevelopment

If the bottom-up paradigm of planning is to beadopted, then community needs in terms of AYUSH(Ayurveda, Yoga & Naturopathy, Unani, Siddha, SowaRigpa, Homeopathy -- the acronym for textual systemsof medicine other than modern medicine alreadyexisting in the country) and LHT (Local HealthTraditions, the non-textually systematised folkpractices) have to be the starting point for considerationof people's health care. 'Architectural correction' ofthe health care system as a whole should be designedwith this perspective. Governance and managementstrengthening of the public services, along withpeople's empowerment, will be essential componentsof action for UAHC from this perspective.

National/State Level

The national and state policy framework may be basedon the following considerations:

i. All providers of health care be viewed asinteracting parts of the whole health servicesystem: public, private, not-for-profit, and self-care; modern and traditional medicine; home totertiary care.

mfc bulletin/February - July 2011 13ii. The service structure be designed in broad terms

with flexibility for state, district and block levels.

iii. The service structure be designed withconsideration to the linkages & dynamics of :

an epidemiological need assessment forelements of comprehensive carepeople's felt needs, and perceptions ofquality health carea mapping of existing sources of healthcare and utilisation patternspractices and perceptions of providers ofall segments of the health care system

iv. Administrative structures should allow forcontextual flexibility, be sensitive to people'sperceptions and take community monitoringfeedbacks seriously, as well as be generous towardsdoctors and all cadre of health workers in termsof their work conditions and dignity as well astheir views on strengthening of the services.

v. Management mechanisms to be developed forthe various sub-systems, such as:

infrastructure planning based on popu-lation coverage and time taken by peopleto access services in specific contextsprocurement and supply of appropriatemedicines, equipment and other medicalrequirements that are need based andtransparenthuman resources in line with the vision,with required levels and number of cadre,orientation and training, conditions ofwork etc. and systems for supportivesupervisionan effective HMIS that provides rapidinformation for monitoring and quickresponses as well as periodic evaluationand course correctionsentinel surveillance for diseases, with theinformation feeding into the ongoingevaluation and planning process, as wellas a rapid response in epidemic situations

vi. Develop technical support structures that assistin assessment of technological options andsystem design at all levels, from the nationalto the block, with wide involvement ofinterdisciplinary expertise.

vii. Setting of Standard Guidelines for Treatment thatinclude from home remedies to validatedtherapies of all 'pathies' at each level of care,with indications for referral to higher levels and/or cross-referral. The Essential Drugs List couldinclude the validated medicines of traditional

medicine as well (as in Thailand).

viii. In light of the framework adopted, appropriatechanges should be brought about in thecurriculum and pedagogy of modern medical aswell as AYUSH graduates, nurses and paramedicalcadres. Highlighting the evidence on advantagesof self-care to patients and to the health careproviders and equipping them with theorientation and skills to support self-care alongwith minimising its risks would be keycomponents.

The MOHFW must strengthen its institutionaltechnical capacity for its policy making and oversightrole; to assess technologies and programme/schemedesigns as well as innovative systems developmenton an ongoing basis. This will require more in-housetechnical personnel who can work on their own andare enabled to coordinate external expertise as andwhen required. The budget must allocate sufficientfunds so that the ministry does not have to dependon international agencies for hiring consultants forit, as is currently the practice. This is important asa governance issue if we want to move towardsindependent, objective, professional expertise toguide the decision making processes.

In addition, more officers are required for adequateattention to the various sub-systems within the overallhealth service system. Presently each officer ishandling so many of them that they cannot do justiceto any, having to coordinate all across 35 states andUTs for a billion plus population.

In the present context, the NRHM is the largestcurrently on-going initiative for strengthening of thepublic services. While variable in implementation andoutputs across the states, it can provide a number ofnegative and positive lessons that need to be builtupon while attempting UAHC.

District Level Planning

In this framework, the District Health Services anddistrict planning would be central to the service system.A framework for an approach to District Health Planningis outlined below, based on the experience of analysingand participating in state and district planning underthe NRHM, the principles of public health planningdiscussed in the previous section, and the findings ofan 18 state study on the 'status and role of AYUSHservices in the public system as well as use of localhealth traditions' (Priya & Shweta, 2010):

1. Map the epidemiological profile of the district-- using institutional data on morbidity profileof patients attending, causes of mortality data

14 mfc bulletin/February - July 2011and priorities identified in consultation withcommunity level health workers and communitymobilisers (AWW, ASHA, ANM, MPW, VHSCmembers, traditional local health practitioners!

2. Map the prevailing health-seeking behavioursof all sections -- including use of LHT, AYUSHand Modern medicine, related to the mostcommon and epidemiologically identifiedpriority health problems. Studies of perceptionsmust be conducted to understand the reasonsfor the observed behaviour. Documentation ofthe health perceptions and behaviour should bean ongoing task at the district and state levels.

3. The documentation should be followed byvalidation of people's practices and local healthtraditions based on the locally prevalentsystematised traditional medicine by the AYUSHdoctors at district level. Validated effectivepractices should then be promoted for use bythe community as well as put to use at the healthcentres. This would not only revitalise the LHTbut also contribute to strengthening theknowledge base of AYUSH and promote its non-commercial practice using local herbs.

4. The IPHS requirement of a herbal garden in eachsub-centre and PHC provides the opportunityto facilitate the linkage between the cultivationof medicinal herbs and plants and their localuse, involving the local traditional practitionersfor this activity and linking it with the AYUSHdoctor of the co-located facility. This should beone of the community linked processes and thepanchayat and VHSC should be associated withthis activity.

5. Use of the LHT and AYUSH for MCH, NCDsand any other conditions found suitable mustbe identified and promoted for self-care, home-based care and institutional care as appropriate.They must be made part of the StandardGuidelines for Treatment for all health careproviders (including the doctors of Modernmedicine and AYUSH, ANMs and ASHAs),stating the role of AYUSH and LHT in primarycare and the points of cross-referral.

6. Assessment should be made of the additionalsupport required through home-based care bythe paramedical workers, the support requiredfrom OPD services provided by a doctor, whetherof the Modern medical system or the AYUSH.Further planning of services should then

optimise the work load and role of the HR ofboth Allopathy and AYUSH in the institutions.

7. A consultative process of block planning beundertaken with the doctors and health workersas well as community members, with mappingof existing services to identify their optimalutilisation, the gaps and barriers in servicedelivery and thereby identify priority needs forhealth service development in the immediateand long term.

8. The principle should be that the point closestto the patient/community where the requiredappropriate care can be provided, should beequipped to handle the condition. No activitythat can be performed at a lower level shouldbe planned for the higher level. This would bethe most cost effective and accessible health carethat can be made available.

9. The extent of complications arising, or theincidence/prevalence of serious illnessesrequiring higher levels of care, should beassessed and infrastructure, human resources etc.planned accordingly.

10. The orientation and knowledge of providers of allcadres should be assessed and in-service trainingsplanned according to the vision for UAHC.

Technical and administrative support structures will berequired at district and block levels, working in tandemwith those at the national and state levels. All this isto ensure provisioning of appropriate, quality healthcare to all. Finally, multiple check and balancemechanisms in place will lead to an incrementallystrengthening, pluralist, flexible and transparent servicesystem that generates trust and effective outcomes.

As Goldberg (2005) has argued after analysing healthservice developments in the USA and Canada in theearly years of this century, it may be advisable to firstdefine health care and then discuss its funding ratherthan the other way round. "We need to agree on thecore principles, values, and practices of the health-care system. There must be frank discussions aboutwhat type of healthcare we will deliver in the future.The qualitative as well as quantitative parameters ofthe system must be defined. The expectations of thepatients must also be clarified ..... Only after there isagreement by all parties on the core-values and qualityof healthcare can there be a meaningful discussionabout how the society will fund such a system."

[See companion paper 'Conceptualising UAHC'Bottom Up': Implications for Provisioning andFinancing]

mfc bulletin/February - July 2011 15ReferencesAnonymous (2010): Montreux Statement from the SteeringCommittee of the first Global Symposium on Health SystemsResearch at http://www.hsr-symposium.org/index.php/montreux-statement, accessed Dec 24, 2010.

Chambers R, G.Wakley and A. Blenkinsopp (2006):Supporting Self-care in Primary Health Care (Radcliffe Pub:Oxford).

Chokevivat, Vichai (2005): "The Role of Thai TraditionalMedicine in Health Promotion," 6GCHP, 7-11 August 2005,Bangkok.

Goldberg R E A (2007): "First Define Healthcare - DiscussFunding Later," The Internet Journal of HealthcareAdministration, 5:1.

Priya R. & A.S. Shweta (2010): "Status and Role of AYUSHand Local Health Traditions under the National Rural HealthMission: Report of a Survey." (New Delhi: National Health

Systems Resource Centre, NRHM, MOHFW).

Shukla, Abhay, Anant Phadke and Rakhal Daitonde (2010-11): "Towards Universal Access to Health Care in India,Concept Note for Medico Friend Circle, Annual Meet 2011,"mfc bulletin, No. 342-344, Aug-Jan.

WHO (2008): The World Health Report 2008: PrimaryHealth Care: Now More than Ever (Geneva: WHO).

WHO (2010): Health Systems Financing: The Path toUniversal Coverage (Geneva: WHO).

WHO-SEARO (2008). Regional Conference on RevitalisingPrimary Health Care, Jakarta, 6th-8th August.

WHO-SEARO (2009): "Self-care in the Context of PrimaryHealth Care", Background Note, Regional Consultation onSelf-Care in the context of Primary Health Care, Bangkok,Jan 7-9.

World Health Organization Report (2000): Why do HealthSystems Matter? (Geneva: WHO)

Health care is a commodity if it is only viewed assomething that can be obtained by accessing servicesthat have to be purchased, whether the provider isin the private sector or a public institution. While thisexternal source of health care is a major part of healthcare, there are others that cannot be thus commodified,and access to those must be ensured as well.

Health care consists of preventive, promotive andillness-management activities, as a continuum fromself-care at home to primary, secondary and the highestlevels of tertiary care. Self-care is the commonest atthe beginning of any illness and in chronic illnesses,consisting of use of home remedies, common medicalprescriptions such as pain killers and anti-pyretics,use of formulations of traditional medical systems and,in long-term conditions consists of modulation ofregimes that are prescribed for repeated or long-termuse. Often, a combination of these is resorted to.Commonly, the second line of action depends on thenature of illness and its severity; based on theircollective experience people develop a general patternof health-seeking behaviour with an understandingof what works best for which health problem in theircontext. It could be going in for doctor's medicine,or in cases where it is known not to be effective therewould be resort to the traditional systems, includingin some cases faith-healing as well. This pattern variesacross different settings and in groups with diverseecological, socio-economic and cultural backgrounds.

This experience-based behaviour pattern of peoplehas been found to be a good guide to cost-effective

Conceptualising UAHC 'Bottom Up': Implications forProvisioning and Financing

-Ritu Priyasolutions in several instances, such as in the case ofdiarrhoeal diseases and pulmonary tuberculosis, wherethe 'default' was found to be more on the part of theservice providers than on the people's behaviour. Thereis also the spectrum of iatrogenic problems that makepeople use various options other than those causingside-effects.

TM (Traditional Medicine) & CAM (Complementaryand Alternative Medicine) are being increasinglyadopted world-wide, even where universal access toquality services of modern medicine exists.Ideological reasons such as dissent with the moderndevelopment paradigm based on eco-socialconsiderations and against the personaldisempowerment due to medical hegemony (women'smovement spearheading this since the 1970s and 80s)have led many to 'return' to TM and CAM. However,larger proportions of the population use such meansto health by choice based on experiential knowledge,viewing them as cost-effective means of dealing withill-health and promoting health. Estimates of up to70% of the world's population using them have beenmade (Bodeker & Burford, 2005).

This is not to deny that there is much suffering thatcan be mitigated by a better access to appropriatemodern health care and that people desperately requirebetter access to medical services. The implication isthat developing systems to ensure 'Universal accessto health care' has to factor in the agency of lay peoplethemselves in action for their own health as well asthe pluralism in forms of health care. It is necessary

16 mfc bulletin/February - July 2011to prevent the developing of hegemony or monopoliesof any one form, it prevents over-medicalisation, andit allows people to get the benefit of the strengthsof each form of health knowledge while allowingothers to fill in the gap due to each ones limitations.

Developing systems for universal access with onlyone form defining the content of health care will resultin de-legitimising the other forms and underminingthe support structures for them. For instance, in Europeand the US people with medical insurance are spendingmore out of pocket to get complementary andalternative forms of medicine (CAM) than they arehaving to on allopathy because CAM is not coveredby most insurance packages. Once there is insurance,people also tend to go sooner for medical servicesthan they may otherwise, decreasing the use of homeremedies and other modes of self-care. Now, in societieswhere there has been a relative saturation with medicalservices, there is also an increasing demand for CAM.So we should not let go of our advantage of havinglive practice of various forms of traditional medicineand discuss a framework that is based almostexclusively on the modern medical/allopathic doctor.Doing so has brought us to a situation where Illich'sanalysis of medical nemesis seems to be proven trueeven while large sections are denied access; medicaland 'cultural iatrogenesis' are evident -- a truthrecognised by 'scientific' medical research as shownby advances in dealing with cases of, for example,

diarrhoea, CVDs., diabetes, personalised treatment,over-medicalised deliveries -- but still unnecessaryinterventions are widely accepted and adopted informal medical practice.

Several committees and Five Year Plans haverecommended using the availability of traditionalpractitioners to advantage as they are providingservices in otherwise underserved populations. Somestates have recruited them to provide allopathicservices in PHCs, such as in Maharashtra, J&K andUP. What public health has ignored until now is theinherent worth that is recognised in the 'other systems'by lay people, elements of which are now increasinglybeing validated even by the frontiers of inter-disciplinary bio-medical research (such as psycho-neuro-immunology, Integrative Medicine, etc.). Wehave also not incorporated the presence of AYUSHfacilities in the public system in our analyses of publicservices, despite the fact that there is a whole parallelstructure of AYUSH dispensaries and hospitals in moststates (see Table 1). The number of service deliveryinstitutions is high, with almost as many stand-aloneAYUSH dispensaries as there are PHCs in the country,and AYUSH hospitals about one-third the number ofallopathic hospitals. The total number of AYUSHcolleges is more than that of modern medicine andtheir intake capacity is somewhat less. However, allthis infrastructure is supported by less than 3% of thehealth budget!

Table 1

Features of AYUSH Services in the Public System

No. AYUSH Modern Medicine

1. Service Delivery Nil for outreach services SC = 1,46,036Infrastructure Dispensaries = 22,312

PHC = 23,458

Hospitals = 3378 RH (including CHC)= 6281UH = 3115Total = 11,613

Beds= 68,155 Beds (R)= 1,43,069Beds (U)= 3,69,351Beds (T)= 5,40,328

2. Colleges Total AYUSH Colleges= 492 Medical Colleges= 300Annual intake capacity= 30,086 Annual intake capacity= 34,595

3. Budget Allocation Department of AYUSH= 2.7% Dept. of H&FW= 90%NACO = 4%Dept. of Health Research=3%

2. Co

3. BuAlloc

Sources: National Health Profile, 2009, CHEB, GOI; AYUSH in India, 2007, Dept. of AYUSH, GOI.

mfc bulletin/February - July 2011 17With the low funding, quality of infrastructure andfunctioning of AYUSH institutions is often weak, andutilisation is reflective of this. This was the findingof a study across 18 states in 2008-09 (Priya & Shweta,2010), a comparative analysis showing that theutilisation is high where quality is good. In states suchas Tamil Nadu and Kerala, where quality of modernand AYUSH services is very good, utilisation wasfound to be high of the AYUSH as well (see Table2). This reflects a demand by choice rather than underthe constraint of access to modern medicine.Household responses revealed an even higher use ofAYUSH and LHT, many going to the private sector.

Responses of doctors of modern medicine in the publicsystem too reflect a high perception of usefulness ofthe AYUSH and of home remedies by them, reflectingtheir perceived/observed strengths, especially in caseof shortcomings of modern medicine. The practice ofcombined therapy and cross-referral being practicedinformally is indicative of the perception of thecomplementary role of the various systems.

Some Key Contemporary Global Issues inOrganising Health Care

There are various streams of thought developingwithin health services development in the world atthis point of time, all charged with some commonlyrecognised problems with the existing systems. Onestrand attempts to reform the financing andprovisioning without questioning the knowledgecontent while the other challenges the prevailingdominant knowledge base and provides openings fora different direction for development of health carein the future. In fact there is much frontier researchthat is changing the state-of-the-art practice ofmedicine from a high technology to a lower and moreappropriate technology use, often drawing from othersystems of knowledge. The findings of a rich bodyof analytical studies can be summarised as follows:

Consequences of Bio-medical Dominance

Over-medicalisation, specialist services furtherincrease unnecessary interventions and costsIatrogenesisCommodification of healthUnaffordable and Escalating CostsPharmaceutical and insurance industryattempting to generate higher markets for fewertechnological advances; pressure for higherpublic funding of medical services and forabsorbing the costs of R&D in curative andpreventive medical technologies.

Challenges to the Bio-medical Dominance

High and increasing NCD load even while

Communicable Diseases remain high; an agingpopulation

Widening recognition of significance of thesocial determinants of health

Increasing use of Traditional Medicine (TM) andComplementary & Alternative Medicine (CAM)

Questioning of development models that ignorenatural environments and processes

Demands around 'right to quality health care','rights of patients' especially in terms ofinformation and role in decision making, 'rightsof providers'; involvement of communities indecision making.

In this context, optional paradigms for solutions tothe lack of access to health care:

A. To make the bio-medical dominance 'affordable'through social insurance/tax based financing.

B. To break the dominance by supporting andlegitimising the cost-effective pluralistic forms,ensuring universal access to all the forms throughmaking knowledge and material requirementsof all forms accessible to all.

Health Services: The Indian Context

In addition to the issues faced by health systemsglobally, some specific issues are relevant forconsideration for UAHC in India (as well as other lowand middle income countries):

Large infrastructure of public services of modernmedicine and AYUSH, but still inadequatecoverageLarger private sector, formal and informal, singledr. to polyclinics and nursing home to corporatehospitals and their franchisee outletsLarge paramedical cadre along with communitylevel 'volunteer workers'Large pharmaceutical industry of modernmedicine and traditional medical systemsYet, access poor due to concentration of servicesin some parts and sparse in others and due tocostsHigh unethical and irrational practice, lack oftrustworthy and quality services; completelyunregulatedPervasive nexus of vested interests,normalisation of unethical practicesHigh availability of health human resources, yetshortages due to lack of/distorted policies ofproduction and deploymentHigh 'untreated' illness episodes on one hand,and high unnecessary use of medicaltechnologies and specialist care on the other

18 mfc bulletin/February - July 2011Table 2

Utilisation of AYUSH Services of the Public System and Use of Home Remedies:

Data from an 18-State Survey

AYUSH & LHT Modern Medicine

1. Utilisation: Highly variable across states Data not available for all states.Average OPD attendance/ from 8 to 78.facility/day) In Tamil Nadu: In Tamil Nadu:

Stand-alone Dispensaries and PHCs = 100-150Co-located PHCs = 50-80

2. Utilisation: Households Households reported use ofreporting use of AYUSH AYUSH services in the past 3months:services in last 3 months. 1/3rd states = 0-30%

1/3rd states = 30-60%1/3rd states = 60-98%

3. Pattern of Use: Morbidity Utilised for all kinds of problems --profile and duration of illness for curative services in case of acuteof OPD attendees and chronic, communicable and non-(exit interviews) communicable illnesses, except[Acute illnesses = less than for emergencies & serious conditions.1 month The proportion of chronic illnessesChronic illness = more than was higher than among the patients1 month] taking treatment of modern medicine.

For preventive-promotive purposes aswell. For instance, as per exit interviews:In Tamil Nadu:Acute illnesses = 40%Chronic illnesses= 60%In Uttarakhand: In Tamil Nadu:Acute illnesses = 42% Acute illnesses = 100%Chronic illnesses = 58% Chronic illnesses = 0%

In Uttarakhand:Acute illnesses = 92%Chronic illnesses = 8%

4. Utilisation of Home Remedies Variable use of home remedies Utilisation of home remediesreported by households across states : together with doctor's medicine was

For common illnesses =12-82% high as reported at exit interview

For MCH care= 40-98% by OPD patients at governmentinstitutions = 2-73%

5. Validity of community Home remedies for a given list of 21knowledge against AYUSH conditions = more than 75% foundprinciples and texts. valid in all states

6. Opinion of Medical Officers 70% respondents said AYUSHof modern medicine regarding were of value; 30% thought theyAYUSH and LHT were redundant.

55% perceived value in homeremedies and also prescribed themto patients, but some were thoughtto be harmful as well.

However, did not write it in theprescription.

7. Combination and Cross-referral Listed conditions that matched well Listed conditions that matched wellof AYUSH and Allopathic with people's utilisation behaviour: with the AYUSH doctor's lists:treatment " in which combined therapy is useful, " in which combined therapy

" for which cross-referral is done to is useful, and from providers of modern " for which cross-referral is done to medicine. and from AYUSH providers.

However, did not write it in theprescription.

mfc bulletin/February - July 2011 19Triple burden of disease with continuing CDs.,increasing NCDs and Injuries

High resort to the private sector (formal andinformal), and to Traditional Medicine (TM) andthe use of Local Health Traditions (LHT) --pluralist health seeking behaviours widelypervasive in all communities

Large no. of civil society experiments andformally trained doctors of modern medicine arecombining TM interventions and modernmedicine for maximum benefit to patient

NRHM is the ongoing country-wide initiativeby the state for strengthening the health servicesystem and any future efforts at health systemsdevelopment must examine and build upon itsachievements/potential/negative possibilities -- (i) setting into motion mechanisms for revivaland internal strengthening of the public systemand its sub-systems on one hand andinvolvement of the private sector on the other;which have been multiple and diverse across thestates, and can provide positive lessons, (ii)strengthening of structures for community levelaction and involvement on one hand andinstitutional strengthening on the other, againmultiple and varied implementation withlessons, but generally weak on people's role ingovernance processes; (iii) commercialisation,contractualisation, and/or monetaryincentivisation of activities, which may becounter-productive to strengthening of thepublic system and community processes.

Challenges for Building an Alternative Paradigmwith UAHC in the 21st Century

In the context of both the global and India specificsets of issues related to a health system that issustainable and cost-effective in improving people'shealth and wellbeing, some challenges are highlightedbelow for evolving any meaningful system of UAHC:

Hegemony of the provider and medicaltechnology needs to be broken--demystifyingthe information gap and role of technology--while simultaneously empowering the doctors/providers to practice ethically and with dignity

Nexus of provider-prescriber andpharmaceuticals is to be broken.

Nexus of provider-prescriber and commercialdiagnostics is to be broken.

Levels of appropriate care that can be providedto all must be publically funded. This has largelyto be by the state, but also by facilitating workers'cooperatives, civil society organisations

organisations, philanthropic bodies, etc., to thetask of providing rational health care universally,as distinct from the commercial for-profit privatesector.

Limiting the escalation in demand for newertechnologies as access to services improves.Escalation in available technologies and theirmarketing strategies change people'sperceptions, especially of those who are alreadyadvantaged in terms of achieving access.Thereby there is a distorting of the rationalityof 'need' such that the system cannot gear upto reach those who do not have access to eventhe basic services.

A wide diversity of context requires thatpriorities be decided based on context specificproblems and ways of handling them.

Centralised, capital intensive structures can onlybe at centres of concentration in order to allowaccess to the maximum number and to ensure allrequired inputs -- for example, hospitals havelargely to be located in urban areas (and wherevera successful rural hospital is set up, the area tendsto get urbanised), therefore outreach services andreferral systems are more necessary for the ruralareas. Even in a setting such as of Canada, it hasbeen found that universal access resulted inovercoming the disparity in mortality rates as wellas in inequity of access for primary level andgeneralist services but not for specialist serviceswhich continued to be disproportionately utilisedby the better-off (Veugelers and Yip, 2003). Thisalso implies that, by norms of equity, developingservices other than hospital based and specialistdependent care should be prioritised for allsettings--rural and urban.

The GP, paramedic, providers of AYUSH servicesand self-care must form a larger part of the formalhealth service delivery system everywhere, bothfor cost-effective rational care for a majority ofhealth problems, and for the widest possiblecoverage and access. This is as necessary for themiddle-class and urban as it is for the poor andrural.

PG education must be oriented towardsproducing specialists who should not only beable to use more and higher level technologybut even more so, be more knowledgeable andskilled in assessing which patient managementapproach will be most suited to a patient withleast intervention, and refer the patientappropriately to the GP / paramedic / providersof TM services, as well as inculcate capability

20 mfc bulletin/February - July 2011for self-care.

Thus, in addition to the norms for coverage ofinstitutions and health human resources, a model forthe structure of health services will have to take intoconsideration: (i) the content of services to be providedsince optional methods and technologies have theirown imperatives for levels and forms of servicedelivery; their inherent rationality varies in diversecontexts; comparative cost-effectiveness analysesmay imply huge financial differentials; (ii) people'shealth seeking behaviours since they may provideindicators of the most cost-effective ways of dealingwith problems within their context, as well as anunderstanding of rationality of people's expectationsfrom a health service; and (iii) the work culture ofhealth care providers since that would determine therationality, quality and outcomes of care. In fact, thenorms may have to be re-considered in light of thesefactors. Diversity of context in terms of the levelof health services development would have to befactored in. An incremental process of strengtheninguniversal access may be envisaged for realisticplanning and implementation.

The Framework for UAHC

There are two clear trends in health care -- a medicaltechnology, doctor and institution-centred approach anda social determinants and people-centred, pluralisticapproach. The model for UAHC would have to adoptone of the frameworks, incorporating within it elementsof the other as required. The former can only be developedas a top down process since it inherently relies on themedical expert. The latter can be developed as eithera top down process or a bottom up process.

If cost-effectiveness is a major criterion for evaluatinga health intervention, then the choice of frameworkis clearly the second, given the prevailing andemerging morbidity profile and the need forpreventive, promotive, curative, palliative andrehabilitative services. However, since it is counterto the prevailing policy environment and the largerpolitical economy framework, the challenge is howto get it accepted and operationalise it. Unfortunately,the imperative of technology development andmarketing, as of the commodified mindset, is to makethe social determinants and humanist health careapproaches seem 'unacceptable' or 'not feasible'.Evidence from experience of countries across the world,at all levels of health service development, tells usotherwise; that the prevailing bio-medical paradigmincluding its public health dimensions, is notsustainable either in economic terms or in terms ofcontinuing to improve health and wellbeing of all.At one end of the socio-economic divide, the US has

faced a recession, partly fuelled by health care costsfor their employees that the corporates have had topay, resulting in a fierce controversy about how tofinance health care for all citizens. At the other endis the revelation by an analysis of implications forthe poor and marginalised of the most rational andlow cost medical care being provided by Jan SwasthyaSahyog-Bilaspur. Presented at the MFC meet at Vellorethree years ago, it showed how even the most lowcost and rational services of modern medicineremained unaffordable for over one-third (35%) of thecommunity members (in an area where they themselvesprovide rational services) who died without accessingany care for their terminal illness (JSS, 2006).Countries that have had an ideology-backed adoptionof the principle of universal health care and of theprinciple of people's empowerment together with aperceived resource constraint, have relied oncommunity structures and TM/people's knowledge forprimary health care (China, Sri Lanka, East Europeancountries). Even Cuba, with its surplus of doctors, hasincorporated TM and is currently teaching childrenabout home herbal remedies through schools. Thailandhas, as part of its UHC initiatives promoted the useof home remedies as well as strengthening ofinstitutional structures for Traditional Thai Medicine.

PPPs for UAHC

Given the reality of our existing health service system,PPPs are a necessity. With what purpose and withinwhat kind of framework are the issues to be workedout in congruence with the larger perspective adoptedfor UAHC. Drawing the private providers into anintegrated system of universal provisioning is essentialfrom the PHC/MFC perspective since they can fill gapsof general and specialist doctors in some settings.Engaging them in the UAHC framework is alsoimportant if a unified, low cost and appropriatetechnology service system is to be generated over time.Without regulation of the private sector is thispossible? Strengthening of the public services, withcontracting in of private providers as a last resort seemsto be the way forward. As the public servicesincrementally increase coverage and quality, more ofthe practitioners could come into the public systemif regular positions are given or be contracted in whenrequired. Both, the public system and the privateproviders will have to work towards developing aneffective working relationship and a work culture ofcooperation that puts the users centre-stage and takesSTGs seriously.

I am proposing that we add on three dimensionsrelevant to provisioning and financing that are missingin the present discussion and need to be incorporated

mfc bulletin/February - July 2011 21as central to UAHC for the alternative discourse tobe meaningful in our real life settings-- self-care,traditional medicine and strengthening of publicprovisioning.

A Model for Universal Provisioning of Health Care

We began by answering some key questions andmaking some assumptions based on a large body ofavailable literature:

1. How do people define 'quality' of health care?

Produces effective results

Convenience in access

Reasonable quality of infrastructure

Knowledgeable personnel

Personnel pay adequate attention to all

Tests and medicines available as needed

Short waiting time

2. What is access most commonly defined by:

Distance

Cost

Trust in providers

3. How to assess comparative advantages ofdifferent pathies, self care and professional care?

Cost and effectiveness for all types of optionalregimens needs to be analysed rather than baseassessments only on RCTs that compare acandidate drug merely with another existingdrug. Also, the assessment should be conductedfor different forms of service delivery--as selfcare, and by primary/secondary/tertiary levelproviders. Providers and users are well knownto have other valid considerations in use of eachregimen within their context. Thus, for example,evaluations of pharmaceutical products, shouldinclude under diverse conditions:

Objective evaluation of proposed/practiced regimens vs placebo orsymptomatic treatment

Objective evaluation of proposed/practiced drug regimens vs druglessmanagement

Provider's assessment of the advantagesand disadvantages of the various options

Users' assessment of the advantages anddisadvantages of the various options

Multi-dimensional and innovative mechanismscould be evolved for dealing with eachrequirement through optimal solutions in lightof all the experience of different countries andwithin India. For instance:

To decrease waiting time:

decrease unnecessary prescribing/demand forinterventions

increase coverage of population with providersand facilities

strengthen management to improve functionalefficiency

To decrease prescribing/demand for unnecessaryinterventions:

by a rational use of interventions,

using a pluralistic approach to management

To evolve a model for UAHC, make evidence basedestimates for common problems, bringing together (i)Epidemiological data on disease profile, (ii) People'shealth seeking behaviour and perceptions, (iii)Providers' practices, (iv) Learnings from realistevaluations of systems of UAHC in diverse settings.Estimation of need may be based on computationsof the following and the service structure and humanresource planning may be done accordingly:

% of illness episodes amenable to home careand not needing allopathic medicines or doctor'sattention

% of illness episodes needing primary care orlong term support from paramedics + allopathicmedicines + AYUSH

% for GP care (allopathic)

% for GP care (AYUSH)

% needing specialist attention

% using home remedies effectively (with orwithout other treatment)

Strengthening Public Services

The Planning approach outlined in the accompanyingpaper "UAHC with 'Community Participation' OR'People Centre-stage'? : Implications for Governance,Provisioning and Financing" provides a frameworkwithin which strengthening of services in thegovernment system can be envisaged. It also providesa rational basis for appropriate 'contracting-in' PPPs.

In addition, if universal access is the goal and the publicsystem is to be strengthened, coverage of services willhave to be increased to bring them physically closerto users. A structure for the public system is given belowto illustrate the possible integration of AYUSH andparamedics for preventive and curative services at alllevels. Introducing a social worker into the system wouldfacilitate the effective operationalisation ofparticipatory structures such as the VHSCs, RKS andvillage to district health planning.

22 mfc bulletin/February - July 2011

Proposed Structure for Public Servicesfor UAHC

[Village level facilitation of government andcommunity action by AWW+ASHA+VHSC

members]

Institutional structure:

1. Sub centres for 2000-4,000 persons with 2ANMs + 2 MPWs + 1or 2 AYUSH doctors+ 1 Social worker

2. PHCs for 15-25,000 persons, with 2 AYUSHDrs. of different systems and 2 GPs of modernmedicine.

3. CHCs/Sub-district hospitals for 50,000persons with GPs and specialists of AYUSHand modern medicine.

4. General District Hospitals and AYUSH sub-district and district hospitals

5. Medical and AYUSH colleges

Existing functional AYUSH dispensaries can be usedto co-locate a sub-centre or a PHC, with the AYUSHdoctor retaining charge. Infrastructure could besuitably upgraded. The AYUSH hospitals should bestrengthened to function entirely for their respectivesystems and provide specialised OPD and indoorservices.

The AYUSH doctors at the sub-centers and PHCs mustprovide only services of their own system and promotecultivation of herbal gardens and use of herbalmedicines, as well as provide supervisory support tothe paramedics for promotion of home remedies anduse of AYUSH as well as specified national healthprogrammes. At the CHC and DH, they shouldexclusively practice their own systems and work withthe allopaths to give patients the benefit of all healthknowledge as well as provide referral support andtechnical advice to the primary level providers.

The ANM and MPW should be trained in multi-pathyhealth care along with public health activities so thatthey provide comprehensive promotive, preventiveand curative services as well as promote and superviseself-care. Regular outreach activities and institutionalservices would constitute their duties. Supervisory staffand other paramedics would be appropriatelyincluded at each level.

The doctors of all systems would need to be trainedin promotion of self-care as well as sensitised to thestrengths of the other systems and oriented to use ofSTGs.

The social worker will have the responsibility ofoverseeing community activities, such as the VHSCsactivation, inter-sectoral coordination and other localspecific needs, eg for palliative terminal care at home,adequate referral linkages and transport etc., as wellas ensuring that the most marginalised sections in thevillages in her area are not neglected duringimplementation of various schemes and servicedelivery.

Thus, by combining all existing infrastructure, theneed for capital investments would be reduced whilecomprehensive and integrated services would becomepossible and provide greater choice of pathy to thepatients. Wherever doctors are not available in thepublic system they may be contracted in from theprivate sector. Where the private doctors are also notavailable, paramedics and referral services need to bestrengthened, along with nurses who can be trainedfor basic care.

To support such a structure, education and trainingcapacities will have to be strengthened at districtlevels. With a large part of the everyday illnesses beingtaken care of by self-care, paramedics and AYUSH,the need for setting up more medical colleges willbe limited leading to saving on capital investmentsand the high recurring costs at that level.

Paramedical education and training will have to bestrengthened all round. Existing ANM-TrainingCentres and Health Schools should be upgraded andadditional institutions after assessment of need.

Technical Support will need to be made part of theorganisational structure for setting of technicalguidelines for clinical practice as well as programmedesign and their implementation. This should includethe following:

Institutionalising mechanisms for technologyassessment and choices would require a national levelbody to work out the modalities and principles onwhich health technology use should be undertakenin the country. The NICE that has been doing thistask for the NHS of the UK provides a structure tostart our thinking on this. However, we would requireexpertise to assess old and new allopathic medicinesand other interventions as well as AYUSH regimens,especially for continuing and emergingepidemiological priorities, including communicablediseases, NCDs, MCH and mental illness.

Creation and updating of RDU guidelines, EDLs andSTGs with the spectrum from home remedies tooptional or combined AYUSH and allopathic regimensat primary, secondary, and tertiary levels, conductingstudies to monitor prescribing practices and identify

mfc bulletin/February - July 2011 23context specific adaptation needs, would all besupportive tasks for improving the quality of clinicalpractice.

The State Health System Resource Centres shouldhave an AYUSH unit to contribute to innovation andchange in the health system. At the district level, aDistrict Interdisciplinary Resource Centre forPeople's Health Knowledge could perform multiplefunctions, including documenting and validatingLHTs, health education for promoting the useful andweeding out the harmful traditional practices,sensitising medical and AYUSH practitioners andother health workers to the local health traditions andthe significance of people's health knowledge as wellas self-care.

The accreditation system for all service deliveryinstitutions should include criteria for 'promotion ofhealth and self-care' as an important element. Thailand,for instance, accredits those hospitals as 'healthpromotion hospitals' that promote self-care, producetraditional herbal medicines and use them for theirpatients. Referral audits could help in restrictingreferrals to higher levels to only the essential, andprovide pointers to the kind of support required bydoctors within the system to perform at their optimal.

Promoting Innovative High Quality Low CostSolutions in Clinical and Surgical care: Severalinnovations are made every day by doctors, surgeonsand health workers in order to provide optimal careto their patients and these largely remain restrictedto individual use or within their hospital. A numberof such innovations and experiments related toscreening and diagnostic tests (Phadke A.), surgery(Thomas G), trauma services (John J), deliveries(Bhattacharji S.), leukemia (Chandy, M) were sharedand discussed at the MFC Annual Meet at Vellore inJanuary 2006, and are available in the MFC bulletin.Several AYUSH medical regimens have been evaluatedby RCTs and found to be effective. Integrativemedicine combining the principles of allopathy andTM has produced good results in seriousdermatological conditions such as the 'elephant foot'of filariasis (Ryan T, 2010). Wound healing inintractable chronic ulcers, and chemical fistulectomyby Ksharsutra (Shukla et al, 1994) are wellacknowledged as more effective than modern surgicalmethods. A Golden Triangle initiative is underwayas a collaborative effort of the AYUSH Dept., ICMRand CSIR for evaluating Ayurvedic regimens for 28conditions and standardising the effective ones (GOI,2010). Facilitating systematic work on suchinnovations, with sharing of the experience anddissemination of findings would be motivational,

generating critical interest and excitement of theproviders in working with marginalised communities,as it provides a professional challenge. It would alsobe useful for all practitioners including those in theprivate sector which can use these in a win-winsituation for their patients as well as profit margins.Institutionalising this through organisations such asthe Association of Rural Surgeons of India is importantbut the resources of time and finances remain stretchedso that systematic dissemination is difficult and doesnot impact the mainstream of the profession. TheICMR/Department of Health Research could developa special unit for the purpose, bring together suchclinicians, publish and publicise their innovations andalso feed them into in-service orientations and CMEs.

Conclusion

Many more organisational and clinical ideas forensuring and facilitating universal access must bein the minds of a large number like us, some basedon evidence from literature and some also workingit out on the ground. The basic issue is the frameworkfor attempting such a challenging task. The buildingblocks are all there. How do we put them togetherto move towards an optimal, long-term, sustainablesystem of universal access? A major barrier is the lackof readiness to think 'with the people'. Whatever modelwe adopt, if it does not deal with the divide betweenthe health provider system and the people, it cannotcreate the sense of solidarity required to ensureuniversal access. Then UAHC may only becomeanother source of greater profits for the health industrywith little addition to the health and wellbeing ofIndia's marginalised, and in fact, even as it providessome relief, it may act as a source of additionalsuffering for a vast majority.

Annexures

1. Costing of the proposed service delivery structure

2. Some rough costing exercises for the alternativeapproaches, as applied to a few disease conditions

References

Bodeker G and G. Burford (2007): "Traditional,Complementary and Alternative Medicine," Policy and PublicHealth Perspectives.

Borkan J. M., Morad M., Shvarts (2000): "Universal healthcare? The views of Negev Bedouin Arabs on health services,"Health Policy and Planning, 15:2, 207-216.

Chambers R, G. Wakley and A. Blenkinsopp (2006):Supporting Self Care in Primary Health Care (Oxford:Radcliffe Pub)

Chokevivat, Vichai (2005): "The Role of Thai TraditionalMedicine in Health Promotion," 6GCHP, Bangkok, August

24 mfc bulletin/February - July 20117-11.

Duggal, Ravi (2010-11): "Organising the Provisioning fora Universal Healthcare System," mfc bulletin, Issue 342-344.

Govt. of India (2010): "Golden Triangle Partnership." http:// w w w . c c r a s . n i c . i n / G o l d e n _ T i a n g l e /20081011_Golden_Tiangle.htm, accessed 021211

Illich, Ivan. (1975): Medical Nemesis.

JSS (2006): "Is Curative Care Possible without a WelfareState?: Lessons form a Non-profit Community HealthProgramme in Rural Chhattisgarh."

Priya, Ritu (2011): "UAHC with 'Community Participation'OR 'People Centre-stage'? Implications for Governance,Provisioning and Financing", Background paper for MFCAnnual Meet, Jan. 2010, Nagpur. Reprinted in this issue ofthe bulletin.

Priya, Ritu and A.S. Shweta (2010): "Status and Role ofAYUSH and LHT under NRHM," NHSRC, New Delhi.

Ryan, Terrance (2010): "Trials in Integrative Medicine: Ashort perspective based on the experience at Institute of AppliedDermatology," Presentation at the 4th World AyurvedaConference, December 10-13, Bengaluru.

Sadgopal, Mira and Alpana Sagar (2006): "Can Public Healthopen up to the AYUSH Systems and Give Space for People'sViews of Health and Disease?", Background paper for MFCAnnual Meet, January 2006, Bangalore.

Shukla, N.K., R. Narang, N.G.K.Nair, S. Radhakrishna andG.V. Satyavati (1994): "Multicentric randomized controlledclinical studies of kshara-sootra in management of fistula-in-ano," Indi J. Med. Res. (B), 177-185.

Veugelers P. J., and A.M. Yip A. M. (2003): "SocioeconomicDisparities in Health Care Use: Does Universal CoverageReduce Inequalities in Health?" Journal of Epidemiology andCommunity Health, 57: 6, 424-428.

Annexure 1

mfc bulletin/February - July 2011 25

The costing framework of District Health System includes two major components - (a) Health Care

Costs: the cost of provisioning services at various levels of facilities (b) Systems Costs: institutional/systems overheads (training, logistics, supervision and monitoring).

For arriving at health care costs, facility-wise costing is done as to what is needed for provision of

services keeping three major components:(1) HR Costs (2) Consumables (3) Overhead Costs. The costingwas done for an "average" district with a population of 20 Lakhs (rural and urban), number of blocks

and number of institutions based on the following norms; Sub center for 3000 population, PHC for

25000 population and CHC for 50000 population District Hospital for 20 Lakh Population. Accordinglythere will be 667 sub centers, 80 PHCs, 40 CHCs and one District Hospital.

The HR costs are calculated as per the IPHS norms and adding the additional HR requirements as perthe norms prescribed in the proposed health service structure. The additional requirements to the existing

are: at the sub center level two MPW, one AYUSH Doctor, and one social worker; PHC level includes

two AYUSH doctors; CHC level includes seven medical officers and seven specialists.

All Figures in Rs. Lakhs

System Costs includes logistics and warehousing costs, ANM training centers, supervision andadministration, referral transport, Monitoring & Evaluation, IEC and Outreach services. The costing

is largely based on NCMH estimates for cost of care for core, basic and secondary healthcare package,while drawing reference to NSSO (60th round) estimates of out-of-pocket expenditure and utilization

of public facilities for hospitalization and OPD services. The costing of supervision and administration,

referral transport, Monitoring & Evaluation, IEC and Outreach services is broadly built around theIPHS norms of NRHM. The cost of logistics, ware housing and ANM training centers is based on actual

data from the state of Bihar.

When the state and national level costs are included, the systems costs are expected to increase toover 10%. Decentralised planning based on local epidemiological needs and the stated principles of

service provision at the lowest and closest level possible is likely to lead to variation in number of

institutions and HR such as decrease in specialists and increase in PHCs, and accordingly a variationin costs.

[We thank Gautum Chakraborty and Arun B. Nair for doing the costing, and for including the systems

heads. This is to get a rough idea of the financial implications for the proposed structure of services.]

Please renew your subscription to themfc bulletin. And write for it.

26 mfc bulletin/February - July 2011

Ann

exur

e 2

mfc bulletin/February - July 2011 27

Cost of the Rational Modern Medicines forTreating the Four Common Conditions

Source: *From govt. pharmacy rates and TAMCOL

Sources:http://www.tnmsc.com/tnmsc/new/html/pdf/drug.pdf

* http://www.medlineindia.com/antibiotic/tinidazole.htm

Cost of the Rational Siddha Medicines for Treating the Four Common Conditions

28 mfc bulletin/February - July 2011

The Regulation of Surrogacy in India: Questions and Complexities

- Preeti and Vrinda 1

While instances of commercial surrogacy have risenby leaps and bounds (a recent article in a leadingnational daily estimates that the cost of the surrogacymarket is over Rs 2000 crore), its regulation or rathernon-regulation has been a matter of concern. Withinthis flourishing market, even as clinics and otherplayers continue to make huge profits, there are severalethical concerns that arise out of the increasingcommercialization of women's bodies and bodilylabour; this includes concerns about the health andrights of the surrogate and the child/children born outof surrogacy. Given such a context, the need for acomprehensive legal framework cannot beoveremphasized. This is particularly evident in casesinvolving legal tussles about the citizenship statusof children born through transnational surrogacyarrangements.

In the proposed Draft Assisted ReproductiveTechnology (Regulation) Bill and Rules-2010,prepared by the Indian Council of Medical Research(ICMR), a substantial section is devoted towardsregulating surrogacy arrangements. Though awelcome step, significant gaps in the protection ofsurrogate women and children still remain. The moststriking of these perhaps is the provision for paymentto the surrogate woman, which appears to undermineher rights by favouring instead the intended parents.According to the present Draft, payment to thesurrogate is to be made in five installments insteadof three (as in Draft 2008, the only previous version).The majority, that is 75 per cent of the payment, isto be paid as the fifth installment, following thedelivery of the child. This is in complete contrastto the Draft 2008, in which there was provision forthe majority 75 percent of the payment to be madeas the first installment. This not only shows a clearpriority accorded to the intended parents, but alsobetrays that the worth of the surrogate's labour,pregnancy, related emotional and physical risks etcare considered reducible to and meaningless withouta tangible reproductive output, the baby. Thepotential health risks that a surrogate might face (as

a result of undergoing IVF) do not appear to be acause of concern at all. For instance, according tothe Bill, only gestational surrogacy, that is throughIVF, will be permitted, and genetic surrogacy, thatis through IUI, which is the less invasive option, isruled out. While this may be to avoid any contestingclaims over the custody of the baby later, it againreveals that the 'commercial angle' outweighs the'human', and no nuanced understanding of thesurrogate's rights, who may have voluntarily enteredinto a contract but may also relate to the baby inemotional ways, .

The present Draft has also increased the number ofpermitted successful live births for a surrogate fromthree (in the previous Draft) to five; this is inclusiveof the surrogate's own children. This provisioninadequately addresses an aspect critical to thesurrogate's health: the number of permitted cyclesshe can undergo. Since the number of live births isnot equivalent to the number of ART cycles, toeffectively ensure that the surrogate's health is notexploited, the maximum number of permitted cyclesmust also be specified.

In lieu of the recent and controversial cases ofinternational surrogacy that have resulted in legalbattles for citizenship status for the child/ren, theBill has made provisions to address this issue. Thedraft Bill now makes it mandatory for foreign couplesto produce a certificate from their countries declaringthat the respective countries permit surrogacy, andthat the child will be considered a legal citizen. Asan increasing number of couples from other countriesaccess surrogacy services in India, such a provisionwill be a useful legal framework. The Draft Billshould take concrete measures to address the legalneeds of the surrogate women.

Therefore, it can be concluded that while alegislation to regulate the untrammeledcommercialism of ARTs and surrogacy in India isa much-needed step towards checking unethicalmedical practice, the human rights of the surrogateand the children - legal, financial, and health-related - need to be better protected.1

Sama - Resource Group for Women and Health,<sama.womenshealth@gmail.com>

mfc bulletin/February - July 2011 29

The Travesty of Informed Consent:Case of HPV Vaccination "Demonstration Projects"

- Sarojini N and Anjali Shenoi 1

The Human Papilloma Virus (HPV) vaccination'Demonstration Projects' were conducted in Andhra Pradeshand Gujarat by PATH International (an American NGO), incollaboration with Indian Council of Medical Research(ICMR) and the State Governments of Andhra Pradesh andGujarat, since 2007. Following reports of deaths, adverseevents and violation of ethics, including fact-findinginvestigations carried out in Khammam district in AndhraPradesh by concerned groups and Smt. Brinda Karat (MP),the 'Post-licensure observation study of HPV vaccination:demonstration project' was suspended in April 2010. At thesame time, the Ministry also appointed a Committee to enquireinto these "Alleged irregularities in the conduct of studiesusing HPV vaccine" with a time frame of three months tosubmit its report.

Almost 10 months later in February 2011, an interim reportsubmitted by the Committee and was made public after ademand from the members of Standing Committee on Healthin Parliament. The Committee has identified severaldeficiencies in the planning and implementation of the project,however, failing to fix responsibility for any of these violationson any individual or agency. In this article we would addressone of the key concerns raised by the members of theCommittee is related to the way the consent was obtainedfor the implementation of the Demonstration project. Thereport establishes that, "The legality and morality of the circularof the Government of Andhra Pradesh authorizing the HostelWardens and Head Masters to sign the consent on behalfof the minor girls included in the study is questionable."

A fact-finding report by civil society groups last year pointedout the similar observation. The report mentioned that thewardens of the residential schools and hostels, which wereselected for the 'demonstration project', were asked to provideconsent or permission for vaccination. The report questionedthe basis where the wardens be considered legal guardiansto provide consent? The report further states that: "Howcan a warden, whether a legal guardian or not, be allowedto sign or provide consent for hundreds of children withoutconsulting with the parents, who are the natural guardians."

The consent form for this project does not include anyinformation on compensation, procedures to be followed,

alternative treatments if available or risk management asmandated by the ICMR guidelines, necessary for informedconsent. The consent form also states that "If you are notwilling to participate you will not lose any benefits that youare entitled to; you will not be fined".

The very nature of this project appears to be in violation ofall ethical norms as a warden, whether a legal guardian ornot, be allowed to provide consent for hundreds of childrenwithout consulting their parents, who are their naturalguardians.

The travesty of the entire process of informed consent inAndhra Pradesh (also pointed out by the Committee in thereport and by the civil society) is in complete and absoluteviolation of both the Drugs and Cosmetics Act and the EthicalGuidelines for biomedical research. Such a process requiresthe 'researcher' to directly provide information mandatory forconsent to the person (s), in this case the parents, which wasnot done. Schedule Y of the Drugs and Cosmetics Act statesthat, "Paediatric Subjects are legally unable to provide writteninformed consent, and are dependent on their parent(s)/ legalguardian to assume responsibility for their participation inclinical studies. Written informed consent should be obtainedfrom the parent/ legal guardian. However, all paediatricparticipants should be informed to the fullest extent possibleabout the study in a language and in terms that they areable to understand. Where appropriate, paediatricparticipants should additionally assent to enroll in the study.Mature minors and adolescents should personally sign anddate a separately designed written assent form." Also,according to the ICMR guidelines, "Before undertaking anytrial, the investigator must ensure that… a parent or legalguardian of each child has given proxy consent; the assentof the child should be obtained to the extent of the child'scapabilities such as in the case of mature minors from theage of seven years up to the age of 18 years."

Although the committee states that there was "no specifictargeting of any particular group' later once again contradictsthemselves when a specific case by remarking on theinappropriate nature of conduction of such a project on younggirls from the tribal belt, particularly where it is 'impracticalto take consent of parents."

While identifying several deficiencies in the planning andimplementation of the project, the report, submitted to theMinistry of Health and Family Welfare, has failed to fixresponsibility on any individual or agency. Rather thansuggesting any punitive or disciplinary measures, the reportidentifies 'minor' deficiencies as lessons for strengtheningclinical research in future.

1Email: <sama.womenshealth@gmail.com>. Sarojini and

Anjali work with Sama Resource Group for Women andHealth, dated March 22, 20112See Sarojini N, Anjali S and Ashalata S (Ed.)

(2010):"Findings from a Visit to Bhadrachalam: HPV Vaccine'demonstration project' site in Andhra Pradesh," March 27-30.

30 mfc bulletin/February - July 2011

Conflict of Interest in Policy MakingAnother Face of Corruption

-Radha Holla1

Most people view corruption as limited to anindividual or group of individuals illegally receivingsome form of gratification, pecuniary or not, in returnfor granting or attempting to grant a favour. However,conflict of interest in decision-making processesgenerates corruption in that the former "bribe giver"now becomes the decision maker.

The Many Faces of Conflict of Interest

Conflict of interest can exist in several forms, bothobvious and not so obvious.

Examples of obvious forms of conflict of interestinclude the following situations:

When persons known for being corrupt framelegislations, rules and regulations forcontrolling/preventing corruption (thepresence of corruption tainted ministers in theGroup of Ministers mandated to draft theLokpal Bill);

When public officials take policy decisionsbased on their personal interest (eg., AshokChavan in the Adarsh Housing Society scam);

When food manufacturing companies sit onscientific panels to evaluate research and toset food standards (eg., Nestle, HindustanLever, Coca Cola, PepsiCo, ITC on scientificpanels of Food Safety and Standards Authorityof India (FSSAI); food manufacturers, pesticidemanufacturers included as members of thenational delegation at international bodiessuch as Codex Alimentarius that set standardsfor foods);

When companies producing geneticallymodified seeds evaluate their own products as"safe" and this evaluation is accepted by publicregulatory bodies without independentvalidation (eg., Validation of Research ofMonsanto/Mahyco for Bt Brinjal by GeneticEngineering Approval Committee in 2009) .

Taking note of the conflict of interest in setting upFSSAI's "independent" scientific panels, on February8, 2011, the Supreme Court of India ordered thegovernment to remove persons linked to food andsoft drink companies from the statutory panels taskedto enforce safety and standards on edible items,including products of these firms. The Judges felt

that company representatives on scientific panelswas a clear breach of the mandate under Section13(1) of the Food Safety and Standards Act, 2006,and asked FSSAI to rectify the mistake and re-constitute the panels with independent scientificexperts as members within two weeks and report backto the court.2

We discuss below the less 'obvious' situations whereconflicts of interests can take several forms.

Front Organisations of Corporations and Conflictof Interest

The Infant Milk substitutes, Feeding Bottles andInfant Foods (Regulation of Production, Supply andDistribution) Act 1992 as amended in 2003,commonly called the IMS Act, prevents baby foodmanufacturers from directly advertising any of theirproducts for children under two to parents and thepublic, as well as prevents them from giving giftsand goodies to health workers or sponsoringconferences, seminars, workshops, lunches, for them.Similarly, in January 2010, the Medical Council ofIndia amended the Indian Medical Council(professional conduct, etiquette and ethics)Regulations, 2002. The modified code of ethicsprohibits medical practitioners from accepting gifts,travel facilities, hospitality and monetary grants fromthe healthcare industry either in their name or inthe names of their family members. The code barsthe doctors and their family members from acceptingrail or air travel facilities, cruise tickets and paidvacations from the industry. They cannot accept anyhospitality either.

Industry has tried to bypass this by creating frontorganisations, often registered as NGOs, or tryingto reach nutrition professionals, which are notcovered by the existing laws in their continuedattempts to influence policies and decisions. Forexample, Nestle has created the Nestle NutritionInstitute; Mead Johnson, the baby foodmanufacturers, have set up Mead Johnson Nutrition;GlaxoSmithKline, makers of Horlicks, as well aspharmaceuticals, has set up the Horlicks NutritionAcademy, which are not covered by the IMS Act.

Examples of conflict of interest involving frontorganisations include:

Nestle Nutrition Institute co-hosting the annual1 Email: <radhahb@yahoo.com>

mfc bulletin/February - July 2011 31conference on nutrition with PGI (Chandigarh)and the Indian Society for Parenteral andEnteral Nutrition in January 2011. Theconference was cancelled because NGOsbrought this to the notice of the governmentand the media.

Nestle Nutrition Institute entering into PublicPrivate Partnerships with agriculturaluniversities to take up programmes for"creating health and nutrition awareness ofvillage women and girls in government schoolsin rural areas", thus expanding their influenceon consumers and strengthening their brands.

PepsiCo was a sponsor of the conference -"Leveraging agriculture for improvingnutrition and health" - organised byInternational Food Policy and ResearchInstitute (IFPRI) in February 2011. PepsiCo isusing fortification and ready-to-use packagedfood as an entry point into the malnutritionmarket. Ironically, the Prime Minister, whoaddressed the conference, chose to remainsilent about the presence of the multinationalcompany's commercial interests in the sector.

BINGOs and Conflict of Interest

Another mechanism leading to conflict of interestis when the private sector creates a lobbying body,usually a Business Interest NGO (BINGO), and thenuses this persona to influence policy making or createmarkets for its products. The Global Alliance forImproved Nutrition (GAIN), Global Alliance forVaccines and Immunisations (GAVI) andInternational Life Sciences Institute (ILSI) areexamples of BINGOs. GAVI and ILSI havepharmaceutical, food manufacturing andagribusiness corporations as their members.

GAIN, for instance, is committed to developingbusiness partnerships in order to increase privatesector investments in nutrition. In 2005, GAINestablished the GAIN Business Alliance to mobilizebusiness to play a greater role in combatingmalnutrition and facilitate business partnershipsbetween governments, NGOs, civil society, academiaand media in order to create opportunities for theprivate sector to enter into the business ofmalnutrition.3

GAVI is a global health partnership that bringstogether developing world and donor governments,private sector philanthropists, vaccinemanufacturers, research and technical institutionsto make new vaccines and create markets for them.Pfizer and GSK were the first beneficiaries of GAVI's

lobbying, followed by Indian Companies such asPanacea Biotech.4 WHO, which influences nationalpolicy related to immunisation, is a member of GAVI.WHO has reworked the classification categories forvaccines to reduce evidence of negative impacts.

ILSI India is a regional branch of International LifeSciences Institute (ILSI), providing scientific inputsand assistance to the South Asian Region. Itsactivities primarily focus on local and regionalcritical public health issues like complementaryfoods and food fortification. ILSI India membersinclude Bikanerwala Foods Pvt. Ltd., Coca-ColaIndia, DSM Nutritional Product India Pvt. Ltd., FritoLays Div., PepsiCo India Holdings (P) Ltd., HaldiramsMarketing Pvt. Ltd., ITC Foods Business, KelloggIndia Pvt. Ltd., Mars Incorporated, MonsantoEnterprises Ltd., Nestlé India Limited, NicholasPiramal India Limited, RSA Vitamins PrivateLimited, and The NutraSweet Company, amongothers. However, there are several members ofgovernment and public institutions on ILSI's board:the Directors of the National Institute of Nutritionand the Central Food Technological Institute andscientists from Indian Agricultural Research Instituteare trustees of ILSI. Senior officials of ICMR, Dept.of Biotechnology, Ministry of Health and FamilyWelfare and other government departments, seniorofficials of universities including agriculturaluniversities are members of the various expertcommittees along with representatives of companiessuch as Coca Cola, PepsiCo, Monsanto, Nestle,Hindustan Lever, etc.5

While it is not possible to prove that the BINGOsuse illegal means or corruption to influence policydecisions, the presence of policy makers on theirboards are clear examples of conflict of interest.

Philanthropy and Conflicts of Interest6

Philanthropic organisations, exemplified by the Billand Melinda Gates Foundation (BMGF), which areriddled with conflict of interest are increasinglygetting involved in the formation andimplementation of national health policies, creatingyet new situations of conflict of interest.

BMGF, together with Berkshire Hathaway Holdings(owned by Warren Buffet and being transferred toBMGF) hold large amounts of stocks/shares in CocaCola, Kraft foods, GSK, Sanofi Aventis, Johnson andJohnson, Proctor & Gamble, McDonald, andMonsanto. Several of the Foundation's members ofthe management committee, leadership teams,affiliates, and major funders are currently or werepreviously members of the boards or executive

32 mfc bulletin/February - July 2011branches of several major food and pharmaceuticalcompanies including Coca-Cola, Merck, Novartis,General Mills, Kraft, and Unilever.

BMGF is an important funder of WHO, GAIN, GAVI,and other bodies that are lobbying for new vaccinesand foods to prevent malnutrition, and promotingcommunities to become business affiliates of CocaCola, develop agricultural technologies togetherwith Monsanto in Africa through the AfricanAgricultural Technology Foundation.

BMGF's recent and earlier visits to India have beenprimarily to get pentavalent vaccine and rotavirusvaccine introduced in the national universalimmunisation programme.

Why should philanthropic organisations be broughtunder national conflict of interest legislation?

Philanthropic organisations such as BMGF havebudgets often larger than national budgets, and usetheir finances to influence national policies thataffect every citizen in the country. However, theseorganisations are not accountable either togovernments or to the people whose lives theyimpact. Their influence often results in policydecisions that transfer public money into the privatecorporations in which they hold shares or stocks.Their influence in policy making thus constitutesconflict of interest.

Movement of Bureaucrats between Governmentand Private Sectors and Conflict of Interest

Movement of persons between bureaucracy andpublic policy-making bodies is a very importantsource of conflict of interest. Such movements areof three kinds:

1. When public servants including bureaucratsand elected representatives of the people, afterleaving public service, work for the companiesthey used to regulate, there is conflict ofinterest, as these bureaucrats can use theirexperience and contacts to get decisions madein the favour of the company. Retiredbureaucrats have recently been joining theprivate sector even before the stipulated twoyears after retirement are over, and providedhuge bonanzas for their private employers. Forexample, Pradeep Baijal, ex-Chairman ofTRAI, joined Nira Radia's companies soon afterretirement. Naresh Dayal, ex-secretary,Ministry of Health, joined GlaxoSmithKlineConsumer Health-care as a non-officialdirector.7

When serving bureaucrats and policy makersare deputed to work for the commercial sector.Such deputation to profit making bodies iscovered under IAS Cadre Rules. Rule 6(2)(ii)in the case of IAS officers, which has recentlybeen changed to allow serving bureaucrats tobe deputed to private sector companies for upto five years.8

Movement of policy makers, includingtechnical persons, to and from the private sectoralso finds place in the new National HealthResearch Policy finalized in April 2011.9

Besides other provisions reflecting conflict ofinterest, point 4 of the "10-point ActionProgramme" of the NHR policy seeks to develop"Mechanisms favouring seamless movement ofpersonnel between teaching, research andindustry." 10

2. Popularly called the "revolving door" policy,this allows the movement of industry-friendlyexperts into positions of decision-making. Anoutstanding example of such policy is thepresence of Arun Maira in the PlanningCommission. Chairman of the BostonConsulting Group, Maira has worked for theTATA Group, and has advised clients acrossa wide variety of industries ranging fromautomobiles, steel, and oil, to pharmaceuticals,and financial services. He has been Chairmanof several of CII's National Councils, includingthe National Council for CorporateGovernance, and Chairman of CII's LeadershipSummit.

Conflicts of Interest Distort National Priorities

The increasing clout of industry and its lobbies likeGAIN, Micronutrient Initiative (MI) and GAVI, inpolicy/decision making allows them to dictatenational priorities. Thus GAIN and MI promotefortification of food products with micronutrientsto reduce micronutrient deficiencies, rather thantalking of or promoting policies that are based onequity - changing agricultural policies to ensureadequate production of diverse foods, making thesediverse foods available to all people by controllingprices, improving the public distribution system andwidening the food basket there, demanding reductionin use of agricultural chemicals because they depletethe soil of micronutrients; these demands will notensure profits for their members. GAVI's pressurehas resulted in the National Vaccine Policyincluding new, costly and unproven vaccines in thepublic system.

mfc bulletin/February - July 2011 33Conflicts of interest in policy making often resultin Public Private Partnerships (PPP) thatoperationalise the transfer of money from the publicto the commercial, profit-making sector.

Public Private Partnerships and the Abrogationof State Responsibility

PPPs allow the state shrug off its responsibility andpass it on to the private sector. When the State doesnot carry out its duty, it can be called to accountthrough tools such as PILs and RTIs. The SupremeCourt Orders in the Right to Food Campaign's PILare examples of how these tools can be used.However, in the case of PPPs, this is not easy. Theanswer to an RTI application to the PunjabAgriculture University on its MoU with Nestle toprovide nutrition education to school children saidthat the MoU could not disclosed as it containedinformation of a commercial nature. This is also theview of the Planning Commission. Reacting to chiefinformation commissioner Satyananda Mishra's letterasking for PPP documents to be made public, theDeputy Chairman of the Planning Commission, ShriMontek Singh Ahluwalia said:11 "Right toinformation is not right to information of privatecompanies. It is right to information on publicauthorities."

The above view blatantly ignores the fact that publicmoney is being transferred to a private corporationfor creating markets and earning profits throughPPPs, which, in the case of the Nestle- PAU PPP,allows Nestle to use the public education systemto strengthen its brand image, and also be paid publicmoney to do this.

Managing Conflict of Interest: Putting PublicInterest Centre Stage

The government 's All India Service Rules andCentral Secretariat Service Rules do not include thewords "loyalty", "integrity", or "responsibility";"public interest" is mentioned only once in thecontext of extending pensions. "Duty" is mentionedonly in the context of "duty posts". There is noreference at all to the fact that the bureaucrat is a"public servant", whose primary duty andaccountability is to the "public".

Mere declaration of conflict of interest is not enoughif the conflict of interest affects decision-makingin governance, especially policies, rules andregulations that impact people's fundamental rightsto a life with dignity. The integrity and independenceof our public institutions is of paramount

importance. Some actions that need to be taken upimmediately by the government include:

Recognise existence of conflict of interest inpolicy making as a form of corruption

Develop mechanisms for managing conflict ofinterest

Legislate to prevent conflict of interest inpolicy making by creating new legislation orincluding it in existing/proposed legislationlike Prevention of corruption Act 1988, LokpalBill, etc.

Create a statutory body to examine cases ofconflict of interest.

Endnotes

2. "Remove food, soft drink co agents fromscientific panels: SC", Times of India, Feb 9, 2011

3. http://www.gainhealth.org/partnerships,accessed on 16th April 2011

4. http://www.gavialliance.org/, accessed 7th July2010

5. http://www.ilsi-india.org/about-ilsi-india/board-of-trustees.htm, http://www.ilsi-india.org/PDF/ILSI-India%20Expert%20Committees.pdf,accessed 16th April 2011

6. This section is primarily based on informationprovided in Stuckler D, Basu S, McKee M(2011): "Global Health Philanthropy andInstitutional Relationships: How ShouldConflicts of Interest Be Addressed?", PLoS Med8(4), accessed on 17th April 2011

7. http://hotnhitnews.com/India_A_Democracy_on_the_Road_to_Kleptocracy_by_Piyush_Pant_020311006.htm, accessed on 8thApril 2011

8. Copyright: India Today. Cited in "Plum jobs inprivate sector for our babus."w w w . t h e f r e e l i b r a r y . c o m /Plum+jobs+in+private+sector+for+our+babus.-a0249594481, accessed on 14th April 2011

9. Aarti Dhar. "National health research policyfinalized", The Hindu, April 4, 2011. http://w w w. t h e h i n d u . c o m / n e w s / n a t i o n a l /article1597255.ece, accessed 4th April 2011

10. "National Health Research Policy", http://icmr.nic.in/guide/draft_nhr_policy.pdf, accessed4th April 2011

11. "Pvt cos outside RTI purview: PlanningCommission", Times of India, March 5, 2011

34 mfc bulletin/February - July 2011

OPEN LETTER TO PRIME MINISTER REGARDING SELECTION OFPERSONS WITH CONFLICT OF INTEREST, AS BOARD MEMBERS OF MCI

Date 26th May 2011

Dr. Manmohan Singh,The Prime Minister of India,New Delhi

Dear Prime Minister,

We, a concerned group of citizens and civil society members, express grave concerns overrecent media reports1 regarding the selection of persons with multiple conflicts of interestas board-members of the Medical Council of India (MCI).

MCI is an apex body that regulates not just medical education in the country, but also actsas a watchdog to ensure that the Indian medical fraternity adheres to the highest level ofethics. However, it has not been playing its expected role. Considering the recent turn ofevents, we believe that MCI would be in a similar situation as it was when Dr. Ketan Desaiwas the president of MCI. Corrupt practices had sullied the image of the MCI2 and affectedthe credibility of the entire Indian medical fraternity. We fear that unless tough measuresare taken, the same situation will recur. People with unblemished backgrounds need to beinvolved in running the MCI otherwise the important role of oversight of medical ethics inIndia will remain unfulfilled.

As you are aware, at the time that Dr. Ketan Desai was arrested, the Central governmentpromulgated the Indian Medical Council (Amendment) Ordinance 2010 suspending the MCIand giving itself the power to re-constitute the Council for one year. The Central Governmentthen appointed a group of esteemed and well respected medical professionals to overseethe reform of medical education and the oversight of the medical community. During theiryear's tenure, one of the foremost tasks of this re-constituted Council related to the revampingof medical education in the country. This work resulted in the key recommendation of thecentralization of Medical Entrance Tests. In May this year the time period under the 2010Ordinance was to expire. However, the Central Government has promulgated anotherOrdinance extending the time of the re-constituted Council by another year. It has comeas a surprise to the health community that along with the one year extention the governmenthas seen fit not to re-appoint a single member of the original re-constituted Council andhas made new appointments.

The manner in which the previous Council has been disbanded and the appointment of thenew members has caused considerable disquiet among the health community. There is adanger that the government's actions will be seen as arbitrary and questions in the mediaabout the potential conflicts of interest of the new Council members are already circulating.

India has a very large private health sector (perhaps the largest in the world) which hascontributed positively in some ways, but has also exacerbated the problems of unethicalpractices like recommending unnecessary medical investigations and over-prescribingmedicines. Today it accounts for 82% of outpatient visits, 58% of inpatient expenditure, and40% of births in institutions3. Private sector interest in medical education has also grown

mfc bulletin/February - July 2011 35

considerably and there is now significant overlap between doctors in the private se\ctor, privatehospitals and the medical education business. This gives us an idea of the extent of the problemwhich needs to be addressed. These practices need to be reigned in urgently so that exploitationof the common people can be stopped. To achieve this we need people of integrity to beat the helm of MCI and definitely not the type of persons that have been reportedly selected.

As the Prime Minister is also aware, the Supreme Court of India had recently given the go-ahead for the Centralised Medical Entrance Test as recommended by the previous Council.In a recent case involving another regulator, the Food Safety and Standards Authority ofIndia, the Supreme Court has also made it evident that appointments to regulatory bodiescannot have conflicts of interest.

The MCI as the regulatory body for medical education and medical ethics cannot affordto be tainted yet again. Towards achieving the goal of transparency and accountability inthe functioning of MCI, we suggest the following:-

1) An immediate review of the manner and reasons behind the disbanding of the originalre-constituted Council and the new appointments made by the Health Ministry;

2) Selection of individuals who have also worked in the field of medical education ratherthan selecting pure clinicians,

3) Avoid appointments and short-listing of persons with conflicts of interest includingpractitioners who are primarily from the private sector, that have ethics complaints pendingagainst them or the hospitals they supervise, have private interest in decisions of theMCI including those related to medical education such as changes in the eligibility criteriaor relaxation of norms for setting up of medical colleges, etc.

4) Create mechanisms for background checks of potential candidates and eliminate peoplewho do not have a clean track record,

5) Ensure that the decision making process, including the selection of board members isdone through a free, non-arbitrary and transparent process.

We urge you to look into this matter on a priority basis as it concerns the future of an importantnational Council. We trust you will take immediate action in this regard.

Yours truly,Members of AIDAN, mfc, et al.

References

1) ‘MCI board smacks of conflict of interest’, Mail Today (E-paper), 17th May 2011, http://epaper.mailtoday.in/Details.aspx?boxid=15354515&id=53362&issuedate=1752011

2) ‘MCI boss Ketan Desai arrested’, The Times of India, 23rd April 2010, http://articles.timesofindia.indiatimes.com/2010-04-23/india/28143618_1_gyan-sagar-medical-college-cbi-on-corruption-charges-mci-boss-ketan-desai,

3) ‘The private sector in India’, BMJ, http://www.bmj.com/content/331/7526/1157.full

36 mfc bulletin/February - July 2011

Editorial Committee: Anant Bhan, Dhruv Mankad, Mira Sadgopal, C. Sathyamala, Sukanya, Sathyashree, ‘Chinu’ Srinivasan.Editorial Office: c/o, LOCOST, 1st Floor, Premananda Sahitya Bhavan, Dandia Bazar, Vadodara 390 001. Email:sahajbrc@gmail.com. Ph: 0265 234 0223/233 3438. Edited & Published by: S.Srinivasan for Medico Friend Circle, 11Archana Apartments, 163 Solapur Road, Hadapsar, Pune 411 028.

Views and opinions expressed in the bulletin are those of the authors and not necessarily of the MFC. Manuscripts maybe sent by email or by post to the Editor at the Editorial Office address.

MEDICO FRIEND CIRCLE BULLETINPRINTED MATTER - PERIODICAL

Registration Number: R.N. 27565/76If Undelivered, Return to Editor, c/o, LOCOST,1st Floor, Premananda Sahitya BhavanDandia Bazar, Vadodara 390 001

Subscription Rates

Rs. U.S$ Rest ofIndv. Inst. Asia world

Annual 200 400 20 15Life 1000 2000 100 200The Medico Friend Circle bulletin is the officialpublication of the MFC. Both the organisation andthe Bulletin are funded solely through membership/subscription fees and individual donations.Cheques/money orders/DDs payable at Pune, to besent in favour of Medico Friend Circle, addressed

ContentsTowards a Regulatory Framework for Private Providers in UHC - Anant Phadke and

Abhay Shukla 1

UAHC with 'Community Participation' Or 'People Centre-stage'? - Ritu Priya 9

Conceptualising UAHC 'Bottom Up': Implications forProvisioning and Financing - Ritu Priya 15

The Regulation of Surrogacy in India: Questions and

Complexities - Preeti and Vrinda 28

The Travesty of Informed Consent:

Case of HPV Vaccination "Demonstration Projects" - Sarojini N and

Anjali Shenoi 29

Conflict of Interest in Policy Making - Radha Holla 30

Open Letter to Prime Minister Regarding Selection of

Persons with Conflict of Interest, as Board Members of MCI 34

to Manisha Gupte, 11 Archana Apartments, 163Solapur Road, Hadapsar, Pune - 411028. (Pleaseadd Rs. 15/- for outstation cheques). email:masum@vsnl.comMFC ConvenerConvening Group: Premdas, Sukanya & RakhalContact Person: Rakhal - +91 9940246089c/o Community Health Cell, No. 31 PrakasamStreet, T. Nagar, Chennai 600 017Email: <rakhal.gaitonde@gmail.com>MFC website:<http://www.mfcindia.org>