medico 379 friend circle bulletinmy life, and who in my opinion, exemplify some of the finest aspects of this profession. This list is not exhaustive, even for me personally, so I

medicofriendcircle bulletin

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July 2018

In Lieu of an Editorial…

2. Dr. P.K.Sarkar. We have a world of academics inIndia, and a world of activists. Dr. Sarkar straddlesboth of them as an academic activist. He served as aProfessor of Pharmacology for 35 years and later asthe Director of School of Tropical Medicine inCalcutta. The Foundation for Health Action, under hisleadership, published two valuable publications,BODHI (one of its kind journal on rational therapy)and Asukh-Visukh (in Bengali for laypersons). At atime when people hang up their boots after retirement,Dr. Sarkar and his wife Krishna (a former NursingSpecialist and Assistant Director of Health Servicesin Bengal) not only put their life’s savings into startingAmader hospital in Phulberia (Bankura) in 2008, butalso run it on their own steam, providing rational andlow cost services, to people drawn from up to 150 kmaway. I had occasion once to visit them in their housein Calcutta and was overwhelmed by their warmth aswell as their commitment to public causes. Dr. Sarkaris now 76 years of age. He has a punishing dailyschedule, foregoing his lunch since there are patientswaiting to be seen, according to Chinu, who recentlyvisited them. Dr.Sarkar, you have been an inspiration,and shall continue to inspire us!

3. (Late) Dr. Rajendra Tandon, Head, Department ofCardiology, AIIMS, and one of the founding fathersof pediatric cardiology in India, after his return to Indiain the 1960s leaving a promising career in Boston,behind. My vision of AIIMS,as an undergraduate atNagpur was that it was a place which has giants like

Dear all,

On the occasion of doctor’s day, (celebrated in Indiaon July 1st, the birth and death anniversary of Dr. BCRoy) I got the usual kind of messages on Whatsapp. Itset me thinking and I decided to send a message ofmy own, a salute to some doctors whom I have met inmy life, and who in my opinion, exemplify some ofthe finest aspects of this profession. This list is notexhaustive, even for me personally, so I may beexcused for exclusions!

1. Dr. Saibal Jana. I can only marvel at Dr. Jana’sunwavering commitment, indefatigable energy andgood humor. I personally know of no other doctor whohas been on call of a community for 35 years (he joinedShaheed hospital in 1983), and who has the range ofskills to serve a community, living in the middle ofnowhere. Which doctor of the present generation cantreat tuberculosis, fix a fracture, do a cholecystectomyor a hysterectomy, and do it without fuss and at thelowest cost for those who need it the most? After avery busy day, you may still see him at 10 pm at night,chatting with a member of the mine worker’s unionwith his hand in his pockets, or chuckling in that waythat is uniquely his. Salute also to Alpanadi who hasbeen an equal partner in their journey. One can sensethe sense of a community in Shaheed hospital, as thatwas how it started, a hospital for workers, built byworkers and with doctors like Dr. Jana to back it up.On behalf of many others, I salute you Saibalda!

2 mfc bulletin/July 2018

Dr.Tandon. He was invited to a CME in Nagpur, where20 patients with very complicated congenital heartdiseases were presented to him, and after he examinedthem, an ECHO was done to confirm that diagnosis.He did not make a single mistake. He was the bestdiagnostician I have seen, and later as a resident atAIIMS I realised his human side, the enormousintegrity, and a remarkable unassuming nature, shornof any arrogance or pomposity. (Unfortunately, thatcannot be said of some of the faculty at AIIMS). Yet,I was in awe of him when I came to AIIMS andremained so throughout my 6 years there, never talkingto him at a personal level. He was immune to the allureof access to the mighty and famous. I remember anoccasion, when a younger faculty member rushed tohis rounds saying that Atal Behari Vajpayee (thenleader of the Opposition) was visiting a patient at bedno 12. He calmly said that we were at bed no 5 andwill reach that bed in due course. He did not spend aminute more on that bed, and his attitude remainedthe same when another faculty member on anotheroccasion, came to inform him that Rajiv Gandhi hadcome for a treadmill. These were valuable lessons forus. Every year I wondered why he had never beenhonored in the Padma lists, when many of his juniorsand even students had made it. Only later we came toknow that he had refused these accolades, not oncebut repeatedly. His wise definition of a good personhas stayed with me “someone who tolerates other goodpersons.”

4. (Late) Dr. Rajwade. He was our physiologyprofessor at Government Medical College(GMC),Nagpur, and one of the gentlest persons I have everseen. He was a double MD, in Physiology andMedicine, and would have made an excellentphysician, but the Government prevented him fromjoining the Medicine department. His lecturers wereentirely original in content and made the subject comealive in a unique way. In the stifling atmosphere ofGMC at the time when caste-based politics was rifein the college and many faculty members generallytried to instill fear in students, Dr. Rajwade was like abreath of fresh air, accessible to all and even taking

personal interest in those students who were having arough time. He would have done so well in research,but the facilities at his disposal were shockinglymeagre. I regret that I could never meet him againafter leaving Nagpur. Rajwade Sir, you are fondlyremembered.

5. (Late) Dr. Manibhai Valand, general practitioner atAnand. Dr.. Valand, a LCPS was one of the first generalpractitioners of Anand, and one of a kind. He was thefirst secretary of the IMA in Anand in 1950. He was arare GP of the old school, a strong proponent ofrational therapy who minced no words (to the extentof bringing irrational prescriptions of consultants anddisplaying them publicly), a writer of pamphlets ofpatient education material and much else (his pamphleton adolescent health was way ahead of the times in itsfrank discussion of issues related to sexual health),and a person with a hunger for knowledge, that neverdied. While we talk of point of care testing now,Manibhai incorporated it into his daily practice. I wasfortunate to see his clinic in Anand. A patient with afebrile illness would be triaged by his assistant and ablood smear taken. By the time the patient’s turn cameto see Manibhai, he would not only examine the patientbut also his smear. Patients with scabies could go onlyafter a bath in his clinic with the first application ofthe scabicidal applied, and explained! As a facultymember at PS Medical College, Karamsad, in the1990s, it was difficult to get an audience of even 15faculty members for the clinical meeting, but Dr.Manibhai and 2 of his old friends would unfailinglybe there, asking pointed questions, which we had tobe prepared for.

In signing off, I would like to point out that both Dr.Saibal Jana and Dr. Sarkar could do with some helpfrom younger doctors.

Regards,Anurag

Anurag Bhargava is Professor of Medicine atYenepoya Medical College, Yenepoya (Deemed to beUniversity), Mangalore, Karnataka.

Email: [email protected]


We Need ‘Health for All Declaration - 2018’

The Alma Ata declaration of Health for All(HFA) was the outcome of balance at that time,of contradictory forces of unregulated capitalistdevelopment and regulated, state capitalistdevelopment with an element of inclusivenessand welfarism. However, as the balance tiltedmore and more in favour of unregulateddevelopment and free market fundamentalism,the Alma Ata perspective was diluted step wise.Today neoliberal theories are on the ascendant. The Alma Ata HFA declaration is not withoutits limitations: it conceptualized health as a goalfor ‘leading a socially and economicallyproductive life’. Now why this rider of ‘sociallyand economically productive life’? Why can’tbeing healthy be considered a value and goal initself? Secondly, and paradoxically, theDeclaration lived in an imaginary world wheredevelopment is inclusive and whose logic is notgeared to private profits, despite the fact that by1978 it was pretty clear that the developmentalpath all over market-based economies wasgeared to profit making. Health and equity gotneglected in the process. Thirdly, the Declarationwas oblivious of the fact that private health careis the predominant form of health care in manycountries including in India and therefore in theAlma Ata declaration there is not even a singlereference to private health care, leave asideaddressing how to deal with this issue. Fourthly,it drew ideas from the experience of barefootdoctors and of community mobilization forhealth in People’s Republic of China (PRC) inthe fifties and sixties but did not mention itssocio-political context. Neither did it take noteof the official support to traditional medicineby PRC and India.

A reformulation of the HFA perspective todaywill have to overcome these deficiencies/

problems. Moreover, it will have to take note ofthe new challenges before HFA. Earlier in the1970s, there was a clamour for inclusivedevelopment. Now we have to add an adjective- ‘healthy’ to the term ‘development’. This isbecause it is now pretty clear that the currentpattern of development itself breeds newepidemics; the more such development, the moreillnesses. HLEG and JSA have criticised theinsurance model of health care and JSA hascriticised the privatization and corporatizationof health care. We need to include these issuesin the HFA-2018. While criticising privatizationof health care, we need also to critique thecurrent bureaucratic, insensitive Public HealthSystem in India which has been vulnerable topriorities set in the West. For instance theemphasis on Family Planning Programme, theslogan of leprosy eradication, the contestedpolio-eradication programme, etc.

We need to go beyond formal, juridicaldistinctions between Public and Private healthproviders and focus on the issue of publiccontrol, transparency, accountability for publicgood. In the MAM background paper, apart fromthe problems of the neoliberal path ofdevelopment, we point also to the politics ofknowledge. We have referred to the point aboutnew contradictions of the processes unleashedby IT technology, and to the unresolved issuesrelated to medical pluralism. We may add newmethods of community based health initiatives,for instance as shown by the experiment by JanSwasthya Sahayog in dealing with certainNCDs. At the end of this exercise, the MAM shouldcome out with a draft of a new, revised “HealthFor All Declaration -2018”, which can beimproved upon in the MFC annual meet forwider circulation.


Revisiting Health For All

Health For All (HFA) means that the opportunity andconditions for good health are within reach ofeveryone. However, it has been variously interpretedand strategised by policy planners and the civil society.While the basic objective of HFA has never beendirectly contested, how to operationally define‘health’, and how to bring it within reach of all havebeen the moot questions. It may, thus, be useful totrace the development of various approaches to HFA,and their critiques, within the official mainstream(international and national) and the social movements/civil society, fully recognising that these two haveinfluenced each other in real time.

Tracing the HistoryInternational

The attempts for HFA began in various countries wellbefore this term actually got coined. Starting with the20th century, considerable progress was made indeveloped countries in nutrition, sanitation, housingetc by overcoming dire poverty among large sectionsof the population. Secondly, starting from socialmedicine in Germany pioneered by the trade unionsand included later in the government programme byBismarck, health care was extended to all sections ofthe society through public funds. Other developedcountries followed suit under popular pressure fueledby the development of social medicine in the SovietUnion. The three-tier structure of healthcare proposedin the Dawson Report in United Kingdom and laterthe setting up of the National Health Services in 1948,the integrated health system developed in SovietRussia, the decentralised and community basedhealthcare delivery through barefoot doctors inChina…these were all attempts to take health carecloser to the masses.

In view of the ‘inadequate and intolerably inequitabledistribution of health resources’ and considering that‘health is a basic human right’, the 30th World HealthAssembly (1977) resolved that ‘the main social targetof governments and WHO in the coming decadesshould be the attainment by all the citizens of the worldby the year 2000 of a level of health that will permitthem to lead a socially and economically productivelife.’ (WHA 1977). And with this, ‘Health for all bythe Year 2000 AD’ became a rallying slogan.

A year later, 134 governments and representatives of67 United Nations organisations, specialised agenciesand non-governmental organisations declared PrimaryHealth Care (PHC) as the key to attaining HFA by

2000. This Alma-Ata Declaration, jointly facilitatedby WHO and UNICEF, defined PHC as ‘essentialhealth care based on practical, scientifically sound andsocially acceptable methods and technology madeuniversally accessible to individuals and families inthe community through their full participation and ata cost that community and country can afford tomaintain at every stage of their development in thespirit of self-reliance and self-determination’ (WHOUNICEF 1978).

Besides including intersectional coordination toaddress determinants other than health care, thePrimary Health Care document recognised the largercontext, such as critical role of livelihoods, wages,and income inequalities, public priority to spendingon development. Thus the Declaration said “Anacceptable level of health for all the people of the worldby the year 2000 can be attained through a fuller andbetter use of the world’s resources, a considerable partof which is now spent on armaments and militaryconflicts. A genuine policy of independence, peace,détente and disarmament could and should releaseadditional resources that could well be devoted topeaceful aims and in particular to the acceleration ofsocial and economic development of which primaryhealth care, as an essential part, should be allotted itsproper share.”

However, in the dominant discourse in the post-AlmaAta developments, even giving due importance towidely accepted social determinants of health wasrelegated to the background and the discussionsfocused mostly on health care. While resourcescontinued to be wasted on building military strength,resources for health were found to be wanting. In 1979,Walsh and Warren proposed ‘Selective’ PHC as aninterim strategy for disease control in developingcountries in view of their limited resources. Theyconsidered each disease as a separate entity andproposed prioritizing between them on the basis oftheir prevalence, morbidity, mortality and feasibilityof control (Walsh and Warren 1979). Subsequently,UNICEF launched GOBI (Growth monitoring, Oralrehydration, Breast feeding and Immunization) toimprove children’s health worldwide, and later, addedFFF (food supplementation, female literacy and familyplanning). Such selective approaches gained morecurrency in the 1980s and 1990s by Health SectorReforms led by the World Bank and formation ofdisease/intervention specific international healthcollaborations like Global Alliance for Vaccines and


Immunizations (GAVI) and Global Fund for AIDS,TB and Malaria (GFATM).

With changing global political and economic scenario,the influence of World Bank and its ideologicalcommitment to markets, gained strength. The WorldDevelopment Report (1993) titled ‘Investing in Health’proposed a three-pronged approach in order to achieveHFA by 2000: a) foster an economic environment thatenables households to improve their own health; b)redirect government spending on health to more cost-effective programs (i.e. shift from specialized tertiarycare services to packages of public health interventionsand essential clinical services at primary level); andc) promote greater diversity and competition in thefinancing and delivery of health services (World Bank,1993). The same sentiments were echoed in the reportof the WHO commissioned group on Macroeconomicsand Health (2001) which proposed a ‘Close-to-Client’system to deliver specific interventions (Sachs, 2001)by state and non-state health service providers, as itwould promote competition, with financingguaranteed by the state.

In 1999, WHO’s own World Health Report (WHR)advocated ‘new universalism’ as an approach whereeveryone would be covered, but for a limited set ofservices that have been prioritized on the basis of theircost-effectiveness and the economic realities of thecountry (WHO 1999). The services would be offeredby provider of all types, but no patient would have topay to the provider at the time of using the service.Interestingly, the WHR published just a year beforeunder a different Director-General mentions that ‘(t)hequest for cost-containment and moreefficiency…frequently take precedence over thehealth-for-all principles and values. Consequently,from the patient’s point of view, often what is referredto as ‘reform’ does not contain any element ofimprovement’ (WHO, 1998).

A decade later, the report of another WHOCommission stated that ‘Health Systems should bebased on the PHC model, combining locally organizedaction on the social determinants of health as well asa strengthened primary level of care, and focusing atleast as much on prevention and promotion as ontreatment.’ (WHO Commission on SocialDeterminants of Health and WHO, 2008). It criticizedthe ‘reforms’ which separate the provider andpurchaser, which privilege cost-effective medicalinterventions at the expense of priority interventionsto address social determinants and which strengthenprivate sector agents.

In the same year, the WHR titled ‘Primary Health Care:Now More Than Ever’ recommended reforms inuniversal coverage, service delivery, public policy andleadership. The report outlined three directions to

move towards universal coverage: a) increasing thenumber of people covered, b) increasing the numberof services covered, and c) increasing the pre-pooledshare in healthcare expenditure (as against out-of-pocket expenses made at point/time of care). Thisaspect of the report got selectively amplified asUniversal Health Coverage (UHC), and has becomethe buzzword in health planning over the last decade.The theme of World Health Day 2018 was ‘UniversalHealth Coverage: everyone, everywhere’ which theDirector General defined as ‘ensuring people can getquality health services where and when they need themwithout suffering financial hardships’. WHO andUNICEF are planning a second InternationalConference on Primary Health Care in October 2018at Astana, Kazakhstan. The draft declaration for thisConference aspires to ‘launch a global movement inpursuit of universal health coverage…’

NationalIn post-independent India, the attempt towards HFAbegan with the establishment of Primary HealthCentres under the Community DevelopmentProgramme in 1950s as per the blueprint given byBhore Committee. This plan was doctor-centric, butwas extensive and gave a comprehensive view ofhealth planning with other sectors. The decade of 60sand 70s saw implementation of vertical programs formalaria and other diseases, and intensification of theefforts towards population control. This marred growthof the general health system, and gave space for growthof individual private practitioners. In an attempt tostrengthen the health services and health programmes,staff of different vertical programs was amalgamatedinto a single cadre of MPWs and, in 1977, theCommunity Health Volunteer Scheme wasimplemented “to give people’s health in people’shands”.

Post Alma-Ata conference, India adopted its firstNational Health Policy (NHP) in 1983 that reviewedthe development of health services sinceIndependence. Criticizing the model as unsuited toIndian context, the policy committed to universalprovision of comprehensive PHC (MoHFW 1983).The decade of 80s saw massive expansion of primaryhealth centres and sub-centres. In parallel, thegovernment also encouraged private sector growth inmedical care through market friendly policies.Beginning 90s, the growth of public sector got haltedunder the pressure of international financialinstitutions. The health budgets plummeted, primarylevel care suffered and private corporate sector enteredin delivery of tertiary, and later also, secondaryservices. The second NHP (2002) formally welcomed‘participation of private sector in all areas of healthactivities – primary, secondary and tertiary’. It alsoencouraged health insurance, both private and social,


and medical tourism (MoHFW 2002). National RuralHealth Mission (NRHM), since 2005, fore groundedcommunitization and introduced flexible financing andimproved management capacity within public sector(MoHFW n.d.). Social insurance was expanded asRSBY by the world Bank through the LabourMinistryr. High Level Expert Group Report onUniversal Health Coverage (2011), going beyond itsterms of reference, stressed on social determinants ofhealth, and defined UHC in a comprehensive fashion(PCI, 2011). But like other national and internationalrecommendations of these times, it saw governmentas the ‘gauranteer and enabler, although notnecessarily the only provider, of health and relatedservices’. The third NHP (2017) puts forth threeobjectives: i) progressively achieve UHC, ii) reinforcetrust in Public Health Care system, and iii) align privatehealth sector with public health goals. The policy isoverenthusiastic to engage private sector in tertiaryand secondary care through strategic purchasing usinginsurance mechanisms, and also in primary care. Likethe NHP 2002, it refers to the role of sectors otherthan health only in the passing. In his 2018 Budgetspeech, the Finance Minister announced ‘AyushmanBharat’ and its two elements: a) Health and WellnessCentre, which would provide ‘comprehensive’ primaryhealth care and b) National Health Protection Scheme,which will provide coverage upto five lakh rupees toten crore poor families for secondary and tertiary carehospitalization (Minister of Finance, 2018).

Social Movements and Civil Society InitiativesThe 1960s and 70s was a time for articulation byvarious social movements of a growing dissatisfactionwith the dominant development model in varioussectors, including health: the anti-war and peacemovement provoked by the experience of world warsand the Vietnam war, the women’s movementattempting to address the concerns experienced bywomen globally, movement’s to express resistance tothe hegemony of the expert, i.e. the doctor, overwomen’s bodies and lay people. The failure of newlyindependent countries to secure benefits of‘modernisation’ to a majority of their peoplecontributed to the Non-Aligned Movement, and ledto the demand for a New International EconomicOrder. It was in this environment that HFA became anexplicit goal and PHC became the key strategy to attainit.

Several experiments in PHC with communityparticipation were gaining roots in the 1970s, the mostwell known in India being the Comprehensive RuralHealth Project in Jamkhed. Forums for demystificationof medical science, ethics in health care, patients rights,HIV positive persons’ rights etc. came up in the 1980s.The experience of ground level work and a critique ofpolicies and programmes fed into each other. The

complexity of issues raised a lot of debate within civilsociety, including MFC, as also in health systemsresearch and planning, reflecting the diversity ofviews.

In November 2000, the People’s Health Assembly heldat Calcutta adopted a charter on ‘Health for All Now’.In December 2000, around 1500 participants fromninety-two countries came together in Bangladesh.Frustrated with the failure of governments andinternational organizations to make the vision of Alma-Ata a reality, and angered by the anti-people policiesof WB, IMF and World Trade Organization (WTO),the assembly came out with a ‘People’s Charter forHealth’ (PHM 2000). The Charter reclaimed health,and not just medical care, as a human right whichshould prevail over all economic and politicalconcerns. It called for, equally for all men and women,right to work, education, freedom of expression,political participation, religious choice, and freedomfrom violence. It condemned unsustainableexploitation of natural resources, spread ofindividualistic and profit maximizing behaviors andover-consumption by a few capitalists from a fewcountries. It urged the ‘People of the World’ to demandradical transformation of international bodies rangingfrom UN Security Council to WTO. It insisted thatpeople must demand from governments, to promote,finance and provide comprehensive PHC, and toregulate the private medical sector. The Charter askedfor de-mystification of medical/health technologiesand integration of traditional healing systems. ThePHM has subsequently acquired salience as therallying point to keep HFA and PHC on the nationaland international agenda.

Several academic institutions, research organizations,field NGOs and public health professionals have beenadvocating, practicing and experimenting with ideasaround HFA. Several allied social movements on food,employment and environment are coherent with thetheme of HFA. However, the interpretation of andapproaches towards the concept form a wide spectrum.

Outlining various approaches and their critiquesThere are several perspectives that can be discerned:one that views health and health care as a social orpublic good and another one that views it as aneconomic activity with profits as a legitimate driverfor the services to reach all; one that aspires to createsocietal conditions conducive to healthy life (‘healthbeyond medicine’) and another one that focuses onmedical services alone, and thus concentrates solelyon health sector; one that keeps equity as its goal andanother one which is more concerned about efficiency;one that is for all and another one which is targeted tothe marginalised; one that aspires to cover everythingand another one that has specific interventions; one


that is solidly effective in long term and another onewhich gives quick results in the present (as ‘we are alldead in the long run!’); one which sees governmentas the provider and another one which sees it just as afinancier, or only as a regulator; one wherecommunities are supported to take decisions andanother one where decisions are taken for thecommunities; one that sees technology and privatesector engagement as a means and another one wheredeployment of technology and PPPs are the ends inthemselves. The historical and political context,existing relationships between the state, market andsociety, and the constraints and complexity of real lifeconditions encountered while operationalising HFAlead to a variety of approaches. Each of theseapproaches has its knobs of perspectives set at specificfrequency, and so each of it plays a different tune.

For the purpose of understanding, one can broadlyclassify the numerous approaches towards HFA since1978 as: Comprehensive PHC, Selective PHC andUHC. It is very important to note that these terms havebeen variously defined, explained, interpreted andunderstood within the mainstream as well as in thesocial movements/civil society space, based on thediverse ideological predilections of those involved.Therefore it is important to examine the way in whichvarious components of health care have been includedand dealt with under each of these terms. The devil isin the detail.

1. Comprehensive PHC (CPHC): ‘Health’, under thisapproach, means a personal state of well being thatenables a person to lead a socially and economicallyproductive life (Mahler 1981). The approach positshealth as an outcome of overall socio-economicdevelopment and advocates close co-ordination of thehealth services sector with other sectors like education,agriculture and industry. It focuses on the dovetailingof improvements in social determinants of health withprovision of health services delivered in an integratedmanner with a Primary Health Care approach and bygiving priority to those most in need. It recognizesthe key role of social determinants of health in shapinghealth and the importance of Primary Health Careapproach in dealing with health care problems giventhe fact that the doctor and hospital centered healthservices are economically unsustainable and cannotreach all. So, in health care delivery it stresses onnurses, para-medics and community health workers,appropriate technology and de-centralization ofservice delivery mechanisms so that they are as closeas possible to where people live and work. It regardsthe community as the primary stakeholder in theprocess of decision making, whether it is planning,implementation or monitoring. It supports contextspecific solutions, foregrounding self reliance and self

determination in choice of technology, and in all otheraspects of health system designing.

This approach has been variously criticized fromcompletely opposite viewpoints, as being tooambitious and resource intensive to being cheaphealthcare for the poorest, for being too ‘socialist’ tobeing a placebo for the social control of the poor, forbeing idealistic to being simplistic and anti-intellectual,and for being too vague and inconclusive, impractical(Venedicktov 1981, Banerji 1984, Wisner 1988, Cueto2004).

2. Selective PHC: This approach builds on the critiqueof CPHC being ‘idealist’ and ‘impractical’, and claimsto make PHC ‘feasible’. Acknowledging the broaderconceptualization of health, it is very concerned aboutthe resource constraints of developing countries andlimited capacities of the health services. As ‘not allills can be attacked now’, the approach prioritizes thehealth issues based on how big the problem isepidemiologically and whether technological andorganisational capacities are available or considered‘possible’ to address it. So, while something likemeasles may get a high priority because there is aneffective vaccine available, an issue like malnutritionmay get a lower priority as it is just too complex. Themechanisms of control, under this strategy, are specifictechnological interventions, evaluated on cost-effectiveness criterion and delivered through verticalprograms.

This approach reduces health from a state of wellbeingto a disease free state. Therefore it has targeted diseaseand mortality specific goals with universal globalsolutions for the low and middle income countries. Ithas been argued that, while it may reduce mortalityand morbidity from the targeted diseases in targetedpopulation groups, it may not actually influence theoverall mortality and morbidity as disease substitutionand wider determinants of health of population groupsremain unaddressed. Thus selective focus on OralRehydration to save children’s lives from diarrhoealdiseases would indeed achieve the objective ofreducing deaths due to diarrheal diseases. However,this single, one sided focus, results in neglect ofchildhood malnourishment which means diarrhealdeaths are replaced by childhood deaths due to thevicious circle of malnourishment and infections. Butas it is easier to implement and monitor by the healthservices, and produces tangible results in the short-term, doesn’t need confronting the existing socio-political situation and involves medical technology, itattracts donors, international agencies, governmentsand industry (Cueto 2004). It gives a sense ofcomplacency, and has therefore been criticized asbeing ‘dangerously counterproductive’ to thepossibility of ever being able to establish a


comprehensive health system (Banerji 1984, Newell1988).

3. UHC: This approach extends Selective PHC in thesense that the prioritization of health issues, populationgroups and interventions on the basis of cost-effectiveness has been supplemented with promotionof market principles in designing the deliverymechanisms, with uncritical acceptance of prevailingand emerging medical technological solutions as auniversal good. So, if engagement of private sectorimproves the coverage of services, government shouldenter into PPPs, or encourage private sector growth.Paying doctors a lump-sum amount (‘capitation’) fora defined population may balance curative andpreventive care better, so this kind of PPP may beuseful. If keeping human resource on contract makesthem more efficient and disciplined, regularemployment should be curtailed. If a particularintervention or service can, arguably, be delivered bythe private sector more efficiently, government shouldwithdraw itself. Those who can pay for health servicesshould pay, and there should be some mechanism tosupport those who can not. To ensure that people donot have to face financial hardships at the time of andafter availing the services, pre-pooling of resources ispromoted, either through taxation or through insuranceor a mix of the two. Thus ‘coverage’ becomes as much,if not more, about medical insurance than about healthcare. And health care becomes hi-tech medical care.

In addition to the criticism of selective PHC mentionedabove, entry of market principles in UHC approachfragments the health system further. This makes itexcessively complex, both for the administrator andthe user. To this gets added the problems that arisebecause of the profit maximization intent inherent tomarkets. This compromises equity and promotesunethical and irrational practices, more so in absenceor ineffective implementation of regulations. The socalled ‘competition’ doesn’t make much sense in thesupply-driven health sector; it only increasesunnecessary care in the private sector and furthermarginalization of the public sector. And when unholynexuses form between the two sectors, from the levelof policy to practice, there is no respite for the commonpeople.

While community participation, self-reliance and self-determination have been emphasised in CPHC andSPHC, their operationalisation has been weak, giventhe top down processes of planning andimplementation, and the politics of knowledgebetween the dominant state-supported experts,dissenting experts and lay people’s knowledge. Whathas largely been neglected by all these approaches isacknowledgement of the ways in which communitieshave been coping with their day to day realities. Across

ages, and across domains, communities have foundways around the problems they face. The knowledgeand practices of communities range from the localhealth traditions (whose rationality is increasinglybeing realized) to those that provide psychosomaticrelief (like faith healing) with those which are franklycriminal (like witch-hunting) forming the other end.These traditions have developed in absence of themodern health care systems, but have informed themodern. Though declining, they continue to bepracticed even today. They have been developed bythe people often at the bottom of the social hierarchiesbut systematised and codified with support of the rulersof the time. Therefore they have layers of practicesand practitioners, catering to those from the mostimpoverished to the elite. They have been practicedover long periods by the people with little interventionof the exploitative market or the authoritativestate,though in recent decades it has also beencommercialised. Historically, they have been victimsto the politics of knowledge arising from caste andgender hierarchies, colonialism and capitalism. In thepresent times, they are losing their popularity as wellas feasibility because of de-legitimisation of theirknowledge by dominant state support to allopathy,degradation and appropriation of basic resources(forests and commons) and commercialization ofmodern as well as traditional knowledge systems. Thepossibility that even such community ownedmechanisms may be of value, in capping the ever-escalating costs of healthcare which have perplexedeven the richest countries, in providing some answersto the clinical, social and cultural iatrogenesis inflictedby the dominant system, has not been incorporated indominant discussion on systems design towards HFA,even though civil society and state examples toapplication are available. This is not to say that suchscope does not also exist in the dominant system, butthat such ‘alternatives’ have so far been largelyignored. When discussed, their role is conceded moreas concession in a debate rather than with anyconviction or clarity of their role and place, and evenless on actual operationalisation at ground level.However, though it does not find much place in healthsystems research and development, there is a parallelprocess on in civil society including academia thatpromotes and facilitates documentation, research andapplication of the other systems at ground level.

Other challenges in the 21st CenturyWhen we revisit ‘Health for All’ we need to take noteof the changes that have taken place since 1978 insocial determinants of health and in health caretechnology including health pedagogy. Whiletraditional social determinants of health continue toplay an important role and new epidemics have beenadded to old killer infections, social determinants of


Non-Communicable Diseases have gainedimportance. Therefore specific strategies are neededto deal with this new reality. Domination ofneoliberalism which has led to unprecedentedinequality and corporatization of all aspects of lifeleading to increased over-consumption, mal-consumption through addictions and consumerismespecially among the well to do on one hand, but atthe same time deprivation among large sections of thepeople globally. Social stress, strife, wars and violenceincluding gender based violence remain unabated. Onthe front of health care technology and delivery wehave seen huge strides with fantastic potential on onehand but in reality leading to more unnecessaryinterventions which breed higher profits for thecorporates and their accomplices but morepathogenesis and paucity of even Primary Health Carefor the vast majority. Unimagined strides incommunication technology has created huge potentialin telemedicine, health education, new vistas forparamedic work and empowerment of people but inreality has hardly benefitted the vast majority. Thesignificance of environmental degradation for humanhealth has not yet been addressed in any of thedominant approaches to health systems. Thesecontradictions need to be studied and strategies needto be devised to achieve the goal of HFA in the 21stCentury.

The discourse on ‘health as a right’ over the last twodecades has acknowledged the heterogeneity ofcommunity and people. Health matters, but whosehealth matters? Departing from a bio-medicalperspective, the social science perspective not onlysupplemented the understanding of health but alsobroadened the horizon to recognise the complex healthneeds of different people. Going beyond ’diseases’ lifesituations affecting the health of people, such as genderbased violence-wherein one in every three woman isaffected, also demands an appropriate response fromthe health system.

Talking about people experiencing exclusion ordiscrimination by the health system is incompletewithout taking cognizance of the overall patriarchaland brahmanical mindset existing within the healthsystem. It therefore, becomes imperative to providespaces to narratives of marginalised groups and theirexperiences with the health system, while advocatingfor quality and dignified healthcare for everyone as asmall but definite part of health for all.

MFC and Health for All

MFC has espoused the cause of HFA as its sharedvision for over forty years of its existence, and itsmembers have been at the forefront of discussions andexperiments in health care in India and abroad. TheMFC Bulletin archives show that the discussion on

HFA started in this forum even before it became aninternational slogan in 1978. From then up to thedetailed discussion on a blueprint for Universal Accessto Health Care in 2009-2012 has been a long andintense engagement. MFC has had shared values onHFA through equitable distribution of health resources,primacy of public health services, low cost and people-controlled primary level care, de-hierarchising thehealth service system, demystification of healthknowledge, creating medical education suited to theIndian needs, scientific examination of the social,economic, environmental and political roots of healthproblems, preventing the influence of the commercialmedical industry, rational use of medicines, etc. It hasdebated on how to define what is commodification ofhealth, which technologies are desirable and whichare unnecessary or irrational, what is communitycenteredness versus community participation,programme and service system designs, the role ofother systems of health knowledge, regulatorystructures and how to deal with the private sector(Debates on Pulse Polio and Hepatitis-B vaccination,Iodised salt; 2011 debates and the papers in MFC Bull.348-350, 345-347).

The 45th Annual Meet of Medico Friend Circle willtherefore require revisiting many of MFC’s owndebates and introspecting on perspectives andapproaches adopted by its members over the years.We need to build on the approach prepared afterextensive discussions in 2010 and 2011, and articulatedin the background paper for the 39th Annual Meet‘Exploring a Roadmap for Health Care for All/UAHC’(mfc 2012). We need to take the discussion beyondthat to explore the logic of what underlyingassumptions need to be made transparent andexplained, what questions are yet unanswered, whatmore needs explication?

Conceptualizing the Annual MeetAs has been discussed, there are various approachesto attaining Health for All, and most ‘alternatives’ forhealth systems being offered today have combinationsof elements from more than one. Each has itsadvantages and challenges, viewed differently by thosewith diverse visions of what a health system shouldideally be. We need to go beyond merely modulatingthe prevailing systems or tailoring the health systemto fit in with prevailing development discourse.Therefore, we think that it will be an enrichingexperience for all if multiple visions get presented anddiscussed at the Annual Meet.

We, therefore, invite background papers on analysisof past visions, drawing lessons for the future. We alsoinvite presentations about the vision for healthsystem(s) that potentially take us towards HFA. Theprinciples and values underlying the visions should


be made explicit, and so should the path envisagedtowards them in the immediate and the long term. Thepresentations should specify the social, political,cultural and economic milieu necessary for this visionto materialize, how do these requirements fare vis-a-vis the present day context, and the strategy to bridgethe gap. Allies in this journey, and the challenges likelyto be faced, should be identified. It should spell outhow the friends would be brought together, and thechallenges confronted. Finally, the presentationsshould lay-out what needs to be done in the immediatefuture to begin the march towards achieving theultimate vision.

The concepts first need to be explained as many ofthe participants coming to the meet would be new,and then critiqued with logic and evidence. Casestudies, based on national or local experiences withefforts towards HFA, may form a substrate to buildthe discussion. Experiences of various global, nationaland local movements for HFA, if shared, wouldhighlight the challenges that lie ahead in followingany particular approach, and how to deal with them.In the end, we may be able to develop some broadconsensus about what all is more appropriate to movetowards HFA in our context, and what is definitelynot. And we should be able to devise some effectiveways to make this consensus widely known andconsidered, nationally and internationally. In any case,we believe that the thinking through of each of ourvisions of HFA and being challenged about them byfriends within MFC, will help all of us.

Proposed Agenda for Mid-annual Meet:

1. Discussion on draft background paper

2. Presentation/outline of potential papers for theAnnual Meet 2019

3. Organising of Annual Meet 2019

4. Participation of MFC at JSA National Meet (Sep2018) and PHM IV (Nov 2018)

5. MFC’s statement for political parties in view ofUnion Elections 2019 (People’s HealthManifesto).

6. Social Composition in MFC: taking forward thediscussion, introspection and analysis

Drafted by the Organizing Committee of MFC 2018Annual: Mohit P. Gandhi, Anant Phadke, Ritu Priya,Kumud Teresa Sawansi, Imrana Qadeer, Arathi PM,Shruti Samant, Dhiraj V. Deshmukh, SantoshMahindrakar, Priyadarsh Ture, Richa Chintan,Archana Diwate, Geetika Vashishth.

ReferencesBanerji, D., 1984. Primary health care: selective or comprehensive?World Health Forum 5, 312–315.Cueto, M., 2004. The origins of primary health care and selectiveprimary health care. American journal of public health 94, 1864–1874.Mahler, H., 1981. The meaning of “health for all by the year 2000.”World Health Forum 2, 5–22.mfc, 2012. Exploring a Roadmap for Health Care for All/UAHC.Medico Friend Circle Bulletin 1–7.Minister of Finance, 2018. Budget Speech 2018-19.MoHFW, 2017. National Health Policy 2017. Ministry of Healthand Family Welfare, Government of India.MoHFW, 2002. National Health Policy 2002. Ministry of Healthand Family Welfare, Government of India, New Delhi.MoHFW, 1983. National Health Policy 1983. Ministry of Healthand Family Welfare, Government of India, New Delhi.MoHFW, n.d. National Rural Health Mission: Framework ofImplementation (2005-2012). Ministry of Health and FamilyWelfare, Government of India, New Delhi.Newell, K.W., 1988. Selective Primary Health Care: The CounterRevolution. Soc. Sci. Med. 26, 903–906.PCI, 2011. High Level Expert Group Report on Universal HealthCoverage for India. Planning Commission of India, New Delhi.PHM, 2000. People’s Charter for Health: Adopted at First People’sHealth Assembly, Savar, Bangladesh, December 2000.Sachs, J. (Ed.), 2001. Macroeconomics and health: investing inhealth for economic development?; report of the Commission onMacroeconomics and Health. World Health Organization, Geneva.Venediktov, D.D., 1981. Lessons from Alma Ata. World HealthForum 2, 332–340.Walsh, J.A., Warren, K.S., 1979. Selective Primary Health Care:An Interim Strategy for Disease Control in Developing Countries.New England Journal of Medicine 301, 967–974.WHA, 1977. Thirtieth World Health Assembly, Geneva, 2-19 May1977. World Health Organization, Geneva.WHO (Ed.), 2008. Primary health care: now more than ever, Theworld health report. World Health Organization, Geneva.WHO (Ed.), 1999. The World Health Report 1999: making adifference. WHO, Geneva.WHO (Ed.), 1998. The World Health Report 1998: life in the 21stcentury. WHO, Geneva.WHO Commission on Social Determinants of Health, WHO (Eds.),2008. Closing the gap in a generation: health equity through actionon the social determinants of health: Commission on SocialDeterminants of Health final report. World Health Organization,Commission on Social Determinants of Health, Geneva,Switzerland.WHO-UNICEF, 1978. Report of the International Conference onPrimary Health Care (Alma-Ata, USSR, 6-12 September 1978).WHO, Geneva.Wisner, B., 1988. GOBI versus PHC? Some Dangers of SelectivePrimary Health Care. Social Science and Medicine 26, 963–969.World Bank (Ed.), 1993. Investing in health, World developmentindicators. Oxford Univ. Press, Oxford.


Book reviewUnhealthy India: Is Privatisation the way forward?

K Sujatha Rao (2017). Do We Care? India’s Health System. Oxford University Press.Purendra Prasad

India is going through a serious health crisis as largenumbers of households are being impoverished everyyear due to health care costs. Over the last few decades,public spending has come down to less than one-thirdof the total health expenditure and as a result,households are forced to pay for two-thirds of theirhealth expenditure from their pockets. Analysing thereasons behind dysfunctional public health system,unregulated private health care, growing healthinsurance markets, the book Do We Care? India’sHealth System by K Sujatha Rao provides insights onhealth care policy in India. She explains the ongoingdynamics involved in policy making from closequarters, as an insider who was an active participantin several decision-making processes in the healthsector for about two decades. The book is presentedin two parts. In the first three chapters of Part One,the author analyses India’s health system, particularlythe challenges and constraints that it has faced fromits evolution, as well as issues related to healthfinancing and governance. This is followed up withthe policy implementation chapters by narrating theremarkable stories of HIV/AIDS, National RuralHealth Mission (NRHM) along with a criticalassessment of these policies including the possibilitiesof moving ahead in the Part two.

The first chapter elaborates on the changing role ofthe Indian state, once characterised as following thetenets of Fabian socialism, and then as the otherextreme of being a liberal state expounding minimumgovernment with maximum governance. The authortraces how this shift entailed further deepening ofprivatization and reduction of public investment in thehealth sector. She cites the reduction of the healthbudget allocation in the Twelfth five-year plan (2012-17), the reduction in public spending, the aggressivepushing of public-private partnerships (PPP), and thedeafening silence about strengthening states’regulatory capacities as evidence for this process.

She then goes on to explain the interface betweenpolitics and economics in the under-financing of thehealth sector. She highlights the interstate and intra-state health differentials and argues that even though70% of maternal, infant and child mortality is

concentrated in the poorer states that have the leastinstitutional capacity to deliver even essential services,the central government does not intervene in thebackward states. Instead, the Indian state is movingtowards health insurance schemes undercutting theexisting budgets towards primary health care andpreventive services. Such a shift, she argues, onlycontributes to the strengthening of the private hospitalsand insurance markets and in no way to the reductionof out-of-pocket (OOP) expenses.

What are the implications of stagnant budgets and poorgovernance on public hospitals? The author explainsthat this situation has inhibited public hospitals fromkeeping pace with the private sector, resulting in therapid growth of the private sector to meet theincreasing demand for services. She talks about howcorruption has crept into the procurement of services,building of contracts, and purchase of equipment,drugs and consumables. Unless corruption iseliminated, no matter what the government does,public systems will remain in crisis. In matters ofcorruption, the private sector is not better, only lesscrude and more sophisticated. It is this environmentfor shady incentives that makes it inadvisable to allowcorporate or profit-based hospitals an entry intoprimary health markets. She concludes, in the chapteron governance, that the worn-down conditions of thepublic facilities utilized by the most vulnerable andthe poorest are a stark reflection of the inequities anddisparities that characterize India’s development storyin general, and the health system in particular.

Despite the structural constraints, the author explainshow the Indian state was able to intervene in reducingHIV incidence significantly through the NationalAIDS Control Programme (NACP III) on the onehand, and conceive the National Rural Health Mission(NRHM) on the other, to revitalize primary health carein rural areas. She illuminates the political commitmentto the health sector which was highest during the UPAI regime, compared to the UPA II and NDA regimes.She also highlights the role of civil societyorganisations such as Jan Swasthya Abhyan (JSA),which questioned the prevailing reasons that hadreduced public health principles to technological fixes


and privatization, and the way JSA contributed to thedesigning of the NRHM. The author points out thatfor a large democratic and epidemiologically diversecountry like India, participation in policy making isconfined to small groups of individuals and a fewresearch institutions.

She provides three insights from her policyexperiences: One, while the public policy persistentlydenies any attempt at privatisation of the health sector,every policy initiative is directed towardsstrengthening the private sector and weakening thepublic sector. Second, India seems to be caughtbetween welfarism and neo-liberalism – large dosesof populism mixed with blatant privatisation. Third,despite the rhetoric of socialism and constitutionalpronouncements, India’s development story continuesto be based on a model of privilege and inequality ofopportunity, safeguarded by an array of institutionalarrangements and value systems. Therefore, she saysthat the biggest challenge India faces today is solvingthis riddle called public-private participation (PPP) inhealth care. These insights are in tune with the mostrecent published works in the healthcare studiesliterature (Hodges Sarah and Mohan Rao 2016; RajanSunder Kaushik, 2017; Prasad Purendra and AmarJesani, 2018; Ravindran Sundari T. K. and RakhalGaitonde, 2018).

The arguments in the book are from a policy analyst’spoint of view, combining a progressive activist streak

with administrative sensibilities. The many anecdotes,multiple narratives, and diverse view points within thepolicy making process make the book interestingreading, even as it maintains the required academicrigour and style. The arguments flow smoothly frompersonal narratives to more serious academic issues.The book is quite useful to students of public health,health economics, sociology, cultural studies, genderstudies, and to general readers.

Purendra Prasad is Professor and Head, Departmentof Sociology at University of Hyderabad. His researchfocus is on health inequalities, agrarian relations,class-caste dynamics, forced migration and urbantransformations.

Email id: [email protected]

References:Hodges Sarah and Mohan Rao (2016) (ed). Public Health and Private

Wealth – Stem Cells, Surrogates and other Strategic Bodies. Oxford

University Press.

Prasad Purendra and Amar Jesani (2018) (ed). Equity and Access:

Health Care Studies in India. Oxford University Press.

Rajan Sunder Kaushik (2017). Pharmocracy: Value, Politics and

Knowledge in Global Biomedicine. Orient Black Swan.

Ravindran Sundari T.K and Rakhal Gaitonde (2018). Health

Inequities in India: A Synthesis of Recent Evidence. Springer

Publications.


Book ReviewTechno-science dominance and the effacing of poverty discourse from Public HealthSarah Hodges and Mohan Rao (eds) (2016). Public Health and Private Wealth: Stem Cells, Surrogates, and

Other Strategic Bodies. New Delhi: Oxford University Press. pp xv + 283Surekha Garimella

Celebratory headlines that cast India as a soon to beglobal power player averaging 7.5 percent growth rateabound in the mass media today. What remainsobscured in this discourse is the rise in inequality andintensification of poverty that has gone hand in hand.Public Health and Private Wealth: Stem Cells,Surrogates, and Other Strategic Bodies, co-edited bySarah Hodges and Mohan Rao is concerned with‘poverty’ at its core and engages with its use as aconcept, current wisdom on poverty amongresearchers, policy makers and practitioners in thePublic Health field and beyond, and also asks, why ispoverty not at the heart of public health discourse?The title of the book is to a certain degree misleadingbecause it is not stem cells, surrogates and otherstrategic bodies that are the focus of the book, buthow Private wealth and Public Health have beenintertwined in Public Health knowledge. Morespecifically, its focus is, how current discourses onpoverty (understandings and solutions) are saturatedwith and techno-scientific approaches.

Today, the ‘private’ looms very large even in the publichealth sector and is being posited as the only way toensure that everyone’s health care needs are met. Theprivate health sector is one of the fastest growing areasof the Indian economy and resides alongside a declinein investments in the public health sector in real termswith increasing commercialisation and privatisationof this sector. This book is a timely and importantexamination which explores the relationship betweenscience and poverty and public health in India and isdivided chronologically into three parts with threechapters each. The range of issues covered include aninterrogation of the contribution of science to thepursuit of poverty reduction during late colonial andearly independence period; the fall out of increasingcommercialisation of public and private hospital careand the advance of a trend that increasingly seesbiotechnology as a solution to a range of health issues.Refreshingly, the chapters in the book useethnographic and narrative approaches which is ararity in the public health world.

Part one (The quest for ‘Improvement) includes threechapters. Through an insightful analysis of official

policies during the late colonial and early independentIndia, David Arnold describes how nutrition studiescontributed to an emergent understanding of the linksbetween poverty and health in early 20th century.However, in this understanding, the cultural and socialexplanations were given precedence at the expense ofthe role of poverty. Although, there was anacknowledgement by health officials that large massesof people were living in poverty the solutions soughtto deal with malaria, cholera, influenza, nutrition andsanitation remained medical and techno-centric innature. In early independent India, large scaleengineering projects were seen as the way to tacklepoverty suggesting that the public health route toaddress poverty was not feasible for the state.Focusing on tuberculosis (TB) and efforts to addressit, Lakshmi Kutty explores the TB control programmeby foregrounding cost effectiveness and a risk basedindividualised approach and how that has led tomarginalisation of efforts to address the linkagesbetween poverty and the disease. Rebecca Williamsin her case study on the “Khanna Study” ablyinterrogates the language of equity used in the studyand how it facilitated the classification of poor bodiesas risky bodies that needed to and could be managedby biomedical knowledge and management while atthe same time effacing poverty from the discourse.The chapters in this section highlight the processesthrough which the focus on ‘poverty’ was effaced andmedical and biological understandings of health anddisease/illness came to predominate instead of seekingto eliminate poverty. This was done throughprivileging of techno-scientific rationales to addressdisease, use of terms such as ‘health equity’ in anapolitical manner and focusing only on social andcultural understandings of nutrition and disease whilenaturalising poverty as a cultural feature of the country.The authors could have enriched their discussionsfurther by attending to the role that issues of class,caste and race may have played in the actions ofadministrators involved in policy making andimplementation and in researchers’ selective use oflanguage to efface and underplay the role of poverty.


Part two (India’s Hospitals: For Whom?) includesthree chapters. Ramila Bisht and Altaf Virani throughtheir case study of a public hospital in Mumbaidescribe how public-private partnerships (PPPs) areseen as a solution to meet poor people’s health careneeds by state policy makers. They also make the casethat these decisions were greatly influenced byinternational organizations and the broader neo-liberaleconomic narratives and that the introduction of PPPhas not achieved its objective of catering to the needsof the poor, instead, it has led to them being moremarginalised in the system. Rama Baru examines theprocess of commercialisation of medical care in Indiaover six decades. She highlights three trajectorieswhich have facilitated commercialisation and include(1) very close linkages between the private healthsector and the health policy space (2) changingcharacter of the not-for-profit health care sector and(3) health reforms that have led to commercialisationof public health services. She suggests that the role ofmedical professional and middle class values need tobe interrogated more closely emphasising the pointthat health systems are social systems and will reflectthe changes happening in the society. These twochapters add to the body of evidence from differentparts of the world that commercialisation andprivatisation of health services does not necessarilylead to better care for poor people. Sarah Hodges’chapter on myth making and the Apollo hospitalsenterprise is a nuanced account of the role imagemanagement has played in consolidation of theenterprise as a success story and how it informs andsustains a narrative of cutting edge technologies andquality care as being synonymous.

Part three (National Techno-science and PromisingBodies) consists of three chapters and focuses on therole of techno-science in India. These chaptershighlight our obsession with technology as a panaceato address issues of poverty and how biotechnologyis seen as the current fix that will address these issues.Mohan Rao describes how Malthusian notions ofpopulation control have persisted over decades in Indiaand have laid a foundation for the surrogacy industryto grow. He also explicates how with the opening upof the economy poor women’s bodies are now seen ascommercially profitable bodies that can be mined toproduce babies and ensure profits for the industry.Priya Ranjan details the rise of biotech companies inIndia and locates in in the context of public investmentin biotechnology research and argues that neo-liberal

reforms have propelled a policy narrative in whichpoverty and the poor materialise as the cause for therise of this sector as well as being beneficiaries of thesenew technologies. He also states that “the sameeconomic, political and ideological processes whichare responsible for the growing inequality and povertyalso underlie the promotion of the biotech industry”(p220). In a similar vein, Rohini Kandhari examinesthe role of the state in facilitating the growth of thestem cell research industry inviting venture capitalinvestments in the sector. She also describes how thestate is absolving itself of any ethical responsibility inan area that encourages speculative treatment and isfraught with lack of regulatory oversight andprotection for users.

The afterword by Dhruv Raina makes the case formainstreaming indigenous knowledge as an alternativemodel for sustainable development in India. He reflectson the revival of indigenous knowledge and sciencein India as a counter to Eurocentric knowledge anddescribes the rise of indigenous groups fighting fortheir rights in development projects and transnationalnetworks drawing attention to the existence ofindigenous knowledge that is localised, located innature and possible contribution to sustainabledevelopment. While the afterword is compelling andinteresting, it is not clear to the reader how this linksto the remaining parts of the book. It would have beenmore useful if the afterword had addressed theconcerns and questions that the other chapters raise inrelation to poverty, public health and private wealthand discussed how we can move forward from here.

Overall, this book is a welcome addition to studies onpoverty, science and public health. It raises importantquestions and seeks to shed light on the invisiblelinkages between poverty and science and publichealth. The book also provides an alternative way oflooking at poverty and health that is not economistic.Most of the chapters in the book make the case thatscience and techno-centric models alone cannotimprove either poverty or poor people’s health. Maybe,the next logical step is to ask ourselves how can weand how do we want to address the problems ofpoverty and health as researchers and policy makers.

Surekha Garimella is adjunct faculty at the Instituteof Public Health, Bengaluru.



Book ReviewPolitics and practices of health in India

Vikas Bajpai and Anoop Saraya (2018). Health beyond medicine: Some reflections on the sociologyand politics of health in India. Delhi: Aakar Books.

Arima MishraSocial science literature has long demonstrated thathealth is socially produced. There is ample evidenceto show that social determinants matter inunderstanding and addressing health inequities. Yetthe history of health governance in India and elsewhere(including the global discourses) is marked by deepcontestations over a narrow vs broad conceptualizationof health as well as the role of technological vsstructural interventions (improving education,livelihoods, nutrition, sanitation etc.) in promotinghealth. While none of these debates are new, thepersistence of health inequities in India oftenexacerbated in an era of globalization necessitatesrevisiting how health is conceptualized and addressedin development discourse. The book on Health beyondmedicine: Some reflections on the sociology andpolitics in India is located in this intellectual junctureto remind us yet again that health is indeed beyondmedicine and it is important to unravel the politics offraming of health as and through medicine. It isinteresting to learn that such a forceful reminder comesfrom two trained medical practitioners who have daredto venture out to deeply engage with issues of class,poverty, power and politics in health. The objectiveof the book as the authors state is to “remove theanalytical blinkers put on our minds by the ruling elitesuch that we can see clearly the links between thesocial, economic and political structure of our society,the shape of our health services system and the healthof the people” (p.2) and they are hopeful that the bookshall ‘succeed in taking the conceptualization of healthamongst its readers firmly beyond health care aloneand integrate it with the larger societal conditions”(p.4).The book runs through nine chapters many of which(five chapters) had earlier been published in differentjournal forums. The first few chapters take the readersthrough a trajectory of the development of the healthservices in India beginning with the Bhore CommitteeReport to the recent National Health Policy 2017. Theyexamine the Bhore committee recommendations ingreater detail in the first chapter. Their contention isthat while the committee had promising recommendations including foregrounding the role of the state,adopting an epidemiological and health system’sapproach to health planning and promoting integratedhealth services taking into account the socialdeterminants of health, the actual operationalizationof health service development in post-independentIndia privileged select other recommendationsincluding adopting a western model of health care

(biomedicine as the main form of service provisionignoring the contributions of indigenous systems ofmedicine), disease and population control programs.The major blow to the committee report came fromthe fact that organizations of health services rested ona welfarist than a rights model of health care. Theorganizations of health services is not independent ofthe overall developmental approach in India. In thecontext of a neo-liberal economy, what one witnessesis an ever-expanding role of the private sector cateringto the health needs of the population with a dwindlingpublic health sector. For the major part, organizationsof health services in India have tended to have atechno-centric approach focusing on curative servicesin urban centres with more and more private tertiaryhealth facilities. The authors contend that what onewitnesses today with large private health facilities, highout of pocket expenditure, commercialization of healthservices, widening gap between poor and rich in healthstatus and outcomes has not been inadvertent rather“the contradictions between developed and developingand the class contradictions within Indian society hasbeen the key heuristic device for interpreting thehistory of health services in Independent Indiaincluding the present state of affairs and the proposedstrategy of future development” (p.3).Chapter 6 reminds the readers the many ills that publicsector hospitals face today including deficientinfrastructure, manpower, high patient load anddubious quality of services. Many such ills areattributed to a market-led model of growth, rural-urban, curative-preventive dichotomy in healthservices, elitist medical education and lack of politicalwill. The chapter ends with suggestions on how toaddress these problems. These suggestions underlinethe need to go beyond a bureaucratic or technocraticmeasure but that “demands popular mobilization ofthe widest possible sections of the society, especiallythe working people, to support policy initiativesdirected at demolishing the elite capture of health careand the medical profession in India“(p. 182). This isfollowed by a very short chapter on discussingevidence on health disparities by caste, class andgender. This perhaps provides a precursor to thediscussion in subsequent chapter on religion as an axisof social inequality in explaining the overall lack ofdevelopment and poor health status in Mewat Districtin Haryana. These last two chapters are based onprimary field work undertaken by one of the authorsin the state of Haryana. Apart from demonstrating howsocial determinants matter in explaining health status,


Book ReviewConcepts, Theories and Evidence: Examining the Landscape of Health Inequities

Research in IndiaSundari Ravindran, T.K. and Gaitonde, Rakhal (2018). Health Inequities in India: A Synthesis of Recent

Evidence. Singapore: Springer. Pp 239 pages. ISBN 10.1007/978-981-10-5089-3Nandita Bhan

Health Inequities in India: A Synthesis of RecentEvidence is a recently released edited compendiumof essays that strives to unpack the multiple socialdimensions and determinants of health in India. Anovel effort by a collective of Indian academics tocontextualize global theoretical knowledge withevidence and insights from India, this volume is usefulto students as well as practitioners in public healthand development interested in understanding thelandscape of health inequities research in India. Thecurrent climate of activism against growing economicinequalities and towards universal health coverage asan instrument of power to undo the impact of thoseinequalities sets the context for this book. India’s largenational public health programs and initiatives (forinstance, the National Rural Health Mission or thecurrent Ayushman Bharat) have also originated dueto widely prevalent inequities in health access andhealth outcomes across multiple social stratifiers suchas caste, gender, income and ethnicity. Essays in thisvolume raise questions on the roots andintersectionality of multiple forms of inequities andtheir impact on disease development, health accessand wellbeing through careful and rigorousinvestigation. In doing so, it makes the argument thatthe goals of health for all cannot be achieved withoutaddressing ‘fundamental causes’ of disease and health.

A Political ProjectIn this volume curated by editors Ravindran andGaitonde, multiple authors collate and analyzeempirical knowledge from research studies in Indiato examine the mechanisms, conceptual moorings andcore issues surrounding the complex interplay of thesocial determinants of health in India. Authorscollectively conclude in the final chapter that theagenda of addressing health inequity in India is a

‘political project’. This conclusion is arrived at throughcareful analyses of evidence, that is intersectional,context driven and historical in nature and givesrecognition to entrenched social hierarchies related topower and privilege that impact health. As thislandscape is mapped by the authors, they exposechallenges of working across multiple disciplines, howquestions are framed and hypothesize explanations forcertain resilient forms of inequities. To me, the bookposed three fundamental questions - where are we onthe research on health inequities in India, how did weget here and where do we go from here?In Chapter 1: Structural Drivers of Inequities in Health,Ravindran, Gaitonde and Srinivas set the context forthe volume, anchoring the discussion on healthinequities within neoliberal politics. The chapteroutlines a range of ideas, referring to the work ofDahlgren, Whitehead, Wilkinson, Stiglitz, Picketty andeven Raghuram Rajan (!). Gaitonde in Chapter 2:Conceptual Approaches to Examining HealthInequities, provides a cogent summary of the historicaland conceptual roots to researching inequalitiesglobally. Theories outlined in this chapter are essentialreading for any student of public health, not just forthose interested in health inequalities. However, inmost of this description, Indian scholarship from thefields of public health and medical sociology/anthropology is silent, which in itself is a statement tomake. In the next chapter, Gaitonde explains thecontours of the book, describing the methodology forthe literature reviewed and the emergent themes thatled to thematic chapterization in the volume, forinstance including separate chapters on socioeconomicposition, caste/ethnic/Dalit/Adivasi inequities, genderinequities, socially-constructed vulnerabilities andhealth system inequities. The review confirms thathealth inequity research studies are predominantlyquantitative and descriptive in nature, with sizeablecontributions from non-Indian authorship/ institutions.

the last chapter also examines how a narrowtechnocratic focus on pay for performance inaddressing maternal mortality and improving healthstatus could be a misnomer.The book lacks a coherent structure and often thediscussion of facts and arguments get highly repetitive.Though each chapter has a conclusion, readers arelikely to miss an overall concluding chapter as a wayforward more so as each chapter reads like anindependent contribution. The book clearly does not

offer anything new. Its strength perhaps lies in itsforceful reminder that health is beyond medicine andaddressing health needs a social than a technocraticorientation. Such a conceptualization is the need ofthe hour as India is racing towards assuring universalhealth care.Arima Mishra teaches sociology at Azim PremjiUniversity Bangalore.Email: [email protected]


A Conceptually Clear Chapter and a Trickiest OnePrasanth’s chapter on Health Inequities in India bySocioeconomic Position is conceptually the clearestchapter in the volume and provides a critical overviewof the research and meaning of socioeconomic positionin the Indian context. His succinct critique highlightsthe overemphasis on the ‘economic’ in socioeconomic,and he argues that we need to bring forth conceptualclarity on what ‘social’ and ‘status’ mean throughdeeper examination of constructs like discrimination.Chapter 5: Inequalities in Health in India and Dalitand Adivasi populations by Sudharshini Subramanianis well-written providing evidence as well asexplanations for caste-based health inequalities.Subramanian uses a historical lens to explain thesesocial categorizations and three explanations for caste-based health inequities are hypothesized: namelyhistorical social exclusion, neo-material factors suchas education or employment differences andinstitutional discrimination.

Perhaps the most ambitious and also the trickiestchapter is the one on Gender Based Inequities in Healthin India (Chapter 6), authored by PriyadarshiniChidambaram; this chapter in my view merits its ownbook! The author tries to cover considerable groundto describe whether research on health inequities inIndia has gone beyond sex-based differences tounderstand the nature of gender-based discriminationsfaced by women. A sincere effort, and one that tries toprovide the reader a range of relevant sociologicalconcepts (e.g. norms, gender roles, autonomy); whatis missing is adequate background and references tothose concepts and definitions, which would help thereader engage with this topic further.

Chapter 7 by G.A. Chitra defines Socially ConstructedVulnerabilities as ‘‘systemic denial of equal rights toa group through social sanctions, policies andprograms’ (p.158) and focuses on two groups - peopleLiving with HIV/AIDS and migrants. This chapter isinteresting as it picks two specific types ofvulnerabilities and examines their intersections; thequalitative content makes the discussion meaningfuland rich. The final thematic chapter in the volume onthe Role of the Health System (Chapter 7) by Gaitondeprovides a critical analysis of structures and relationsin the health system and equity impacts from the lensof neoliberal economics. This chapter raises the scopefor reflective discussion on a range of issues such asaccountability, access and coverage, systematicstarvation of the public health system, fragmentationof the market, political commitment and non-financialbarriers. While the chapter structure is sometimeschaotic, Gaitonde’s critique is sharp, engaging anddeeply analytical.

This collection of essays on health inequity researchin India comes at a time when private sector models

for delivering health services are found to beinequitable and remain out of reach of a large sectionof the Indian population, while the public healthsystem is unable to address health needs of populationsand is underfunded. Systematic investigations intohealth inequities such as this volume are a reminderabout the resilient nature of social inequities that leadto unequal health access and disease development forIndian populations. The challenge for authors of thisbook was to strike the right balance betweendescription and critique and between evidence andmeaning; this varies across chapters.

Two Particular Epistemological InsightsTwo particular epistemological insights reverberatedthrough the book. First, a majority, if not all conceptsand theories used to study health inequalitiesoriginated outside of India; concepts and theories oninequalities from Indian social sciences do not seemto have trickled down to the teaching and practice ofpublic health locally. Public health is largely an applieddiscipline, expected to draw from diverse social andmedical sciences; research on health inequities in Indiashows that public health has not capitalized on therich knowledge base of social science scholarship fromIndian theorists. Authors attribute this to predominanceof the biomedical perspective in public health practiceand a resistance to engaging in social science inquiryin medical research. This continues to be a barrier intransforming public health into a truly interdisciplinaryas a science.

Second, research on health inequities oftendemonstrates an inertia in defining, elaborating,linking and contextualizing definitions, theories andframeworks, which has impeded conceptual clarity.Authors in this volume are able to overcome thissometimes and clarify concepts and distinctions, forexample, differences between inequality and inequity,or horizontal versus vertical inequity, and definitionsof terms such as exclusion, marginalization anddiscrimination. While one may intellectually disagreewith their definition or typology, the effort by theauthors to offer explanations demonstrates meaningfuland mindful engagement with constructs and issues.

To conclude, this new volume represents a welcomestep that contributes to the field on health inequitiesresearch, pushing researchers and practitioners to askthe right questions, conceptually grounding researchquestions to add meaning to findings and provides arich tapestry of the past and present research on healthinequities in India.

Nandita Bhan is a research scientist at Center onGender Equity and Health, University of CaliforniaSan Diego, and is based in Delhi.



Book ReviewA timely and exhaustive overview of the multiple dimensions of food security in India

Vikas Bajpai and Anoop Saraya (2018). Food security in India: Myth and reality. Delhi: Aakar books.Sylvia Karpagam

This book, covering several aspects of food securityin India, is relevant to researchers, activists and policymakers working in the fields of public health, nutrition,agriculture, economics, poverty, even human rights.The authors quote national and international statisticsfrom the International Food Policy Research Institute(IFPRI) 2016, National Sample Survey Organisation(NSSO), National Family Health Survey (NFHS) etc.to forcefully show that hunger is an urgent and pressingproblem in the country, with some groups beingextremely vulnerable. These groups, which fall out ofmost social safety nets and lack purchasing power toaccess food include the adivasi and dalit communitiesas well as vulnerable groups such as the elderly, peoplewith disabilities, widows, orphaned children, personsafflicted with serious illness and people displaced bynatural calamities, war, internal strife etc.

The official poverty figures, as well as the caste andeconomic census, show that, as a social group, tribals,followed by dalits, are the most food insecure groupsand have not significantly benefited from poverty and/or hunger alleviation schemes or programs. They havethe largest number of below poverty line (BPL)households and are the most vulnerable to foodinsecurity shocks, hunger, poor health, discrimination,exclusion, political powerlessness, physical insecurityand disarticulation. Women in these communities sharea double disadvantage and are even more vulnerableto hunger, Chronic Energy Deficiency (CED) andanemia. The strongest argument in the book is thatthe national discourse over the last 25 years,increasingly dominated by multinational promoted‘neoliberal economic and development policyparadigms’ and stop gap schemes, ignores underlyingstructural factors and have not, in reality, extended tolocate hunger within a larger social, economic andpolitical system. This, is in spite of aggressivecampaigns and public interest litigations by the Rightto Food campaign, leading to almost 40 interim ordersin the Supreme Court to expand the food andnutritional entitlements of the people.

The book argues that chronic food insecurity orendemic hunger has to be understood, not only due tolack of purchasing power which itself is an outcomeof poverty, lack of employment and low wages butshould also take into account impoverishment offarmers who are adversely affected by forcibledeprivation of livelihood, acquisition of theirproductive assets, degradation and diversion of theirresource base, volatility of output markets, dumpingof cheap imports, withdrawal of state support and

corporate friendly policies. Hunger has a seasonaldimension, with risk of starvation and migration underexploitative conditions for small/marginal farmers andagricultural labourers.

As defined by the World Health Organisation, healthis located as a multidimensional and complexphenomenon, of which health services are only a part.Fairly consistent correlations are made of the StateHunger index with infant mortality rates, maternalmortality rate, crude death rate, under five mortalityrate and anemia. The authors also draw evidence fromMcKeown thesis to show that declining mortality dueto major disease in England and Wales occurred muchbefore any major medical interventions, and moreclosely related to improved nutrition. They feel thatIndian health administrators have deliberately ignoredthe crucial relationship between food and disease,choosing instead the easy path of purely technologicalinterventions to address disease, rather than locate howboth mortality and morbidity can be influencedsignificantly by appropriate and adequate food intake.

While stating that micronutrient deficiency isinvariably associated with poverty, food insecurity andundernutrition, they also assert that seldom does asingle nutrient deficiency express itself in isolationfrom others nutrients. However, since this would entail‘engagement with larger societal questions’ and‘mitigating social exclusion based on class, caste andgender’, the authors feel that ‘such solutions do notsuit the interests of the ruling elite and the dominantsections of the society who maintain their dominationprecisely because of the present arrangement ofthings’. Policies pursued by Indian ruling class aredescribed as dismaying and aggravating the deepeningagrarian crisis, as evidenced by suicides of more thana quarter of a million farmers between 1995 and 2011.

While language like ‘hunger’ and ‘food’ are seen toallow those most disaffected to participate indiscussions to alleviate and address food insecurity, adeliberate attempt, highly criticised by the authors,seem to have been made to move everyday experiencesinto the realm of the inaccessible ‘scientific’ with itscomplex and dense language. “Making issues highlytechnical, replacing the commonly understoodvocabulary and idioms in which common people canexpress their suffering and experiences with esotericterm and jargon is a time tested method of regulatinga potentially threatening discourses into safe channels’.The authors do not see these trends as ‘inadvertentacts of omission or commission but with an underlying


base in politics and design’. If the genuine demandsof people had been met, the authors predict that therewould be a dearth of food and the illusion of plentyonly comes because of the crippling lack of purchasingpower of large sections of people.

The book offers a scathing criticism of the GreenRevolution (and its proponents such as the agriculturalscientist, MS Swaminathan), for its contribution toecological degradation, episodes of drought, cropfailure, short sightedness, failure to understandrelationships of small farmers with land and issues ofsustainability. Besides worsening land relations, it hasalso led to perpetual dependence of farmers for seeds,fertilisers, insecticides on technological support byWestern ‘experts’. Indian agricultural universitiescame to be dictated by these same experts to cultivatenew hybrid varies rather than developing indigenousvarieties of seeds better suited to the local agro climaticconditions.

The authors have also challenged the Right to Foodcampaign for soft pedalling around the vital issues ofland rights and livelihood and instead chasing behindthe more respectable ‘strengthening’ of the publicdistribution system. With the poor in India reelingunder unprecedented rise in food prices and the acutefood crisis, the government, instead of responding ina comprehensive manner, has resorted to providingsubsidised food grains. The authors express strongconcerns that the mostly dysfunctional social securityschemes, supported by activists, economists and eventhe “Parliamentary left’, actually pave the way for neo-liberalism and serve the purpose of diluting people’sstruggles for land rights. They argue for the centralityof land reforms to address the current agrarian crisis.

The book, refreshingly, does not take the side of onegovernment or the other but honestly reviews policies.Each chapter provides strong technical arguments, butthe conclusions on each chapter provide a goodsummary for those who don’t want to go into detail.

Although the authors have devoted entire chapters totearing apart the interventions of governments and civilsociety, they offer very little in terms of the wayforward, apart from exhortations towards a militantupsurging by people. Is it not known from pastexperiences in India that militant uprising bycommunities have been met with vicious and violentrepression by the army and other state arms? Wouldthe authors see these as worthwhile ‘collateraldamage’? Should India wait for such a time andchannel all energies and resources for that landmarkuprising which will overturn all the ‘weak’ policiestill date? Will the elderly, destitute, widows and orphanchildren also participate in militant uprisings? Whatshould people eat in the meantime? Are communitiesexpected to mobilise on hungry stomachs for landrights? Will those who have migrated and settled to

even distressing lives in the cities go back to till land?How will land be of value to the elderly, people withdisabilities, orphaned children and those who arebearing the brunt of internal strife and uprisings? Theauthors have breezed past these day to day issues andtalk about a utopian world that one may constantlyaspire to, but may never reach. While land and landrights have long term benefits, especially for oppressedcommunities, it may not be the only panacea to thepressing issue of hunger.

Although the authors are highly critical of internationalagencies and the national elite, they seem contentedto quote from data produced by these very samebodies. Data from multinationals about India’s hungermay come with its own vested interest of openingdoors to predominantly market driven ‘solutions’.Neither the Tendulkar report nor the widely criticisedpoverty lines nor IFPRI offer a real database of howpeople experience and articulate hunger. Much of thedata available now are funder and agenda driven. Ifthe country were to accept the data on hunger and‘micronutrient deficiency’ pushed forward by thetransnational corporates, the solutions will alsonecessarily be corporate led and driven. Goingforward, the authors have not put forward tangiblesolutions on how hunger should be measured andarticulated. How should tribal and dalit communitiesexpress the nature of hunger experienced by them?Further how can this be measured? How to ensurethat these experiences influence mainstreamdiscourse? This discussion has to be had with a varietyof stakeholders and not purely as an academicrecommendation.

Producing cereals, as was the focus of the economistsand the Green Revolution, means that for many peoplecalorie needs are met almost entirely by cerealscomprised of rice and wheat. While this may be thecheapest source, it is definitely not the best, but thiswas hardly the concern of the predominantly brahminvegetarian economists who constantly strived toprovide the cheapest calories to people, especially thepoor. What the country should aspire to is that peopleget nutrients from multiple foods and each foodprovide a variety of nutrients. The calculation ofpoverty line, dominated by economists, should havebeen best left to nutritionists.The PIL in the Supreme court, with its interim orders,did serve the purpose of bringing the courts and civilsociety together for immediate respite to people atdifferent points in time. Criticising the PDS alsoimplies criticism of the role of social security schemesin a society. Anecdotal evidence from communitiesthat have received even rice through the PDS showthat the burden on women to keep starvation at bayand negotiate hunger in the family on a day to daybasis, is reduced. Women and men who migrate saythat a functioning PDS gives them respite to look for


Book ReviewIt works: Tamil Nadu’s Medicines Procurement Agency

R. Poornalingam (2017). Change: Change Management Strategies to Transform your Organization. Madras:Productivity & Quality Publishing Private Ltd. Paper Back. ISBN-13: 9788185984872

S.Srinivasan

‘A True Story”The third line in the inside title pages says it is basedon a true story - contrary to a certain genre of Kolly/Bollywood films which, as the credits roll by, denyany connection to real life incidents and aver anycoincidence is accidental. But we have it from the youtube clips1 of the book release function in 2017 thatthe book is about the Tamil Nadu Medical ServicesCorporation (TNMSC) of the Government of TamilNadu. So the book is a ‘true story’ – a barely disguisedfictional narrative of sorts of factual events where thefictional quality is sought to be enhanced by givingdifferent names to all key characters with no datesgiven throughout the ‘true story’. A ‘timeless’ storytrue still for many parts of India.

TNMSC started as an organisation with the apparentlysimple goal of sourcing quality medicines in genericnames, and ensuring their availability, at all publichealth facilities in Tamil Nadu. That was circa 1994-95. The author was the State Health Secretary at thattime and also the first Chairman of the TNMSC. BeforeTNMSC came into existence, you could supplymedicines to the Government of Tamil Nadu only bylining up the pockets of gatekeepers and rent collectors– as a result there were monumental shortages, drugs

were of poor quality when and if available, and werepriced way above what it should have been. To quotea popular quip, you would need to take two tabletsinstead of one to have some effect.

This book is a gripping (‘rivetting’ according to theauthor’s mentor) account of the process of howTNMSC came to be, and continues to be, anorganisation that procures and distributes qualitymedicines in a transparent, efficient way and at lowprices. TNMSC has since been heralded, rightly, as asuccess story – defying all cynics including the State’sown IAS officers and ministers of that time. Mostbureaucrats would have shied off saying it will lookbad for their biodata to handle an unknown devil. Butkudos to the author - he took on the challenge and thisbook tells the tale of his efforts and his team.

TNMSC’s Continued SuccessTNMSC has sustained its zeitgeist till date andsuccessfully. Medicine and surgical shortages arehistory in Tamil Nadu government health facilities. Ithas been so now for over 20 years. All who use thepublic health system in Tamil Nadu get free medicines.Other state governments, at least 11 of them, have triedemulating the TNMSC; but for the Rajasthan MedicalServices Corporation (RMSC, from 2011), and a

some way of improving the economic status of thefamily. The authors are also quiet about the role ofother social security schemes like the mid-day mealscheme, the ICDS, maternity benefits etc. Would werather our malnourished children eat Ready to EatTherapeutic pastes manufactured by multinationalsand pushed by our own Minister of Women and ChildDevelopment or a meal cooked at the anganwadi oras part of the mid-day meal program by local women’scollectives? State after state has banned the slaughterof cows and is withdrawing eggs from schools. Aboutthe growing saffronisation, criminalisation of beefeating and imposed vegetarianism – the authors arelargely quiet.India is already facing the threat of cash transfers,complete shutdown of the PDS and food productionbeing handed over to the markets entirely. There arealready concerted efforts by a colluding complex ofmultinationals, large financial corporations and thegovernment to make social security schemes less andless accessible and more and more undignified andhumiliating. In the quest for long term solutions let us

not lose what we have till now. The understanding offamines is complex and all solutions may not comeout of a book. The solutions to hunger cannot beunilateral, top down or academic. One cannot pushfor a long term sustained solution while throwing asidethe short term measures. Hunger is an acute problemthat needs urgent solutions. So while the authors arewell within their right to critique the short termsolutions and demand long terms sustainable solutions,it need not necessarily be about pitting one againstthe other. With hunger at bay, the community mayfind the energy to come together for a revolution. Forthat day, we will all live in hope.AcknowledgementWith acknowledgements to Dr. Veena Shatrugna,Retired deputy director, National Institute of Nutrition,for inputs and suggestions.Dr. Sylvia Karpagam is a public health doctor andresearcher. She is a part of the Right to Food and Rightto Health campaigns in Karnataka.



couple of others, these others have not got their acttogether beyond forming a corporation, reinforcingthe stereotype that nothing good happens in thegovernment.

The author’s character, called Ram in this true story,first appears in Chapter 1, and is described as (or ratherhe describes himself as) a “middle level officerbelonging to the IAS, well-known for his output-oriented management style … a hard-working officerwith a reputation for honesty and integrity, he believedthat a public servant’s primary duty was to addresspublic concerns.”

The narrative format in third person eschews theembarrassment of what could seem as a post-dinnerwar story – but war story it is not. This is a true story.At the end of each chapter the author summariseslessons learnt that would sound like pedagogichomilies in any other setting but it becomes clear bythe time you are half way through the book, that herethe author and his team have lived through theirlessons, the hard way, and have become organicexperts, as contrasted to academic ones, withtremendous insights into the process of change, intowhat moves and what gives. The author prefers to lookat the change effected in the TN public health system(of 100,000 government employees) as a series of wellthought out change strategies that clicked at the righttime – and the whole process is seen as a ‘reform’than the revolution that it was and is. Any series ofsustainable measures taken by elected governmentsin the interests of the poorest – that is doing publicservice in a public system and efficiently achievingthereby set targets without scams – and one thatcontinues to work after two decades, must be indeedtermed as a transformatory act than a reform. Besides‘reform’ has mixed connotations nowadays.

No Political InterferenceThe key factors in this transformation of a scam riddengovernment drug procurement system, used to sleazeand grease all the way from top to bottom, to atransparent, lean, system driven, quality conscioussupply chain organisation, were many. But apart fromthe honest, goal oriented IAS officer at the top, theauthor was singularly lucky in having a HealthMinister (S. Muthusamy) as his boss, who had hisinitial doubts about the whole exercise but after beingopen to persuasion by the author, the Ministerpromised full support and no interference, and kepthis word – that in retrospect was/is a wonder as thereader would appreciate, especially when the CM inpower was a strong willed lady, since deceased,revered by her followers and vilified by her opponents.The Minister himself had a relative who was amedicine supplier but the Minister refused to yield toany temptations to nudge the author into doling out

any favours. Instead he told the author to makeTNMSC as a model for all states in efficiency andintegrity, which it has become. He also supported thesenior management team in countering the endlesscriticism and cynicism by vested interests amongdoctors, pharmacists, nurses and politicians andjournalists and patients.

The author during his 3-year term as Chairman saw agovernment change and a new party come to power,the DMK. The new health minister also had his doubts,having being persuaded by critics and lobbyists andkeen to see the TNMSC fail – vested interests whotumbled out of the wood works with the change ingovernment. The new Minister, saw as a goodpolitician, and let us concede he had public good atheart, supported the TNMSC effort wholeheartedlyand again promised no interference - and stuck to it.Credit should also go to both the AIADMK and DMK,who have alternately ruled Tamil Nadu, for not pullingdown the previous government’s achievements, notat least the TNMSC.

Functional AutonomyA fundamental requirement apart from efficient,sincere, people-oriented IAS officers at the top isfunctional autonomy for those who are implementing.Among the many other important factors for thesuccess of TNMSC was the author’s team, theManaging Director Joseph (Jacob in real life, alsoIAS), a relentless goal driven achiever, mover andshaker, rolled into one; the Senior doctor representativewho could garner support from the disbelieving,unenthusiastic, medical professors/senior specialiststo PHC doctors as to how on earth can government-supply medicines be really good, and genericmedicines at that, purchased at unheard of low prices;the Pharmacist who developed quality systems allacross; the supply chain head who became a crucialinnovator, and a few others – all handpicked by theauthor and who grew up to be experts in theircomplicated jobs with any international organisationwilling to ‘grab’ them for their invaluable experience.Orders for those handpicked by the author to join histeam were passed within days by the Government. Tothis, two other things stand out: firstly, the author’sown insight on the primacy of building systems thatwould stand even when ‘indispensable’, competentpeople get transferred or leave; and secondly, for thosetimes, the mid-1990s, with only a primitive dial upinternet, and computers that were not as user friendlyas now, developing a computerised supply chainsoftware with the appropriate software company(Frontline in the narrative and M. Arumugam ofBroadline Technologies in real life), who would workwith the TNMSC team hands on, eventually totallyidentifying themselves with the cause.


In its first year of operation around 1995, the TNMSCprocured medicines worth Rs 80 crores. In 2016-17,the figure was around Rs 600 crores with 314 essentialdrugs and 591 specialty drugs (all dosage forms).TNMSC now also operates “CT Scan centers, MRICenters, Lithotripsy centers in the medical institutionsof the State on user charge collection basis”2. A plainCT scan costs Rs 5003.

The author, or Ram, himself seems to have been, apolite, focussed, no nonsense doer, who sensed thatcommunication at all times with critics, nay sayersand shirkers, was an important part of his job in achange process – even as he himself had as healthsecretary the demanding challenge of overseeing TamilNadu’s public health, the medical colleges, theadmissions, the legal challenges, along with thewrangling and the court cases by genuinely unhappyand disgruntled suppliers who found they could nottweak the system to their favour, as in the past. .

Other Reasons for SuccessAmong the most difficult challenges in the author’stelling was the doctors, senior and junior, who did notlike being told to prescribe only unbranded genericmedicines from a list of 264 essential drugs. To satisfythe demands of tertiary care doctors, the simpletechnique of allocating 10 % of the total drug budgetto district/teaching hospital for decentralised purchase,solved the issue. As the procurement system becamemore efficient, this 10% would prove superfluous.

The author in all becoming modesty gives credit tohis mentor, Sundar in the book, who in real life is MrAnup Mukerji, retired Chief Secretary, Governmentof Bihar.

The concluding Chapter 15, titled “Reasons for thesuccess of the Reform”, is a back and forthconversation with the author’s mentor Sundar, withthe latter trying to prise out the many reasons for thesuccess of TNMSC - not the least of which was theauthor’s, rather Ram’s, leadership quality: “fearless,goal-oriented, reform-focussed and passionateleadership, willing to take responsibility and sharecredit with its team.”

Apparently these qualities are scarce in the ecologyof most other states. More scarce are politicians withthe sense not to interfere when they see a good thinggoing.

The book, the reviewer read the paper back, is printedand edited excellently, justifying the name of thepublisher, and the reviewer has no cause to say thatthe book could do with better editing. Nor is heinclined to pick holes with the author’s effort, for thesake of ‘balance’. The author could write his next bookon how Tamil Nadu, with usual divisive politics asany, has a better public health system than most.

‘Chinu’ (S Srinivasan) is an activist in pharmaceuticalpolicy and is affiliated with LOCOST StandardTherapeutics, Baroda.

Email: [email protected]: https://www.youtube.com/watch? v=x EQvFoq Zs4g& list = PLFRY pSofe ZTe5KTLX CUfXi5MsdxjH4twX, accessed 29/6/182Source: http://www.tnmsc.com/tnmsc/new/html/services.php#, accessed 29/6/183Source: http://www.tnmsc.com/tnmsc/new/html/services.php#cts, accessed 29/6/18.


The stories of Dalit poets’ deathsGogu Shyamala

[The mfc egroup has recently carried a self-criticaldiscussion about caste. While the main question beingaddressed was regarding the caste composition of mfc,discussion also extended along lines of how mfc shouldbe sensitive to caste: i.e., through questions ofmarginalization (Dalits are largely rural/not-permittedto speak), exploitation (Dalits are mostly poorworkers), linguistic discrimination (most Dalits arenot able to communicate in English). There washowever, a continuing tendency to conflate issues ofcaste with issues of class.

This essay by Gogu Shyamala, explores thecomplexities of physical health, mental wellbeing,social/marital stress and (sometimes inexplicable)disease that resulted in the death of ten dalit poets inthe last twenty years. The question Shyamala dealswith is how the structure caste functions to undercuteven elite dalit individuals — poets (who, by definition,can write, speak, will be heard and revered), thoseembraced in left avant garde groups (thus not at allmarginalized), belonging to middle class professions(thus not poor by any stretch of imagination).

The essay helps us understand how to isolate theprecise caste dimension of discrimination withoutnecessarily putting the blame on a specific oppressorcaste. The point made by the essay for the mfcreadership is that while the dimensions ofmarginalization, poverty and linguistic exclusion areimportant, the caste question is not reducible to them

This essay was first presented at the DevelopmentBeyond the State seminar at Anveshi in January 2018].

The tragedy is that, in the past twenty years ten Dalitpoets died in the Andhra/Telangana region. In thisessay, I would like to look at them as not victims, notas success stories. I would like to explore how theylived, died, and the confrontations and battles theyfought.

We are all aware of the reasons for these Dalit poets’death.

All are below 40 to 45 years of age. All are firstgeneration educated, they are not dropouts, but haveentered in to main stream institutions with theirprofessions: teaching faculty in Universities, MandalRevenue Officer, social activist, singers and poets,teachers. They were two sided: one side pursuing theirrespective professions, and other side influencing

society with their writings, and activities in the media,literature, and culture.

1. John Wesley: PhD in Mass media from OsmaniaUniversity Hyderabad, taught in OsmaniaUniversity and at Andhra University inVishakhapatnam. He worked with APCLC, andwrote book on Globalization in Telugu.(Kanipinchani Shatruvu or, the Invisible Enemy).He married a Kamma woman. He became analcoholic and committed suicide in the year 1999.

2. Maddela Shanthaiah: Teaching faculty in PottiSriramulu Telugu University in Hyderabad. Hewas a poet. He died of Jaundice in the year 2003.

3. Madduri Nagesh Babu: he worked in the MRO’soffice. He is a major Dalit writer and has authoredmany books. The poems mostly written towardsthe end of his life were published in Veliwada,Loya, Meerevutlu, Naraloka Parthana Putta,Rachabanda, Nishani. As a Dalit poet he touchedmany issues of Dalit life and gave novel expressionto many themes in Dalit literature. He wrote manypoems on atrocities committed against dalits, casteoppression, institutionalized violence, critique ofcultural practices of caste Hindus, he valorised thedemocratic life of dalits and so on. He was analcoholic and died in 2004.

4. Nagappagari Sundara Raju: He worked asteaching faculty at Telugu University. He editedAnthology called Madiga Chaithanyam. And hewrote stories and poetry he was published.Madigodu, Maa Ooori Misamma, ChadaludiChatimpu, He committed suicide in the year 2000.

5. Gyara Yadhay: He belong to Nalgonda district,worked as Teacher. He wrote poetry and publishedbooks like Arkoshi, Goutam Dhebba etc. Hecommitted suicide in the year 2000.

6. Varre Rani: She worked as a Teacher, wrotepoems, published in Nalla Poddu. She married aBrahmin man. She committed suicide in 2000.

7. Kalekuri Prasad: He is from Kanchikacharla,Krishna district. Also called Yuvaka, he workedas Journalist and activist in Virasam(Revolutionary Writers Association). He wrotemany poems and songs. He married a kammawoman. He worked for the Dalit Human RightsWatch magazine. He also wrote songs for cinema.


He participated in the Durban conference in SouthAfrica in 2002. He died an alcoholic in the year of2014.

8. Chandra Sri: She was from Prakasam District,one of the great singers, a writer dancer andcomposer known across Andhra Pradesh. Sheworked with left party politics. She has releasedAmbedkar Suprabhatam, also she was founder ofthe Dalit Women Theatre Group. Worked withprogressive, Dalit cultural institutions. Shesuffered with cancer in her last days, and died inthe year 2013.

9. Paidi Tereshe Babu: He worked in All IndiaRadio as an anchor. He was a great writer andsinger. He wrote wonderful poetry, publishedseveral books. He was infected with Jaundice. Hedied in the year 2014.

10. Koppula Nagaraju: Born in Sarapaka village inKhammam district, Nagaraju lost his father whenhe was very young. We may notice signs andhoardings signed by Nagaraju in and aroundBhadrachalam town and Sarapaka village.Nagaraju died of cancer on the morning of 12thApril 2015.

These writers who died lived under conditions thatmay be seen and listed as follows: inter-caste marriage(two), alcoholism (three), health problems (four:cancer, jaundice – some interlinked with alcoholism).Four committed suicide.

If these were some visible conditions, I have observedsome more issues around them and I would like todiscuss them here.

How do I see the contribution of these writers?

If I leave out Kalekuri, all the others are first generationliterates. Though these individuals were born in thevelivada (Dalit settlement on the boundary of thevillage), they have been the vanguard of communitysocial and economic development. Thus, they rose tojoin the middle class, and were living as neighboursto non-Dalit society (colonies, universities, offices,etc,).

Even if there are many other Dalits living in such astatus, I think we need to examine these exceptionallives more closely. This is because these ten writersasserted their Dalit identity in the locations where theylived: as poets, artists, academics and journalists. Thus,they seemed to be representatives of the strength andhopes of the community. They were seen as the voicesthat were born in the movements after the

Karamchedu, Tsunduru, Vempenta massacres. Thesewere Dalit identities rather than welfarist Harijan,Lohiaite, or Marxist. This is why they inverteddominant values, asserting the goodness of the Dalitidentity.

Most of them poets, they battled the mainstreamideology, symbols and usages through their poetry,songs and writings in general. They wrote against thenational hegemonic canon. For example, in the placeof the veena the canonical instrument of mainstreammusic, they praised the kinnera whose strings are madeof cattle veins. In the same way they praised the dappuwhich is made of the skin of dead cattle. It is importantto understand that this struggle brought to light theroots, history and beauty of labour which formed theDalit aesthetic. This had two effects. One, it gave acommunity that was enslaved and excluded a newdignity to stand as members of civil society. Two, itenlightened the dominant castes and made them thinkabout the routine and habitual insults they used onDalits every day.

All this happened in the decade 1990-2000. Duringthis period many changes occurred in Indian societyand more specifically in Andhra Pradesh. A majorexample of this is the SC/ST (Prohibition of Atrocities)Act. There were many changes in the Dalit community:consciousness of untouchability, and of forms ofoppression developed. The modern Dalit strugglelearned step by step how to stand up against theseoffences, give evidence in courts, say no where theyonce accepted their fault. The proceedings of theTsunduru and Karamchedu court cases give usexamples of this.

After 2000, the condition of Dalit life, struggle andliterature have changed yet again. Everything ourintellectuals had opposed and criticized in theirliterature was hitting back. Opposing conditionsbecame more reactionary. The stream of Dalit anti-caste criticism needed to continue in the mainstream.In addition, reactionary tendencies among Dalitcommunities were to be fought. Media support wentdown. The poets had to find their own publications,money.

Examples of the contributions of these poets are:

1. Madduri Nagesh Babu began writing with therealization that battles both outside and inside thecommunity needed to be fought. His Putta exploreshow the elite of the Dalit educated get pulled intomainstream culture and abandon their communities.It talks about the loss and damage to the communityas a result of this imitation.


2. Chandra Sri composed a song out of BhoiBheemanna’s poem Ambedkar Suprabhatam cut a CDand distributed it to Dalit communities in the villagesbefore she died.

3. Kalekuri Prasad translated more than 70 progressivebooks from English to Telugu.

However, these intellectuals who had succeeded ingiving strength to marginal voices through theirliterature are no longer with us. We need to understandwhy this is so.

What were the struggles these poets had to face intheir lives?

Every step these poets took were ideological battles.Thinking about these steps took all their energy andtime. They were fully focused on responding criticallyto what happened in mainstream society. This led tostrain, lack of interest in proper food (sometimes evensafe drinking water). In need of energy, moods andtempo, some took to cigarettes and alcohol. Theirbodies and spirit began to fail.

In this context, their communities and families wereunable to support them for two reasons. Thecommunity food culture of the ghetto could notprovide these poets with food support. They could not

provide emotional support because they could notunderstand the struggles of these poets.

In the progressive society where they fought theirbattles there was no sympathy. No friendships – thosewho were friends abandoned them because they tookthe poet’s criticisms of upper castes as individualattacks. They didn’t have friendships with other dalitpoets and intellectuals because of the mainstreamideology of individualism.

They were completely alone. Their inter-castemarriages did not support them. Their health gave way.Some suicides occurred.

We do not yet have a perspective to understand thelink between their political battles and their personalhealth and deaths. We only knew how to talk abouttheir arrogance, alcoholism, suicide or disease. We donot have a language to understand our complicatedanti-caste battles.

Gogu Shyamala is a senior research fellow in AnveshiResearch Centre for Women’s Studies. She works inthe area of literature and dalit politics.



State of Health In India 2018: A partial snapshot

[Note from editors: This is a new initiative with thebulletin. The idea of it arose in the context of the MFCegroup discussions on recent wide-rangingdevelopments in health. There seemed to be a lack ofknowledge of these developments except with thosedirectly involved with the activism and policy inspecific areas. We have commissioned the reportsegments with the assumption that the longer historyof these issues (e.g., population policy) are somewhatfamiliar or will be sought in several other sources.Our objective was also to avoid putting a burden of along essay with full background and references on theotherwise busy contributors (alas, in spite of which,many contributors did provide copious notes andreferences!). Thus, what follows is a collection of shortcritical news reports on developments in different fieldsas available. You, dear reader, don’t need to read allof them in sequence — dip through sections as andwhen you have the time. We hope this compilation isuseful, and would welcome feedback from you. We willcontinue this trend perhaps once a year (in the mid-annual issue) of the bulletin.]Reining in the Private Health Sector

Ravi DuggalThe 71st Round (2014) of NSSO reveals that theprivate health sector has gained further momentumwith utilisation for hospitalization jumping to 65%from 59% in 60th Round (2004) perhaps boosted bythe government sponsored health insurance schemeslike RSBY and its state variants. Interestingly incontrast the private sectors share in the 71st Roundfor outpatient care has seen a small decline to 74%from 79% over the 60th Round, perhaps reflectingsome strengthening of primary healthcare underNRHM. The consequence is that the out of pocketburden has also grown substantially and according tothe 2015 draft NHP this pushes over 63 million personseach year below the poverty line. OOPs in the 71stRound was as high as Rs 25850 for eachhospitalization and Rs. 575 for each Outpatient ailmentand this added up to Rs.3200 billion for the year (2014)in sharp contrast to only Rs. 1250 billion thatgovernments spent in the same year and Rs 220 billionthat went through the insurance route. While at onelevel this is due to the failure of the public healthsystem to meet the healthcare needs of people,especially the poor and the middle classes, at anotherlevel the private health sector has grown by leaps andbound over the last two decades.The drivers of this growth of the private health sector,apart from the failure of the public health system are:· Private medical education which hasdistorted healthcare markets by its further

commodification. Private medical schools charge hugecapitation amounts and have very high fees and thisleads ultimately to graduates from such medicalschools wanting a quick return on their investmentwhich in the absence of ethics in medical practice leadsto high levels of irrationality in medical practice,including malpractices such as unnecessarydiagnostics, referrals, procedures, prescriptions,implants etc. in order to maximize profits● Health insurance’s rapid expansion at over 25%

per year which helps the corporate sector hospitalsto increase its occupancy and rein in profits. Notonly has private individual and group insuranceincreased at a rate over 30% in last 5 years butalso government schemes that use insurance as aroute that ultimately benefits the private sectoroccupancy and utilization.

● The dominating private pharmaceutical companies,which have historically grown on the crutches ofstate subsidies through low priced bulk drugs frompublic sector companies to protection by state fromproduct patenting, dictate the medical markets withprice control largely out of their way. The Indianpharma sector accounts for 10% of global drugproduction by volume at $30 billion of which $17billion are exports. Its one of the most profitablesectors in India but it is also responsible forencouraging huge malpractices by enticing themedical fraternity through gifts and paybacks invarious forms which only helps consolidate theunethical practices within the profession.

● The rapidly expanding diagnostics business thatis developing as an independent segment of thehealth industry using modern technology to rakein huge profits. The diagnostics industry isprojected to be worth $10 billion with 70% shareof pathology labs and 30% share of imagingcentres and it is growing at over 15%. This industryis increasingly operating independent of medicalproviders by contacting consumers directlythrough aggressive marketing. This direct accessto users, similar to OTC drug purchases, is inflatingmedical markets and is one of the strong driversfor increased OOPs burdens on households.

● PPPs which transfer public funds to privatehealthcare providers who piggy back on suchschemes to make huge profits is a mechanism ofstate subsidies to the private health sector. This isnot something new. There have been various formsof subsidies being delivered to private healthsector. For instance, since Independence or evenearlier hospitals run as Trusts and Research Centresget huge tax write-offs, earlier many of them were


genuine charities that provided free care to the poorbut now most of them operate within the marketframework and do not honour the law under whichthey are registered that mandates 20% free orconcessional care for the poor. A quick estimatefrom Maharashtra shows that there are nearly 5000such free beds that should be available to the poorand if the value of this is costed at about Rs. 2million per bed per year then we are talking of asubsidy of Rs. 10 billion to the private sector justin one state. This lack of accountability drains thepublic exchequer substantially and fattens theprivate health sector. There are many other suchsubsidies like free land, tax free imports of medicalequipment etc. and these too mandate free care insome form but there is no accountability of that.Most PPPs suffer the same fate. They milk outresources from the state exchequer and enhanceprofiteering without any significant benefitsaccruing to the beneficiaries identified under suchPPP schemes. Without strong regulation andaccountability PPPs are bound to fail.

● Unregulated private provisioning of healthcarewhich lets unqualified and untrained persons toset up private healthcare facilities is a huge riskand is responsible for not only malpractices andnegligence but also for the huge drug resistanceand other adversities we see within medicalpractice. It is estimated that over half the healthsector providers are unqualified and even of thosequalified there is an overwhelming number thatpractices wrong medicine – for instance over 80%of qualified non-allopaths practice allopathy. Allthis has bloated the private health sectorsubstantially and is responsible for all the ills thatprivate healthcare suffers from in India.

The above drivers of the private health sector haslanded us into a scenario wherein the private healthsector is too big to dismantle, suffers from ills thatrequire very strong medicine, pushes crores of peopleinto poverty each year, and has been the cause ofdestruction of the public health system.So what can be done to rein in the private health sector?The private health sector needs huge reformation bothstructural and functional. Like in most of the developedworld, except USA, the private health sector needs tobe put on a path of socialization wherein it issubservient to the needs of the public health system.A few suggestions below:● Regulation and accreditation are the first steps thatare required to rein in the private health sector. Thepace of implementation of the CEA is too slow. Infactthe major states like Maharashtra, Karnataka, Andhra,Telangana and Tamil Nadu which have predominantprivate health sector have failed to adopt thislegislation yet. Unless this law is implemented acrossthe board and strictly adhered to the ills of the privatehealth sector will continue to grow.

● Linked to the above medical student and doctorsneed a strong course in medical ethics to inculcate aculture of humanism and professionalism. They mustimbibe a culture that healthcare is a humane serviceand not a dhanda or business from which one can makeobscene profits.● Prices in medical markets need strong regulationand control. We need to go back to the old price controlregime of the seventies. Not only drug prices but alsoall other health related consumables, devices,procedures, interventions, consultant charges, hospitalcharges etc.. need to be strictly regulated. If we canregulate, petrol prices, taxi fares, air fares etc, there isno reason why prices for health care services andcommodities which often relate to life death situationscannot be controlled. The present policy of respondingto public outcry and reducing prices of specific itemslike anti-cancer drugs, stents or knee implants is notthe right approach. What we need is a comprehensivepolicy of determining costs and working out theappropriate price bands for all health services andcommodities across the board.● Remove all subsidies from the state to the privatehealth sector. Give them an option to work in aregulated partnership with the public health sector oroperate within markets without any state subsidies.Where there is a public health system deficit thereprivate health providers could be reined in with aregulated contract like for instance NHS in UK orCanada.● After graduation and post-graduation anoverwhelming proportion of doctors and nurses jointhe private health sector or migrate abroad. This tooneeds regulation. The government spends Rs 30 lakhsto train an MBBS doctor and over Rs. 50 lakhs totrain a specialist. This contribution from the publicexchequer needs a return on investment. This can bedone through compulsory public service for 2 to 3years ( or what is called supervised practice in somecountries) after their graduate and PG degrees. Allgraduates must serve PHCs for atleast 2 years and PGsfor 2 years in CHCs and public hospitals before theycan get their license for independent practice. Thiswill strengthen the public health system substantiallyand improve its credibility in the eyes of the people.Nurses and other paramedics should be givenopportunities for lateral entry into medical schoolsafter completing 5 years of public service. This willnot only make the public health system more attractivefor them but will also eliminate the unqualifiedpractitioners from the market.● Health insurance needs to be weeded out, especiallythe publicly financed health insurance schemes. Theseonly benefit the insurance company profits and do nothelp the beneficiaries in any significant ways. Evenindividuals who buy insurance are often at thereceiving end and have to struggle for benefits and


ofcourse they do not get cover in their older ages whenthey need healthcare most and insurance companiesdon’t want them. For those who work social insurancelike ESIS must be made compulsory and universal (noincome ceiling barriers as currently). This will bringin all the resources needed to double public healthspending and will also create a collective voice of classneutral beneficiaries who will demand an efficientworking of the system.● Finally the overall healthcare system in the countryneeds transformation if we have to move towards auniversal healthcare system which is equitable andnon-exploitative. Healthcare has to be removed fromthe market framework and needs to become a publicgood through a public health legislation. Once thishappens a NHS kind of healthcare system can beevolved wherein the private health sector would getsocialized and become an integral part of a healthcaresystem that is driven by public mandate.Ravi Duggal is an independent researcher and activistin public health.Email: [email protected]

Fractured approach towards the criticalpublic health sector

Tejal Barai – Jaitly

The recent, move by the Bombay MunicipalCorporation (BMC) to bring on board private playersto manage intensive care units (ICU) at civic hospitalsin Mumbai is amongst the more recent public privatepartnerships (PPP) announced (Singh, 2018). Thegovernment will be giving around Rs. 25 crores overa period of two years to manage about 200 ICU beds.The cost of an ICU bed in the public sector for patientsneeding it is Rs. 200 per day. Through the PPP, thegovernment will give about 10 times this cost to aprivate agency and how this ensures care for the pooris not clear. While the patient will continue to pay theoriginal cost, clearly, such a move diverts funds awayfrom the public sector towards the private. These aredangerous trends right in the face of clear and clinchingevidence against PPPs in the health sector as in caseof public health insurance schemes including RajivGandhi Jeevandayee Yojana (RGJAY, now called theMahatma Jyotiba Phule Jan Arogya Yojana) inMaharashtra and Seven Hills Hospitals (Wagle andNehal, 2017; Godbole, 2018).Is the public sector redundant?Proponents of PPPs have commonly used the argumentthat the public sector is redundant, which is clearlynot true. Public facilities continue to remain relevantand a sizeable population in the country still accessesthe public sector in both rural and urban areas.According to the NSSO 71st Round, relatively highpercentage of treatment at public hospitals was notedin the rural areas of Assam (84%), followed by Odisha

(76%), Rajasthan (44%) and Tamil Nadu (42%). Itwas also high in the urban areas of Odisha (54%),followed by Assam (44%) and Kerala (31%) (NSSO,2014).It has also been argued that with insurance coveragethrough PPPs, services will be more accessible to thepoor and people in rural areas and they are more likelyto therefore opt for private sector services. The nextsection presents evidence against this.Do Public Private Partnerships increase access?Through continued government patronage, promotionand subsidies, the Indian private health care industryhas expanded phenomenally and is now valued at $40billion and is projected to grow to $ 280 billion by2020 (GoI, 2017). Notwithstanding this achievement,it has failed miserably on several counts. Charitablehospitals have violated the legally mandatedcommitments to the poor that they were obligated togive in return for the free land and subsidies that theyhave received from the government (Kurian, 2013).Secondly, the private healthcare sector has managedto escape regulatory mechanisms that would make itaccountable. Despite this entire context, PPPs continueto be promoted.In a study by the Centre for Enquiry into Health andAllied Themes (Wagle and Shah, 2017) on the RGJAYin Maharashtra, revealed that the private sector wasusing the scheme to increase profits by selectivepromotion of procedures which were quick exits andtherefore more profitable for them. Despite theschemes enrolment of the private sector, there wascontinued high accessing of the public sector; turningthe theory upside down that insurance coverage wouldresult in people turning away from the public sectorand preferring the private sector. In Mumbai, forinstance, there are more private hospitals empanelledunder the scheme (19 public hospitals and 32 privatehospitals under the scheme in Mumbai). Most of thepre - authorizations under the scheme were raised inMumbai (37%); and more than half of these wereactually in the public sector. There is also evidencethat enrolling the private sector has not necessarilyincreased access to health services. Merely 12% ofthe total empanelled hospitals belonged to the 12 leasturbanized districts of Maharashtra put together. Inseveral districts it was found that even though theprivate sector dominates the proportion of empanelledhospitals, it has not been utilized. In Chandrapur, forinstance, there were 9 empanelled hospitals under thescheme of which 8 were in the private sector and yetmore than 90% preauthorizations from Chandrapurwere outside the district. Also in terms of increasingaccess to rural and marginalized groups, lack of privatesector presence in itself is an indicator of the fact thatsuch a PPP would fail to increase access. Nandurbar ,has more than 65% ST population, has only oneempanelled hospital, which is a public hospital, and


no private empanelled hospital. Moreover, medicaloncology is unavailable across 12 districts,intervention radiology across 17 districts and radiationoncology across 16 districts through the private sectorunder the RGJAY. There are also other critical issuesthat plague the scheme including continued high outof pocket expenses, whereas the scheme wasenvisaged as cashless. There was also evidence of poorquality of care and poor responsiveness towards agrievance.The public health sector continues to be relevant andevidence indicates that it can be equipped to perform.Findings of a pilot study in Tamil Nadu revealed thatpost the strengthening the primary health care therewas an increase in the utilization of the sub centersfor outpatient services, reduction in the outpatientshare of the private hospitals in the area as well asreduction in out of pocket expenditures(Muraleedharan, et al, 2018).PPPs come at a high cost - worsening access for thepoor and further jeopardizing the public sector markedby the movement of funds away from it. Critically,the government needs to reflect on its role in promotingthese PPPs; as it continues to do so despite the factthat public private partnerships have led to theexclusion of population as against universal access.AcknowledgmentsI would like to thank Dr. Padmini Swaminathan (TISS,Hyderabad); Ms. Sangeeta Rege and Dr Sanjida Arora(CEHAT, Mumbai) for their valuable comments.Tejal Barai-Jaitly is a researcher with the Centre forEnquiry into Health Themes (CEHAT, Mumbai)Email: [email protected], V. (2018): 9 civic hospitals to soon give low-cost privatecare in ICUs, https://timesofindia.indiatimes.com/city/mumbai/9-civic-hospitals-to-soon-give-low-cost-private-care-in-icus/articleshow/63823194.cmsWagle, Suchitra and Shah, Nehal. (2017). Government FundedHealth Insurance Scheme in Maharashtra: Study of Rajiv GandhiJeevandayee Aarogya Yojana. Mumbai: CEHAT.Godbole, T (2018): Seven Hills Hospital: An expense for taxpayersat the cost of public health, http://www.cehat.org/uploads/files/Seven%20Hills%20Hospital%20An%20expense%2 0for%20taxpayers%20at%20the%20cost%20of%20public%20health.pdfNSSO (2014): Health in India. Ministry of Statistics and ProgrammeImplementation. GOI. http://mospi.nic.in/sites/default/files/publication_reports/nss_rep574.pdfGOI (2017). Situation analyses. Backdrop to the National HealthPolicy 2017. Ministry of Health and Family welfare. GOI. https://mohfw.gov.in/sites/default/files/71275472221489753307.pdfKurian, Oommen C. (2013). Free Medical Care to the Poor: TheCase of State Aided Charitable Hospitals in Mumbai. Mumbai:CEHAT, 2013.Muraleedharan V R, et al.(2018): “Universal Health Coverage-Pilotin Tamil Nadu: Has it delivered what was expected?”, Centre forTechnology and Policy, Department of Humanities and SocialSciences, IIT Madras, Chennai, Tamil Nadu.

Public Private Partnership / P3s inHealth Sector in India

Bijoya Roy

IntroductionPublic Private Partnerships (P3s) in health sector inIndia has become popular and private sector is beingincreasingly seen as an alternative in meeting theprovisioning and infrastructure gaps. Clearly a greaterrole of the private sector by mean of contracting outof services and in infrastructure development is beingenvisaged. Today the role of state is being restructuredas a regulator and transferring of the management ofthe public entities.

At the international level, Sustainable GoalDevelopment 17 (2015) places greater emphasis onpartnerships to achieve the SDGs. In India thirdNational Health Policy 2017 reiterates the need toinvolve private sector in achieving public health goalsthrough contracting out, selective purchasing ofservices and private financing in meeting theinfrastructure gaps. Increasingly, the expansion of P3sis justified on declining and scarcity of publicfinancing for healthcare services (both infrastructureand workforce), more than 70 percent of the populationaccessing private sector both in the rural and urbansites and ‘the private sector provides a complementarymeans to expand health services, products, andinfrastructure’. Lastly, but not the least private sectorrealizes that public sector can provide links for theirexpansion in the underserved areas or to themarginalized communities. Overall, now there is apolitical climate favouring private investment, marketexpansion and P3s in the health sector.

P3s for Services and Infrastructure GapsContracting-out and PPP of clinical and ancillaryservices that began as ‘an innovation’ by the end of1990s within the public sector healthcare services isnow in the process of further change. A secondgeneration of complex P3 projects is emerging withthe private sector participating in raising of capital,design, construction of public infrastructure, long-termmanagement and delivery of services.

In 2017 NITI Ayog proposed P3 model based onModel Concessionaire Agreement to deliver servicesrelated to Non-communicable diseases at the districtlevel, even though it was not later followed up. Theseare much complex long-term concession PPP models.It was not the first of its kind. There have been repeatedattempts earlier as well to get into these kinds ofventures. In Uttar Pradesh in 2010 and 2016 the stategovernment had invited bids based on ManagementOperation and Maintenance model for district leveland below health services and Operate MaintenanceTransfer model for primary health care respectively.Both of them are long-term concession model. Despite


the proposal for creating infrastructure assets it didnot operationalize. Overall this shows state’scontinuous preference for the private sector provisionand deep embedded belief of private sector’ssuperiority over the public sector healthcare facilities.In other sectors like roads, urban development andinfrastructure, education and energy P3s have emergedas one of the preferred ways for creating infrastructure.P3 contracts in healthcare are overall changing theprocess of procuring services. In different states andat the central level in order to enable and promote P3policies, designing of complex infrastructure P3projects, and capacity building for economic and socialsector PPP cells have been created. Along with thisfinancial and legal frameworks in India are beingdeveloped for furthering the partnerships forinfrastructure.Promotion of P3 PoliciesIn developing countries international consultancycompanies like PwC, Deloitte, McKinsey; multilateralinstitutions like World Bank, its financial armInternational Finance Corporation (IFC), regionalbanks like Asian Development Bank (ADB) and donorgovernments are playing a major role in the transferof P3 policies, promotion of P3 projects, anddeveloping capacities at various levels. Non-stateactors and international agencies have played animportant role in the transfer of P3 policies in India.Evans (2013) argues that in this process of developingand implementation of P3s, private sector interests arefundamental.World Bank Group along with UK’s DFID has beenpushing for greater privatisaton of health services.Beside IFC investing in private health sector in Indiait is also helping different state governments likeMeghalaya, Bihar, Jharkhand1 and Odisha indeveloping PPP modalities in health sector. IFC inJharkhand helped in developing a 10-year concessionPPP model for the radiology and diagnostic servicesin 24 district hospitals and 3 state medical colleges.Lethbridge argues that through all these projects IFCcontributes ‘to the expansion of Indian commercialhealthcare companies, rather than focussing…. onassuring health outcomes’. Beside IFC other activefinancial institution is ADB. Since 2006, ADB has beenassisting Government of India to develop PPPs acrossthe sector including health and education. ADB withKPMG consultants have done an assessment study todevelop PPP solutions for the health sector.International Consultant companies across regions andsectors have promoted P3s through country level andor generic reports on how PPPs can contribute in thedevelopment of infrastructure. In 2010 PwC publisheda report titled Build and Beyond: The (r)evolution ofhealthcare PPPs. This reported elaborated howgovernments in different countries are looking forwardto PPPs as a means to solve the problems of

provisioning, financing and management of thecrumbling public services. In 2012 Deloitte came outwith Global PPP Market report that clearly mentionedabout the ‘growing appetite for PPP in emergingeconomies’. Transition countries like India are seenas the future P3 markets. These international consultantagencies play as important roles as multilateralinstitutions and the state in the spread of P3 policies.Ensuring Universality or MarketIt is important to note that P3 models in health sectorvary across different states and within states as well.There is high level of heterogeneity and complexity.P3s are contributing to organisational transformationof public health care services i.e. creation of internalmarkets with a split between the purchaser andprovider. These contracted-out and P3 based servicesrange from short term (5 years) to long-term (10-30years) contract. The designs of such contracts are notsimple with multiple private partners and results inhigh transaction costs. Almost after 15 years of suchservices in different states it is clear that outsourcingand PPPs have emerged for services, which can bringin certain revenue to the private sector. In the field ofhigh end-radiology and general diagnostics presenceof P3s can be found in a major way followed bydialysis. They have proliferated with for-private profitsector. This very nature reflects that P3s undermineuniversality of provisioning and fragments the serviceprovisioning.Concerns have been raised about the welfare of thepatients. PPP contracts take longer to negotiate andare costlier than the normal procurement process (Hall,2017). It is found these kinds of contracts are largelybased on the output specifications and inputs are littlespecified. The private operator as a result has highprobability of cutting down costs bearing an impacton the quality of personnel and care (Karpagam et al.,2013, Roy, 2015). The district level health departmentsare not well equipped to monitor and regulate suchP3s on a regular basis. Further there is little evidenceof transparency of the outsourced and PPP contractnegotiations. This limits their public accountability.The long-term concession contracts usher in new kindsof problem. Some of the states with IFC negotiatedP3 model have embarked upon 30 yearlong contracts.In this context it is important to draw upon the UKexperience of Private Finance Initiatives (PFI) in thehospital sector. The private sector borrowing is alwayscostlier than the government sector; almost double thelater deal (Hall, 2017; Hellowell and Pollock, 2010).Moreover this increases the cost of PFI hospitalservices and resulted in 30% reduction in hospital bedsand staff (Pollock and Price, 2013). The NHSorganizations pay much higher for the use of the PFIbuildings than the capital charges they pay to thetreasury within the traditional regulations. Thistransforms the power relation between the two sectorsand the provisioning of services is then governed bymarket and profitability concern.


ConclusionWith the turn of this century public health services inIndia across primary, secondary and tertiary level carehave increasingly been exposed to commodificationand marketization through outsourcing and P3 models.Health movement and academicians have time andagain raised concerns about subsidizing P3 modelsand enabling the expansion of private sector in healthcare at the expense of public fund. This has contributedto the fragmentation of health care services, creationof newer structures, indirect governance, and increasedthe tensions between the different partners competingfor resources. P3 models have scarcely addressed andcontributed towards strengthening of the public healthservices. The future high costs of P3 will bear animpact on the provision of merit good impeding equity,sustainability and quality of care. Despite its unprovenefficiency track record P3 continues to be promotedin India.Bijoya Roy is Assistant Professor, Centre for Women’sDevelopment Studies, ICSSR Institute, New Delhi.

Email: [email protected]://blogs.worldbank.org/ppps/sustainable-health-diagnostics-network-in-Jharkhand-IndiaReferencesHall, D. (2017) PPP: Issues and Alternatives, www.gre.ac.uk/business/research/centres/public-services, www.psiru.orgHellowell, M and Pollock, AM. (2010) Do PPPs in SocialInfrastructure Enhance The Public Interest? Evidence fromEngland’s Public Health Services, Australian Journal of PublicAdministration, February DOI: 10.1111/j.1467-8500.2009.00658.xKarpagam, S., Roy, B, Seethappa, V. K., & Qadeer, I. (2013)Evidence Based Planning – A Myth or Reality: Use of Evidence bythe Planning Commission on Public Private Partnership, SocialChange, Vol. 43, No. 2, pp 213-226Mark, E. (2013) New Directions in the Study of Policy Transfer,Routledge.Pollock, AM and Price D (2013) PFI and the National Health Servicein EnglandRoy, B. (2015) Public Private Partnership in Healthcare: Trajectoriesand Experiences from West Bengal in I Qadeer (Ed.) INDIA: SocialDevelopment Report 2014: Challenges of Public Health, OxfordUniversity Publication, New Delhi.

Reorienting Medical Education toaddress Health Inequities

Sangeeta Rege

Despite an established role of social determinants inhealth care , neither medical education nor publichealth services in India have taken cognizance of it.Scholars have critiqued the field of medicine as beinggender-blind and male-biased because the body ofmedical knowledge views the male body as the norm,with men’s experiences forming the basis for

describing signs and symptoms of illness. Gender-based inequalities between women and men have alsonot been factored-in as critical social determinants ofhealth and disease. One of the consequences of gender-blindness in medicine is the limited gender-sensitivityamong medical practitioners, contributing to thecompromised quality of care. Another manifestationof gender inequities is violence against women andchildren; laws in India cast legal obligations on thehealth sector to provide comprehensive services tosurvivors of violence against women(VAW) andchildren. Years of struggle by civil societyorganisations in India have led to some reforms in thehealth sector in the context of seeking accountabilityof the sector vis a vis violence against women. Thispiece describes two important efforts made with theformal health system to mainstream gender sensitiveresponse to VAW and integrate gender concerns inthe medical education system.Creating gender responsive health services for VAW:An evidence based model Violence of any kind isknown to have an adverse impact on the health of thoseimpacted. Despite an association between violence andhealth, health sector in India has yet to take cognizanceof it in a systematic manner. One of the first efforts toaddress violence as a public health issue was made byMCGM (Municipal Corporation of Greater Mumbai)in collaboration with CEHAT. Such a joint ventureled to setting up of a public hospital based crisis center,Dilaasa for responding to violence against women andgirls. Key features of this model comprised ofengaging health providers to recognise reasons foroccurrence of violence, health consequences of suchviolence, their legal responsibilities to respond andrefer survivors to Dilaasa centers. Over the past 17years,4000 survivors accessed Dilaasa services, 75%of who had reached hospital with health consequencesof violence, such as assaults, suicide attempt, sexualviolence, unwanted pregnancies, sexually transmittedinfections and the like.An important reason that has enabled the continuedfunctioning of Dilaasa centre was the recognition ofits relevance by the public hospital, namely, thatcounselling is a health care need and health providershave a role to play in mitigating consequences ofviolence. As responding to VAW was enshrined in thejob responsibilities of health providers it became a setpractice to orient newly appointed resident medicalofficers and nurses to be oriented to VAW as a healthissue as a part of the existing hospital orientation andseek reporting from respective departments onreferrals made to Dilaasa. The next step was tomainstream these centers in the health sector. Thefollowing important and visible indicators helped inthe process of mainstreaming the Dilaasa model; onewas the evidence that this model had sustained formore than 17 years in a public hospital within theexisting resources of the hospital, second was the


emerging evidence from Dilaasa regarding the sheernumber of survivors accessing services because of thehealth consequences suffered by them as a result ofviolence. NUHM as a flagship program had the scopeto allocate budget for training of health providers aswell as appointment of counsellors for providingpsychosocial care. Strategic dialogues along withexisting evidence enabled the replication of 11 Dilaasacentres in public hospitals of Mumbai. The replicationis a clear acknowledgment by Maharashtragovernment of violence being a health issue and thatthe public health sector has a role to play in respondingto it.Integrating gender concerns in medical education:An experiment As far as medical education isconcerned, WHO (2006) recommendations ofintegrating gender concerns in medical curricula bothin service and pre-service provided the foundationalbase for an experiment; Maharashtra department ofmedical education and research(DMER) incollaboration with CEHAT made efforts to facilitategender perspectives in medical educators of sevenmedical colleges in Maharashtra. Medical educatorsfrom disciplines of medicine, gynecology andobstetrics, psychiatry, community medicine andforensic science and toxicology underwent a rigoroustraining to understand associations between genderand diseases, gender biases in diagnosis, genderdiscrimination in health services planning and deliveryand the like. The training enabled medical educatorsto review their medical textbooks and teachingcritically. Having developed a gender lens, educatorscollaboratively designed gender integrated curriculumfor MBBS students so as to facilitate gender sensitivityin health care. The efficacy of the gender integratedmodules was also tested through a research studywhich clearly showed a positive shift in genderattitudes of medical students. An important learningof this effort was that ‘gender” cannot be relegated tojust an introductory lecture but should be integratedin all medical topics where social determinants have arole to play. This enables better retention of conceptsand enables a continuum of gender informed healthcare. Importantly medical educators teaching genderintegrated curriculum achieved doing so in existinglecture time dispelling the myth that additionalteaching time is required if gender concerns have tobe integrated in MBBS curriculum. These moduleswere reviewed by board of studies and academiccouncil and approved by the Maharashtra universityof medical science (MUHS) for implementation in allmedical colleges of Maharashtra from 2018 . Thissuccessful experiment at Maharashtra has come at anopportune time where the NHP 2017 speaks of creatingpatient centered high quality care and stronglyrecommends strengthening access to care formarginalized groups. Additionally, MCI is also makingefforts towards competencies based medicalcurriculum. There is a clear opportunity to use the

gender integrated medical curriculum by MCI andother states for developing competencies in studentsto deal with medical illnesses and also prevent genderbiases. Gender mainstreaming by strengthening accessto health care for marginalised communities ,addressing social determinants of health andresponding to violence against women are keyprinciples in NHP 2017; each of which fit well withthe successful initiatives described in this piece andtherefore there is a clear opportunity to use emergingevidence and the policy directive to make the healthsector responsive to gender and other socialdeterminants of health that play a pivotal role inaddressing health inequities.Sangeeta Rege is the coordinator at Cehat and herinterests include gender, public health and medicaleducation.Email: [email protected]

The impact of NEET on an individualinstitution

Anand Zachariah

This article is a view on the ground as a teacher inCMC, Vellore indicating how NEET is affecting ourmedical education. Christian Medical College iscelebrating its 100th year of medical education. Atthis time we are both looking back at the developmentsin our education over 100 years, and looking forwardon how to address the challenges of medicine in ourcountry at the present time. Towards this, CMC Vellorehas initiated a process of curriculum renewal tostrengthen and energise our undergraduate andpostgraduate education. It is at this critical juncture inour history that the force of the NEET regulations isbeginning to affect us.CMC’s model of medical education and selection processThrough its 100-year history CMC, Vellore has triedto orient its medical education towards meeting healthcare needs. CMC is owned by about 50 protestantchurches that run over 200 mission hospitals acrossthe country many of them in rural and underservedareas. Students of all courses both undergraduate andpostgraduate courses are sponsored from thesehospitals. Students are selected by a combination ofacademic merit based on an all India entranceexamination followed by a second stage of assessmentthat includes interview and skills test to assess aptitude,teamwork and motivation to work in needy areas.CMC’s entrance examination was not based on CBSEbut a more pan-India secondary board syllabus. Theselection system at the undergraduate level, is basedon inter se merit, which allows for equity ofopportunity between different churches, so that thereis geographic representation of students from acrossthe country. This allows students who are from adisadvantaged background from Orissa or Jharkhand


an equal opportunity to applicants from Kerala.Therefore the selection combines assessment ofacademic merit and suitability for training at CMCand work in rural areas.All undergraduate students work for 2 years followingtraining in sponsoring hospitals towards their serviceobligation in lieu of the subsidised education that theyhave received. Sponsored postgraduate students alsohave a 3 year service obligation.The undergraduate MBBS curriculum also hasgradually developed to prepare the graduates forworking in primary and secondary care throughcommunity medicine, family medicine training andexposures in rural secondary hospitals across thecountry. Through all these initiatives CMC hasdeveloped a unique model of medical educationtowards relevant training of doctors to meet the healthneeds of the country. An important element of thismodel of medical education has been the process ofselection.When examined in the international context, CMC’sselection method is not unusual. In the majority ofcountries across the world selection for undergraduateand postgraduate medical courses combines academicassessment, aptitude tests and interviews.NEET regulationsIn the background of the dissolution of the MCI, theSupreme Court directed the Medical Council of Indiato conduct a common entrance exam as a way ofregulating the private medical education industry. TheNEET was notified in 2010. The purposes of NEETwere: (a) that there be only one entrance examinationto reduce hardship for students who have to writemultiple examinations; (b) admission be only basedon merit in the NEET examination; (b) To prevent anyform of malpractice such as donations, profiteeringand capitation fees. The only institutions that areexempt from NEET are the Institutes of NationalImportance (INI) such as All India Institute of MedicalSciences and Jawaharlal Institute of Postgraduatemedical education and Research (JIPMER),Pondicherry.These regulations were challenged by severalorganisations, institutions and the state governmentsof Tamil Nadu and Andhra Pradesh in various courtsacross the country. The cases were eventuallytransferred to the Supreme Court. Close to 178 writpetitions were filed and heard in the matter. In thereview petition on NEET case judgement 2013 (CMC,Vellore & ors vs Govt of India ors), the bench headedby Chief justice Kabir quashed NEET on 18 July 2013.On April 28 2016 a 5 judge bench of the SupremeCourt headed by Chief Justice Dave (who was thedissenting judge in the earlier judgement) recalled itsearlier judgement on the grounds that there had beenno discussion among the judges before the judgementwas delivered and there were some binding precedents

which required reconsideration of the judgement. TheSupreme Court allowed MCI and GOI to go aheadwith NEET. In 2016 the parliament passed the IndianMedical Council Amendment bill 2016 that providesconstitutional status to the NEET examination.Following this all admissions in medical collegesacross the country have been based on NEETexcepting in the institutes of national importance.CMC’s argument in the NEET caseThe NEET examination system was implemented asa means to regulate the private medical educationindustry. However the new system adversely affectsCMC’s selection process and education system ofselecting students based on their suitability for trainingat CMC and for work in needy areas.CMC is not against the purposes and merits of NEET.It does not disagree with the need to regulate theprivate medical education industry. It has acceptedNEET as a qualifying entrance examination. Its caseis that (1) minority rights need to be protected.Establishing and administering minority institutionsalso includes the right to selection (2) its own selectionmethod has been fair, transparent and non-exploitative,(3) merit cannot be defined only by marks in anentrance examination. (4) The method of selection andsponsorship has benefited rural mission hospitals inproviding human resources and thereby in providinghealth care in needy parts of the country.The impact of NEET on CMCSelection has been a significant part of the system ofeducation at CMC and has contributed to the quality,culture and distinctiveness of the institution. There isconcern that a change in the selection method mayhave adverse consequences to the different dimensionsof our work.Teachers: There has been significant negative effectof NEET on the morale of teachers. This has beenconsequent to the inability to select suitable candidatesand concerns regarding maintaining the distinctiveform of CMC education.Services: Patients come to CMC from across thecountry and neighbouring countries (Nepal,Bangladesh, Bhutan) to access the quality andaffordable specialty care. There is a close balancebetween the quality of service and training. We areable to maintain the quality of these services becauseof the postgraduate training programme. If there is noprovision of assessing the suitability for trainingincluding clinical skills and aptitude and interest forthe particular postgraduate course, this could affectthe quality of patient services.Medical education: It remains to be seen how NEETwill affect the process of CMC education. There islikely to change in the student profile at theundergraduate and postgraduate level. They may beacademically focussed with a more limited range of


broader interests and social skills that are essential forthe practice of medicine and to be good doctor. Thereis concern that the students selected based on NEETat the undergraduate and postgraduate level may notbe able to adapt to the requirements and orientation ofCMC education. This may in turn affect the quality ofour education.Service obligation: CMC has given weightage forfulfilment of rural service to enter postgraduatetraining. Students prefer to join coaching centres toprepare for the NEET examination rather than workhard and fulfil the requirements for the serviceobligation.Mission hospitals: There is concern that NEET mayaffect CMC’s ability to provide MBBS, generalspecialty postgraduate doctors and super specialistsfor the mission hospitals. This would have negativeconsequences to the services in the rural areas wherethe hospitals are located.Conclusion:Medical education in India is in crisis. There areconcerns about the overall poor quality of educationand inability of the medical education system to meetthe human resource requirements of the countryparticularly at the primary and secondary level.Privatisation of medical education is obviously animportant contributing factor.There are several medical colleges such as ChristianMedical College, Ludhiana, St. Johns MedicalCollege, Bangalore and Mahatma Gandhi Institute ofMedical Sciences, Sewagram that have a societalorientation and a distinctive process of selection thatassesses both academic merit and suitability fortraining. In a bid to control the commercialisation ofmedical education through the NEET regulation,government policy is stifling such well performinginstitutions.The potential long-term impact of NEET on medicaleducation and health care in the country is yet unclear.The government’s position is that the NEET isfunctioning well. However when viewed from theperspective of a single institution, the negative falloutis already becoming evident. If there should be hopein medical education, it is important for wellperforming institutions to be provided autonomy intheir selection methods and the processes of education.It is important that selection for medical trainingshould combine both academic merit and a secondstage assessment of skills and interview to assesssuitability and aptitude for entering medical training.PostscriptThe postgraduate selection for MD/MS/Diplomacourses at Christian Medical College (2018-19) wascompleted through Tamil Nadu state counselling withcategories for candidates who were sponsored by the

CMC network hospitals, those who had completed 2years of service in areas of need and for general merit.All candidates after completion of the PG coursewould have to fulfil a service obligation.Anand Zachariah is Professor of Medicine at ChristianMedical College, Vellore.Email: [email protected]

Integrated Child Development Scheme:current status

Dhruv Mankad

BACKGROUND Nearly 40 percent of India’spopulation consists of children out of which over halfthe children in the country are moderately or severelymalnourished and 30 per cent of newborns areunderweight. While acceleration of infant mortalityrates have declined from 126 in 1974 to 34 deaths per1000 live births in 20161, malnutrition is not decliningat the same speed. In this context, the Integrated ChildDevelopment Services (ICDS) scheme, world’s largestcommunity based programme is yet to prove itself tobe a relevant programme to make India a malnutrition-free country. This scheme is targeted at children uptothe age of 6 years, pregnant and lactating mothers andwomen 16-44 years of age. The main objectives areto improve the health, nutrition and development ofchildren.ICDS provides directly health, nutrition and hygieneeducation to mothers, pre-school education to childrenaged 3 to 6, supplementary feeding for all childrenand pregnant and nursing mothers, growth monitoringand promotion services, and it is linked to primaryhealth care services such as immunisation and vitaminA supplementation.Each Anganwadi has Anganwadi Worker and a helper.The Anganwadi Worker is supposed to undergo a one-time induction training of 8 days, job orientationtraining of 32 days and refresher training of 7 days,while the Helpers, a one-time job orientation trainingof 8 days and refresher training for 5 days.Immunization, health check-up and referral servicesare delivered through the public health infrastructurei.e. the Health Sub Centre and Primary Health Centreunder the Department of Health and Family Welfare.Remaining through ICDS overseen by the Ministryof Women and Child.Launched on 2 October 1975, the scheme hascompleted 43 years of its operational age and has about1.3 millions active Anganwadis and 1.4 millionAnganwadi workers providing its services to morethan 102 million of 0-6 year old children, pregnantwomen and lactating mothers2.In a nutshell, the ICDS was set up with two centralpurposes: Early Child Care Education and


Supplementary Nutrition for integrated approach forEarly Child Development.Early Child Care Education (Pre-school Education):One of the main purposes of sending children toAnganwadi is to provide them with “…stimulatingand enriching physical and psychosocial environmentso as to form a foundation for inculcation of socialand personal habits and values that are known to lastslifetime. Such early habits inculcated in preschoolyears will shape his/her personality for the future”3.Curriculum is shaped to encourage the child to imbibethe skills and values.Children going to the Anganwadican learn through play, experimenting, observationsetc. Recently, Government of India has recognized thispart and under the approved National Early ChildhoodCare and Education (ECCE) Policy in 20134,“Strengthening and Restructuring of ICDS”, theAnganwadi is to become the first village outpost forhealth, nutrition and early learning and theGovernment has also proposed minimum 6 hours ofworking of AWCs.Supplementary Nutrition (SN):Six months to six year old children, pregnant andlactating mothers belonging to low income groupfamilies are entitled to avail the facility of SN for 300days in a year. 500 calories and 12-15 grams of proteinto children in the age group 0-6 years 800 caloriesand 20-25 grams of protein to severely malnourishedchildren under 6 years of age while pregnant (3rdtrimester) and lactating mothers (first 6 months oflactation) are given 600 calorics and 20 g proteins perday as SN. Usually it consists of a hot meal cooked atAWC. It contains a combination of pulses, cereals,oil, vegetables and sugar. Some AWCs provide a‘ready-to-eat’ meal while a ‘take-home’ strategy for2–4 weeks at a time for children under 2 years andpregnant and lactating women.ICDS: CURRENT STATUSDuring the past 43 years, several reviews, evaluations,assessments of these laudable but faltering serviceshave been carried out; policies, programmes andadvocacies have been changed and implemented. Butin a nutshell, challenges remain to strengthen andrestructure this programme5. There are some keyissues:Effectiveness of ICDS to achieve its objectives:Most of the evaluation studies have found that, theICDS programme has impacted positively children’sgrowth, development and their survival6,7,8,9. Forexample, a study conducted in “…rural areas of threesouthern states (Tamil Nadu, Andhra Pradesh andKarnataka) found that the programme had a significantimpact on the psychosocial development of children,for both boys and girls. The study also showed thatundernourished ICDS beneficiaries attained higherdevelopmental scores than well-nourished children

who were not enrolled in the programme”10. One ofthe recent evaluation study of 19 sample states andUTs carried out by the Niti Ayog indicates that around75% of AWCs were functioning smoothly, monitoringthe growth and development of the children as theyare required to do11. However, this does not underminethe criticism, published often because these studiesare considered credible even though not subjected torigorous peer reviews.Here we can look at the following components of thecurrent status of the ICDS: Physical Infrastructure,Quality of services like pre-schooling andsupplementary feeding, Human Resources- theirmonitoring, training and status.Anganwadi Centres: the Physical Infrastructure of ICDSMost of the studies indicate that the Anganwadis areperforming in community owned building and wereinaccessible distances (100-200 metres). However,around 40%-60% were ‘proper’ buildings withadequate space to accommodate 3-6 year old children.One of the key gaps in the evaluation is that it is notclear whether there is enough space for the activitiesfor pre-school education. There is enough evidencefrom micro-studies particularly from urban areas thatinadequate space is a major concern impacting theAW’s performances12,13 Going by findings of anotherstudy 24% of sample AWCs did not have safe drinkingwater facilities and 62% AWCs could not maintaingood hygiene condition. No update is available abouttoilet facilities at Anganwadis which was a challengeas shown in earlier studies.Quality of ECCE and Nutrition ServicesA groundbreaking, 5-year longitudinal study about theshort-term and long- term impacts of the quality ofearly childhood education has been recentlypublished.14 This study included 13,686 children in 362villages in Telangana, Assam and Rajasthan states andidentified the quality of the preschool physical settingas one of the most important predictors of schoolachievement at the age of 7. Children who hadparticipated in ECCE performed significantly betteron overall cognitive achievement than those who hadnot. Notwithstanding this, preschool education hasbeen found to be a weak component of theseprogrammes and children graduate with low levels ofschool readiness. This is a sad situation as NIPCCDhas made available Guidelines of planning andimplementing ECCE universally, thanks to NITIAyog’s reinforced directives. On the other hand, whatthe left hand considers important, the right does not.The budgetary provision is reduced at state level orits share to ECCE is meager.15,16

ICDS is a centrally sponsored scheme to beimplemented by the States/UTs. Responsibility ofameliorating the complaints received against theQuality of supplementary food is theirs. The Food andNutrition Bureau had analysed and had found


nutritional quality of 515 samples not upto the mark.17

This is a challenge which despite several recommendations remains a operational glitch recognized byNITI Ayog recently as one of the factor which mayimprove nutritional status of children.Human Resources- monitoring, training and status.Monitoring the ICDS staff performance

The Central Level ICDS Monitoring Unit of theMoWCD monitors the ICDS scheme. MoHFW alsomonitors immunization, health check-ups etc. Theprimary objective of the report is is on the input side.For example, data are collected on the number ofbeneficiaries of supplementary nutrition, number ofbeneficiaries of preschool education and number ofAWCs etc. Although, the AWC maintain weightregisters and charts, its coverage, timeline, accuracyis weak and unreliable due to many reasons:inadequate archaic instruments, absence of itsmaintenance system, inadequate skills of using theinstruments and recording, maintaining growth charts,pressures from above to show improving reduction inlevels of malnutrition. Recent studies done byMoHFW in Maharashtra at district level, thediscrepancy was evident18. This was recorded by NITIAyog in its quick evaluation of Anganwadis.Monitoring their performance in ECCE is not the same.There is no regular curriculum transaction unlikeSupplementary Nutrition, hence no supervision ormonitoring.Training and Qualification of the ICDS staff:The evaluation by the Planning Commission foundthat AWWs are satisfactory about their qualificationsbut they did not have required skills, apart from thefact that they had heavy workloads and were poorlypaid during the training/performance.According to NITI Ayog, regular training should beprovided to AWC workers and their supervisorsincluding on-job training to handle registers regardingand other records independently. For SN these includechild registers, growth chart, stock registers of grainsand take home rations (THR), distribution registerson supplementary nutrition (SN) and THR.However, it should be noted that the one-month- longjob training and one week refresher training in ICDScovers all six services of the ICDS including, SN andECCE. The training curriculum has about four daysin the job training and one day in the refresher trainingfor ECCE. This duration of training in ECCE is itselfhighly inadequate to enable Anganwadi workers toexecute a quality preschool programme.Work Satisfaction and Status of Anganwadi WorkersAlmost all evaluations have recognized thatAnganwadi Workers are overburdened and underpaid.As of today, the Anganwadi Worker has to provideSN to 81 beneficiaries and ECCE to 31 on an average,

if one goes by the data available. This exceeds thenorms of 60 for SN,19 and 20 for ECCE.20 Consideringthe existing levels of malnutrition, on an average shehas the responsibility of making 5 SAM children, 8MAM children normal if the malnutrition prevalenceas per NFHS 4 is applied.21 Strictly speaking, there isno such norm of this service in any document referredfrom but all the fingers always from their Program,often by media and sometimes by us, too. If one looksat spent by an AWW for all activities against therecommended by NIPCCD, the main gap of burdenemerges. A study shows that out of the totalrecommended 270 minutes, on an average, anganwadiworker spent 35 to 131 minutes on record keepingagainst 30 minutes! In supplementary nutrition almostsame time was devoted which was recommended i.e.30 minutes. Mean time spent in preschool educationin all the Anganwadi centre was nil to one hour againstthe recommended time of 120 minutes. Mean timespent on home visit was only nil to 7 minutes againstthe recommended time of 60 minutes. Time spent onrecord keeping is a major strain, this is shown in manyother studies.22,23,24

Last ChallengeRecently, there have been instances where an AWWhas committed suicide due to overburdening orunderpaying etc. Personally, I sincerely feel that theburden of curing (not caring) malnourished childrenhas been passed on to the ones who formed a backboneof Child Care. Any new intervention for malnutritionreduction should take this into consideration as AWWs– the women, are often the key intervenors andtherefore the ‘targets’.What needs to be done?It’s simple!● Put the last first – make the scheme human (child

and AWW) centric scheme● Increase the number of AWCs and human

resources required● Improve training, quality of performance and

grievances of the human resources● Ensure participation of children – and their parents/

family in all activities: SN, ECCE etc.● Design a child centric schedule and curriculum for

ECCE● Have more space available for children to play,

learn and experience● Involve community to understand that it is the

experience, plays, observations which makechildren ready for the 3Rs which the parents want

● Make adequate financial packages available forall of the above

Dhruv Mankad is Managing trustee, AnusandhanTrust, Mumbai, Director, Vachan. Nasik



Endnotes1 Ministry of Health and Family Welfare, Govt. of India (https://community.data.gov.in/infant-mortality-rate-imr-in-india-during-1972-2012/) and SRS October 20172http://www.icds-wcd.nic.in/Qpr0134forwebsite 23092014/currentstatus.htm3National Institute of Public Cooperation & Child Development,Guidebook for Planning and Organization of Preschool EducationActivities in Anganwadi Centers, February 20184National Early Child Care Education Policy, 20135N. Rao & V. Kaul, India’s integrated child development servicesscheme: challenges for scaling up, Wiley & Sons Ltd, Child: care,health and development, 44, 1, 31–40, September 20176National Council of Applied Economic Research (NCAER) (2004)Rapid Facility Survey on ICDS Infrastructure. NCAER, New Delhi.7National Institute of Public Cooperation and Child Development(NIPCCD) Three Decades of ICDS – An Appraisal. Government ofIndia, New Delhi, 2006 Available at: http://www.nipccd. nic.in/reports/eicds.pdf8Planning Commission, Government of India, Evaluation report onIntegrated Child Development Services. Planning commission,program evaluation organisation. Available at: http://planningcommission. nic.in/reports/peoreport/peo/peo_icds.pdf9Ministry of Women and Child Development, Government of India.Rapid survey of children (2013–14). Available at: http://wcd. nic.in/sites/default/files/India%20fact%20sheet.pdf10https://www.unicef.org/earlychildhood/files/india_icds.pdf11Niti Aayog, Programme Evaluation Organisation: A quickevaluation study of Anganwadis. 2015 Available at: http://niti.gov.in/mgov_file/report-awc.pdf12Damanpreet Kaur, Manjula Thakur, Amarjeet Singh, SushmaKumari Saini, Workload and perceived constraints of Anganwadiworkers, Nursing and Midwifery Research Journal, Vol-12, No. 1,January 201613A. Vinnarasan, Enrollment of Children: A Study on FactorsInfluencing Non-Enrollment of Children in the ICDS AnganwadiCentres at Chennai Corporation, published in Research on ICDS:An Overview (1996-2008) Volume 3, NIPCCD, 200914Kaul, V., Bhattacharjea, S., Chaudhary, A. B., Ramanujan, P.,Banerji, M., & Nanda, M. (2017). The India Early ChildhoodEducation Impact Study. New Delhi: UNICEF. Available at https://www. academia .edu/34458607The_India_Early_Childhood_Education_Impact_Study15Integrated Child Development Services (ICDS) GoI, 2018-19 inBudget Series Vol 10, Accountability Initiative, Centre for PolicyResearch, Dharam Marg, Chanakyapuri, New Delhi – 11002116Integrated Child Development Services (ICDS), Budgeting forChange Series, 2011, CBGA and UNICEF17Public Information Bureau, Ministry of Women and Child, GoI,Measures to Ensure Quality of Food under ICDS, 12th August 2014.18 http://indianexpress.com/article/india/malnutrition-cases-in-maharashtra-under-reported-finds-survey-nfhs-4-5138960/19Evaluation Report on Integrated Child Development ServicesVolume I, PEO Report 218, Planning Commission, New Delhi,March 201120NIPCCD, IMPLEMENTATION OF EARLY CHILDHOODCARE AND EDUCATION POLICY IN INDIA, New Delhi.21Indian Institute of Population Studies, National Family HealthSurvey, Mumbai, 2016

22Tripathy M, Kamath SP, Baliga BS, Jain A. Perceivedresponsibilities and operational difficulties of anganwadi workersat a coastal south Indian city. Med J DY Patil Univ 2014;7:468-72.23Borgohain.H, Saikia J P, Job Satisfaction of Anganwadi Workers:A Study in Sivasagar District of Assam International Journal ofInnovative Research in Science, Engineering and Technology, Vol.6, Issue 9, September 2017, 19372 – 19381.24Patil SB, Doibale MK. Study of Profile, Knowledge and Problemsof Anganwadi Workers in ICDS Blocks: A Cross Sectional Study.Online J Health Allied Scs.2013;12(2):1. Available at URL: http://www.ojhas.org/issue46/2013-2-1.html

Population Policy and PopulationStabilization: Where are we today?

Smitha Sasidharan Nair

The current framework for population stabilizationprogrammes in India is embedded in the NationalPopulation Policy 2000 (NPP). The policy portraysan understating that family planning should be aninformed choice; a marked departure from the historyof coercive population control programmes of thecountry. The document at a conceptual level elaboratesthe importance of inter-sectoral convergence anddecentralization for population stabilization but at animplementation level these ideas have been narroweddown to the achievement of certain socio-demographicgoals. The goals set by NPP included free andcompulsory school education up to age 14, reducingInfant Mortality Rate and Maternal Mortality Rate,delayed age of marriage, institutional deliveries,increasing the basket of choices of contraception andregistration of births and deaths. After the formulationof NPP, the tenth five year plan (2002-2007) witnessedincreased funding for population stabilization and arenewed interest in increasing the ‘basket of choice’for contraceptives. The reproductive and child healthprogramme got a boost after the NPP, where the focuswas to provide ‘continuum of care’ for every stage ofa woman’s reproductive life so as to ensure populationstabilization. The notion of women as ‘only’reproductive beings was cemented in the eleventh fiveyear plan (2007-2012) with the introduction ofNational Rural Health Mission (NRHM). Since the1990s’, privatization of health care has received greatimpetus and state’s role has reduced to that of amediator. In this context health was narrowed downto individual responsibility, limiting the small familyunit was considered as a responsible decision, one inwhich the male members were to take equalresponsibility.Where are we today?The decade of 2001-2011 has witnessed the steepestdecline in population growth rate from 21.54% to17.64% and has added lesser number of peoplecompared to the other decades. The stateacknowledges that the 2011 census report is an


important milestone and that the population of thecountry is in an inflexion but views populationstabilization as an important factor in the developmentprocess.The National Health Policy (NHP), 2017acknowledges the importance of improved access,education and empowerment to achieve populationstabilization.But in reality the efforts for populationstabilization focus on individual responsibility and arevisible in the targeted steps taken by the state. Theseinclude schemes like Mission Parivar Vikas formulatedto increase access to contraceptives and FamilyPlanning services in 146 high fertility districts.Expanding the basket of choice to include Injectablecontraceptives and enhanced sterilizationcompensation in 11 high focus states. Incentive basedschemes of Jansankhya Sthirata Kosh (JSK) isimplemented in eight empowered action group statesand targeted towards increasing private sectorintervention in family planning and rewarding thedelay in age of marriage. It is evident from the stepsthat there is an increased focus on meeting the unmetneed for contraception and increasing the role ofprivate sector in family planning.Over the years the efforts to achieve socio-demographic goals have yielded results with a declinein maternal mortality rates (130/1,00,000 live birthsin 2018) and infant mortality rates (34/1000 live birthin 2013). But a worrying trend is visible in the GlobalNutrition Report, 2017 which shows that about 38 percent of the children under five are affected by stuntingand about 21 percent of children under 5 have beendefined as ‘wasted’ or ‘severely wasted’. Fifty onepercent of the women of reproductive age suffer fromanemia. The high levels of malnutrition in the countrypoint to the fact that there is a neglect of the overallhealth and well being of the population.The situation is complicated by poor budgetaryallocation for public health care. Although on paperthe NHP emphasized the role of the government inhealth and importance of increased budgetaryallocation, in actuality only 0.29% of the budget wasearmarked for health. The current public health careis driven by insurance based schemes and is focusedon secondary and tertiary infrastructure development.There is a neglect of primary health care and nutritionprogrammes such as the Integrated Child DevelopmentServices (ICDS). There has also been a decline inallocation for the Mahatma Gandhi National RuralEmployment Guarantee Act (MNREGA) scheme,primary education and even the much hyped SwachhBharat Abhiyan. It is argued that the budget declineof allied social sectors will have an adverse impact onthe health and nutritional inputs of the population.Another concern that is accepted as challenge topopulation stabilization is the disturbing trend ofdecreasing child sex ratio (919 females per thousandmales in 2011) which signifies the gender biasness

that exists in the country along with the poor standardof living for children. The two child norm that hasbeen linked to many of the welfare schemes of theIndian government harms the most deprived andcontributes to the decreasing child sex ratio of thecountry. The rise of Hindu fundamentalism in thecountry has led to baseless theories like ‘love jihad’and ‘population jihad’ being propagated through themanipulation of census data. They have called for thecoercive limiting the size of the Muslim communityand other minorities and the two child norm will alsobecome a weapon to that effect. It can be concludedthat in letter the state acknowledges and commits tolarger structural changes, social determinants of healthand inter-sectoral convergence as important factors toachieve population stabilization. However in spirit itremains market driven within the intersections ofreligion, power and patriarchy.Smitha Nair is assistant professor at the Centre forHealth and Mental Health, School of Social Work, TataInstitute of Social Sciences, Mumbai.

Email: [email protected]:Ghosh Sourindra Mohan and Imrana Qadeer.2017. “An Inadequateand Misdirected Health Budget”,The Wire- Available on- https://the wire.in/health/health-budget-2017-18Government of India.2017. Situation Analyses Background to theNational Health Policy 2017,-Ministry of Health and Family Welfare– Available on https://mohfw.gov.in/sites/default/files/71275472221489753307.pdfHartmann Betsy and Mohan Rao.2015. “India’s PopulationProgramme-Obstacles and Opportunities”, Economic & PoliticalWeekly;1(10):pg10-13Nair Smitha Sasidharan.2016. “Women’s Health Movement,Collective Action And Population - A Study Of Three SelectCampaigns In Delhi” Unpublished, Ph.D Theses submitted to Centreof Social Medicine and Community Health, Jawaharlal NehruUniversity, New Delhi.

Then and Now: From the boondocksSunil Kaul

ThenChhota saghar hoga, baadalon ki chhaaon me, ashadeewani man me, baansuri bajaae Hum hi humchamkenge, taaron ke uss gaaon me, aankhon kiroshni, har dam ye samjhaaye!

(“A small house we shall have, under the shade of theclouds” - a flute in my heart, crazy hope plays.“Only we shall shine in that hamlet of stars”- is whatthe sparkle in the eyes tells me, always!)This old Kishoreda song may summarise what manylike me had entered the rural development sector, somedecades ago. The nation was poor, the people illiter-ate, and we thought we could help put our shoulder tothe yoke that the Government was trying to bear. Then


called sanstha or a (voluntary) organisation, we usedto feel satisfied, nay happy, to do our bit through it.Some of us came down to settle in the hinterland witha patriotic zeal, others came with socialist or Gandhianidealism to try and make an egalitarian society bereftof caste or class or gender disparity. Yet others camefor a few years in their prime, before they could settledown to think of a better future for their family, espe-cially the children. No roads, no electricity, no toiletsor bathrooms either – funnily these added glitter toour haloes. Many of us dropped out of the rat racemuch before Manmohan Singh unleashed the Indianeconomy. We were fortunate that the difference be-tween the standard of schools or hospitals that we hadgot used to in the cities we came from, and the stan-dard that our children had to now face in the boon-docks was not much. The jhola, the khadi kurta – of-ten faded and with holes, defined us. Unlike the not-for-profit sector of our neighbours like Bangladeshand Pakistan, possibly Mother Teresa and Gandhi hadset the bar high for us in India for a life of austerity,self-abnegation and sacrifice. It helped us actually asit allowed some respect and dignity to pass off fromthem onto us who were trying to do charitable socialservice in the voluntary sector.But sooner than later the organisations were found toget transformed where professional social workersworked in NGOs (Non-Governmental Organisations)and tried to bring sustainable development.Though there always was a wide variation in terms ofthe issues that the founders and their followers in theorganisations would passionately follow in variousregions of India, the general aim of organisations thenwas to do small meaningful work, which could beshown to the Government or rarely to the corporatesector as a model.Gradually the Government got richer and under pres-sure from international donors, decided to fund theNGOs. With its classical anti-Midas touch, it not onlybrought corruption into the sector, but also sucked inthe wrong kind of money-minded people and broughtthe sector to disrepute. Traditional philanthropy thatwould either fund religious bodies or spend on issueslike blindness or TB, etc. was soon to see the rise ofIndian entrepreneurs who were not loathe to spend-ing money on organisations that could translate theirimpact to larger areas. Funders started pressurisingNGO leaders to up-scale, to work on issues that couldimpact more people in shorter time and to do work inmore than a few districts or a few states, as the need todepict their work graphically or on the website, dic-tated work to be carried out at a much larger scale.NOW!Let me admit that by now, I have lost it. I no longerhave the time to feel the zing, the smile, or the sparkleof many an eye. The smile of a child that I helped, orthe moist eyes of an old lady for whose surgery I ar-

ranged for some money, can’t perk me up today. Mylife now has no place for such things. Between theauditor, the banker, the funder and the Government, Ihave lost my sleep and my bearings, both. All of themseem to be doing things to help me to help the poor,but I seem to have lost it all.The PF authorities want me to file PF from day onefor every new employee, but I can’t register them be-cause they don’t have an Aadhar and can face a bigpenalty. There is only one Bank in the town close tomy village which registers Aadhar only for its owncustomers and even if I shifted all my accounts there,it only receives 10 odd applications a day as it alreadyhas a pile of 4000 applications pending. For the olderones, I can only file and pay the PF online, but myBank doesn’t allow any online transactions from myFCRA account meant for donations given by foreigncitizens or organisations. As I am the only one whohas activated an Internet Banking I help out by pay-ing the PF from my Bank and get reimbursed by myNGO, but this is a risky affair as the Income Tax au-thorities keep a watchful eye on any money that theTrustees have received!Also, the Bank is scared of the Home Ministry thatregulates foreign contributions, and has made its soft-ware so tight that its left hand doesn’t know what theright hand is doing. So it usually takes 4 to 6 weeksfor me to receive foreign donations sent for legitimatesocial work. The Bank also asks me for a certificatestating the purpose of every payment that I make. Rulesare rules, I am told. I complain to the Home Ministry,but to no avail.I get fed up ask the Home Ministry to change my Bankaccount that has been registered for receiving foreignfunds. I have to do this online. And I just can’t uploadthe documents for weeks, until I realise it is the slowinternet speed that is corrupting and blocking the sev-eral documents to be uploaded for the change. FinallyI manage this in July 2017. It is June 2018, but theHome Ministry site continues to show “Under Pro-cess.” Meanwhile the new Bank Account I opened hasbecome dormant. Any new application can also notbe filed unless the previous one is cleared. So we nowface legal action because we were to inform about thechanges in the Board of our Trustees within 15 daysof the change – in the same online application form. Itried meeting the Home Ministry people directly, butto avoid corruption, they do not encourage such prac-tice and turn down my request.Meanwhile a funder notices that the District mentionedon our letterhead is not the same as given in the FCRAregistration renewed a few years ago. We explain withgreat difficulty to this donor that district on our letter-head was freshly carved out in 2005 and though itexists in many Government sites, the Home Ministryonline process doesn’t show the new districts in Assamand hence we can’t click on it for permission for achange in address. And yet, the show goes on!


The other big change is about donors. Foreign donorshave been warned off from J & K, Chhattisgarh andthe northeast. So the purse has shrunk. Some othershave started inviting Global bids that require sophis-tication of a kind that can be found usually only in thebig metros, so the smaller grassroots NGOs like ushave lost the charm that earlier enticed funders to us.The Corporate Social Responsibility funds have be-come available, but a majority of the corporates wouldlike to use them in close vicinity of their factories, oroblige the areas pointed out by their concerned Min-ister. Our areas have only the rare industry and henceare unlikely to attract such money.Last but not the least is the clampdown on NGOs whoeven remotely question the policies of the Govern-ment. In a move akin to the US McCarthyism of yore,NGOs are being targeted. Public protests have becomerarer by the day and the Civil Society tries only withgreat difficulty to remain relevant on behalf of the poorand the marginalised.Majoritarianism has been fraudulently legitimised inthe name of democracy. NGOs partial to the Dalits,the poor or the minorities are now seen to be hurtingIndia’s image and are easily bandied as Western, orCommunist or even Pakistani.In other words, the work has lost the zing that one feltjust 10 or 15 years ago. With so much time gone infretting about the documentation, in filing reports andreturns, and in hitting a blank wall while doing many,many things, there is very little pleasure left in thework that we do. Maybe that is what THEY want. Tobore us enough to get out and leave the field open forthem to exploit. To push us enough to bang our headagainst the wall till it bleeds.There is no energy left and it seems the best way is tosurrender to the might of the State and sing Que serasera…….Sunil kaul is a medical doctor who heads a voluntaryorganisation based in rural Assam.Email: [email protected]

Health Budgets 2017-18

Ravi Duggal

Public health budgets in most states continue to re-main extremely low. Budget estimates for 2017-18show that the Centre and state governments togetherhave allocated about Rs 2,00,000 crore or Rs 1,538per capita, which is a mere 1.18 % of the GDP andwhich is less than half of the promise of 2.5% of theGDP made in the National Health Policy. The short-fall is Rs 2,37,000 crores. Graph 1 shows the patternof per capita public health spending across states.There are 14 states that are spending below thenational average, but they account for 84% of thepopulation and include big states like Uttar Pradesh,

Maharashtra, Bihar, Madhya Pradesh, Rajasthan, andWest Bengal, amongst others. There are 17 states thatspend more than the national average, but amongstthem only seven spend more than Rs 2,592 per capita,which is equivalent to 2.5% of the GDP. These topspenders are Arunachal Pradesh, Sikkim, Goa,Mizoram, Puducherry, Jammu and Kashmir, andHaryana. Most of these states have robust health indi-cators and have strong primary healthcare servicesbeing delivered through the public health system. Whatis also worth noting for these states is that, exceptHaryana, the other states do not have a significant pri-vate health sector, and hence the public health systemis forced to invest substantially in healthcare. In con-trast, almost all the 14 states that spend less than thenational average have a well-developed private healthsector, and this is perhaps the biggest reason forunderspending by these states. Other states that spendless than Rs 2,500 per capita, but more than the na-tional average are Kerala, Delhi, Himachal Pradeshand Meghalaya, and they also do reasonably well interms of health outcome indicators.Table 1 shows public health expenditure trends acrossthe last 4 years, and it is evident that we are not seeingany significant shifts in public health spending. Thepattern of spending across states remains more or lessthe same as discussed in the preceding paragraph,though some states like Bihar, Assam, Haryana, andJharkhand have shown a spurt, albeit at a lower level.The same states continue to spend above the nationalaverage, as well as the seven states mentioned abovethat continue to spend more than Rs 2,500 per capita.The National Sample Survey Organization’s (NSSO)71st Round (Table 2) further provides evidence thatout-of-pocket expenditure for both inpatient and out-patient care continue to increase, adding to the miseryof households of not only the poor but also the middleclass, and contributing to increasing pauperisationbecause the state is unable to commit a mere 2.5% ofthe GDP towards universal access to healthcare forall. The 2017 NHP roll-out is going to damage furtherthe budgetary commitments for health if we go by therecent NITI Aayog recommendation that district hos-pitals be converted into teaching hospitals throughprivatization for strengthening non-communicable dis-ease care and expansion of RSBY into the NationalHealth Protection Mission using insurance as a modeof financing which will facilitate access of the bottomhalf of the population to private hospitals for hospi-talization care. So, in the coming years, we may bewitnessing further expansion of the private sector andthe next round of the NSSO would be recording amuch higher out-of-pocket burden on households.Further in states that already have a strong privatehealth sector, especially amongst the 14 states spend-ing below the national average, there is an increasingreliance on health insurance schemes for secondaryand tertiary care through state-sponsored schemes like


the RSBY, Arogyashri, Jeevandayi, Yashaswani, etc.In 2015-16, government health insurance schemesalmost doubled the coverage to 27 crore persons from14 crores in 2012-13. This has resulted in Rs 2,500crores from the public exchequer each year beingutilised mainly to subsidise the private sector (seeTable 3). Further, private health insurance has alsobeen growing rapidly by 30%-40% annually in thelast decade. The total premiums being collected areover Rs 24,000 crore (over Rs 27,000 crore if we in-clude travel health insurance), and these mostly trans-late into spending in the private health sector.In Table 3, we see that the burden of insurance premi-ums is mostly on individuals and in private group in-surance policies. The government insurance schemeshave started showing a declining trend because of thehuge frauds unearthed and dissatisfaction amongstbeneficiaries. Several state governments, likeKarnataka, Tamil Nadu and Andhra Pradesh, elimi-nated the insurance company in their schemes and haveset up a Trust Fund instead. Despite this adverse ex-perience with insurance, a number of states are in theprocess of setting up insurance-based schemes becauseof the push by the NITI Aayog. Given the experiencewith insurance-based schemes across states, especiallybecause these tend to be targeted at the poor who donot have the capacity to negotiate with the providers,it is clear that insurance cannot be an option forhealthcare financing, and the government should re-vert to strengthening tax-based financing of healthcarethrough substantial budgetary increases for strength-ening public provisioning of services to move quicklytowards the 2.5% GDP target to begin with.

What is even more interesting is that NSSO data re-veals that these very states which have resorted to theinsurance model are also states where out-of-pocketexpenditure has increased (Table 2). So, the insuranceroute is clearly undesirable because not only does itdivert resources to the private health sector and de-prives public health services adequate budgets, but italso fuels the private markets in health and increasesthe out-of-pocket burden on households.

So, the differential patterns of health spending we seeacross states convey an honest message that to pro-vide for a reasonably robust healthcare service statesneed to invest immediately at least Rs 2,500 per capita(and in the next few years reach Rs 3,400- 3800 percapita, which would equal 2.5% of GDP at currentprices). This will ensure that the required infrastruc-ture is in place and is well-maintained, that all neededhuman resources are in place, and all other inputs likemedicines, diagnostics and equipment are adequatelyprovided for. Further, the unregulated growth of theprivate health sector and the increased reliance onhealth insurance to finance hospitalisations becomebarriers to an effective functioning of the public healthsector. We do have good models of robust public healthsystems in states like Mizoram, Sikkim, Puducherryand Goa, and have seen transformations in Tamil Naduand Kerala. So there are no reasons why other statesshould not learn from them and emulate them.

Ravi Duggal is an independent researcher and activ-ist in public health.


Source: Respective State Budget Documents and the Union Budget 2017-18. States with asterisk refer to 2016 - 17budget estimates.


Table 2: Average total OOPS medical expenditure for inpatients in last 365 days and outpatients perailing person in last 15 days (in Rs)

States Avg Exp Inpatient Avg Exp Outpatient

Andhra Pradesh 18551 437Arunachal Pradesh 6247 868Assam 14810 610Bihar 12865 716Chhattisgarh 14475 893Delhi 34658 778Goa 26270 656Gujarat 16952 343Haryana 24214 726Himachal Pradesh 19431 569

Table 1: Trends in Per Capita Expenditure on Health (in Rs.) across states 2014-2018States 2014-15 2015-16 2016-17 2017-18

Actuals Actuals Revised Budget Budget EstimatesAndhra Pradesh - 578 652 789Arunachal Pradesh 4496 4893 6706 —Assam 605 891 1280 1485Bihar 356 558 952 898Chhattisgarh 920 1050 1591 1671Delhi 1551 1596 1907 2299Goa - 1427 2310 2536Gujarat 846 950 1079 1160Haryana 839 1851 2337 2667Himachal Pradesh 1634 1756 2227 2334Jammu & Kashmir 1181 1565 1763 2797Jharkhand 478 650 881 912Karnataka 931 894 1040 1069Kerala 1090 1347 1640 1905Madhya Pradesh 624 683 779 978Maharashtra 682 820 1040 975Manipur 2250 2069 2019 —Meghalya 2106 2205 2595 2567Mizoram 3329 3601 5396 4304Nagaland — 2081 2716 2565Odisha 766 878 1154 1329Punjab 869 940 1123 1215Rajasthan 911 1078 1175 1319Sikkim 4131 4096 4865 5575Tamil Nadu 1117 1229 1276 1457Telangana 1012.2 1539.1 1769.5 —Tripura 1783 1684 2648 2000Uttar Pradesh 526 564 726 892Uttarakhand 1403 1335 1346 1787West Bengal 681 834 875 806India average (Rs.) 980 1252 1411 1538India (Rs. Crores) 121600 157743 180657 200000India (%GDP) 0.99 1.15 1.19 1.18

Source: State Budget Books - for data on State Health Expenditure; India includes Union Govt. and UTs; Populationdata from Population Projection for India and States 2001-2026, Registrar General


States Avg Exp Inpatient Avg Exp OutpatientJammu & Kashmir 9536 854Jharkhand 11270 566Karnataka 17148 527Kerala 16775 379Madhya Pradesh 16713 673Maharashtra 24085 599Manipur 7226 1196Meghalaya 6974 182Mizoram 11031 795Nagaland 8394 405Odisha 12095 589Punjab 28539 621Rajasthan 13976 601Sikkim 8543 263Tamil Nadu 18006 384Telangana 20021 827Tripura 6942 1114Uttar Pradesh 22540 771Uttarakhand 13985 660West Bengal 15910 475A & N Islands 5437 409Chandigarh 34604 586Dadra & N. Haveli 5821 269Daman & Diu 7309 375Lakshadweep 8744 154Puducherry 11821 526All States & UTs 18268 556

Source: NSSO 71st Round, 2016

Category 2011-12 2012-13 2013-14 2014-15 2015-16Premium (in Rs crore)Govt Schemes 2225 2348 2082 2474 2425Pvt Group 5948 7186 8058 8899 11621Pvt Individual 4896 5919 7355 8772 10353All 13069 15453 17495 20145 24399Public Sector 8015 9580 10841 12882 15591Private Sector 3445 4205 4482 4386 4911Pvt Standalone 1609 1668 2172 2828 3946All 13069 15453 17495 20096 24448Coverage (in Lakh persons)Govt Schemes 1612 1494 1553 2143 2733Pvt Group 300 343 337 483 570Pvt Individual 206 236 272 254 287All 2118 2073 2162 2880 3590Premium per Insured (in Rs)Govt Schemes 138 157 134 115 89Pvt Group 1983 2095 2391 1842 2039Pvt Individual 2377 2508 2704 3454 3607All 617 745 809 699 680

Table 3: Health Insurance Premiums and Coverage

Source: IRDAI Annual Report 2015-16


Contents Page numberIn Lieu of an Editorial… 1We Need ‘Health for All Declaration – 2018’ 3Revisiting Health For All Organizing Committee of MFC 2018 Annual 4Book reviewsK Sujatha Rao, Do We Care? India’s Health System. Purendra Prasad 11Sarah Hodges and Mohan Rao (eds), Public Health and Private Wealth:Stem Cells, Surrogates, and Other Strategic Bodies Surekha Garimella 13Vikas Bajpai and Anoop Saraya, Health beyond medicine:Some reflections on the sociology and politics of health in India Arima Mishra 15Sundari Ravindran, T.K. and Gaitonde, Rakhal, HealthInequities in India: A Synthesis of Recent Evidence Nandita Bhan 16Vikas Bajpai and Anoop Saraya, Food security inIndia: Myth and reality Sylvia Karpagam 18R. Poornalingam, Change: Change Management Strategies toTransform your Organization S.Srinivasan 20Essay: The stories of Dalit poets’ deaths Gogu Shyamala 23State of Health In India 2018: A partial snapshotReining in the Private Health Sector Ravi Duggal 26Fractured approach towards the critical public health sector- Tejal Barai – Jaitly 28Public Private Partnership / P3s in Health Sector in India Bijoya Roy 29Reorienting Medical Education to address Health Inequities Sangeeta Rege 31The impact of NEET on an individual institution Anand Zachariah 32Integrated Child Development Scheme: current status Dhruv Mankad 34Population Policy and Population Stabilization: Where are we today? Smitha Sasidharan Nair 37Then and Now: From the boondocks Sunil Kaul 38Health Budgets 2017-18 Ravi Duggal 40

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