The viral AIIMS Twitter post and the state of healthcare in India
Tragedies, and not just medical ones, are a regular feature of India’s hospitals both public and private. One such heart-rending tragedy was recently brought to people’s attention by the relative of a patient at AIIMS New Delhi. Among other things, the concerned family’s experience threw light (once again) on the deplorable state of India’s hospital system and of the patient-doctor relationship. Many insightful commentaries followed. One was reminded of the situation just a few years back when the Covid pandemic had dissolved away almost all of the temporary band-aids that we had time and again put on our wobbly healthcare structures and institutions, providing a real opportunity for a national reckoning. That much-needed reckoning, despite the optimism of some experts, never arrived. A nation of a hundred and thirty crore people apparently had other, more important issues to attend to.
We all want reform, and the people of India indeed deserve progressive, equitable healthcare reform. However, it is clear that as long as our public discourse and policymaking circles continue to be dominated by the same old elite communities and attitudes, especially privileged-caste groups and their hierarchy-centered worldviews, reform will remain as evasive as a specialist doctor in a remote rural health center. Below I present this analysis in more detail, written first more than three years ago for The Wire during the Covid pandemic.
With Covid exposing the fragility of India’s healthcare system and the profiteering nature of corporate hospitals, there has been some optimistic expectation of substantial change in the healthcare scenario of the country post-pandemic. However, the cynic knows that there rarely is a “trickle-up” of activist sentiments and intellectual rationale into the elite corridors of power.
In fact India’s administration has its priorities sorted. The NITI Aayog is going ahead with their plans to create more private medical care centres by privatizing district hospitals. Ayushman Bharat authorities seem to think it’s a good idea to allow the World Bank — the ideas of which have weakened government healthcare facilities in many countries — to influence their analyses. And major personalities in the government seem to be living in a parallel universe cleaved from reality. The refusal to acknowledge community transmission of Covid, the ICMR-led HCQ fiasco, and the downplaying of the migrant crisis are just some examples.
With such indifference, arrogance, and denial around, we cannot expect the administration to be argumentatively convinced to implement progressive reform post-Covid. That leaves us with privileged citizens, who often exert some influence on government policies: have they at least woken up to the need for healthcare reform? Most privileged Indians indeed are furious with corporate hospitals. However, it seems much of this anger springs from the individually-oriented peeve that healthcare was made too pricey for them, than the universally-oriented principle that everyone deserves quality and affordable care. In fact the principle of everyone receiving adequate medical care “irrespective of their ability to pay for it” (as expressed in the 1946 Bhore Committee report) has hardly animated political and elite discourses beyond the early years of independence.
The privileged public’s anger regarding healthcare in India mostly springs from the individually-oriented peeve that healthcare was made too pricey for them, than the universally-oriented principle that everyone deserves quality and affordable care.
But that doesn’t mean that people in India did not, as is often lamented, prioritize healthcare. They actually have always lobbied for good, affordable healthcare services — but only for themselves: i.e., as a group-based demand and not a universalist demand.
Consider the Central Government Health Scheme, or CGHS. When it was proposed in the early 1950s for central government employees based in Delhi, the goal was gradually to scale it up to other cities and, over the subsequent years, to most of the population. What happened is that the CGHS did expand to other regions, but was kept exclusive to Union government employees and their families. Most of India’s elite officers climbed the ladder of this generous healthcare scheme, but on reaching the top they kicked it away instead of sharing it with others (see here for sociologist Satish Deshpande’s thesis on how the privileged in India frequently ‘kick away’ the ladders of socioeconomic mobility).
Though there was organized lobbying for medical services in the early decades of independence, it rarely was universalist: central government employees, ESIS members, Railway employees, defence personnel all lobbied for better healthcare services for themselves and their families, and sought to restrict ‘outsiders’ from accessing their facilities. Privileged Indians who did not belong to any of the above groups used private nursing homes and private wards of government and charitable hospitals as their domains, and the super-privileged oftentimes just flew abroad. Later in the 2000s, the rise of private multi-specialty hospitals and employment insurance made even the occasional middle-class visit to the government hospital a rarity.
Though there was organized lobbying for medical services in the early decades of independence, it rarely was universalist: central government employees, ESIS members, Railway employees, defence personnel all lobbied for better healthcare services for themselves and their families, and sought to restrict ‘outsiders’ from accessing their facilities
In short, over time all privileged groups in India have managed to carve out more-or-less comfortable medical care niches for themselves depending upon their paying capacities. And as they kicked the ladders away, they also looked the other way. For decades the privileged in India have known but quietly ignored the disrespectful, at times abusive, nature of care provided to the underprivileged, as well as the fact that many of them slip into lifelong poverty due to healthcare expenses. It is, thus, perhaps too optimistic to expect that the pandemic will bring about a radical change in such entrenched attitudes. In summary, an indifferent political class, and an inward-looking, injustice-inured privileged class, together point to a status-quoist post-Covid future for India when it comes to healthcare and reform.
What I mean here by healthcare reform is universal healthcare, or UHC (which, in Amartya Sen’s eloquent words, is an affordable dream). For India this means major improvements in preventive and primary healthcare, and in the quality and quantity of care in government facilities at all levels (and not just the “tertiary”, hospital-intensive level), eventually halting the over-dependence of India’s millions on private, out-of-pocket spending. Unfortunately, the much-publicized Ayushman Bharat is unhelpful in the Indian context with respect to UHC. Insurance-based schemes are at best a temporary stop-gap measure, and at worst an expensive distraction from putting in place the more equitable and sustainable structures of UHC. The underprivileged are not unwilling to pay for healthcare and preventive measures like nutrition, but our existing system makes them pay far more, sometimes catastrophically more, than they can afford. It is this asymmetry that UHC seeks to remedy.
As we demand healthcare reform in India, we must remember that the powerful and the elite are not suddenly going to be convinced of the towering idea that the underprivileged deserve the same kind of quality healthcare services and protection from financial stress as the privileged.
Now as we demand healthcare reform for a post-Covid India, we must remember that the powerful and the elite are not suddenly going to be convinced of the towering idea that the underprivileged deserve the same kind of quality healthcare services and protection from financial stress as the privileged. Public health experts have done tremendous research and written several volumes on the urgent need for UHC, but the translation of research findings and expert recommendations into popular ‘common-sense’ is a political act, and cannot be accomplished by academic experts alone. UHC needs, along with these experts, the skills of many others like social scientists, activists, journalists, and grassroots advocates working on the ground with communities.
Considering that Covid won’t be the last pandemic our generation encounters, and that serious climate change-induced healthcare challenges are knocking on our doors right now, the absence of UHC in a country of 1.3 billion means that we are in a disastrous state of affairs. India cannot afford to neglect putting in place, as quickly as possible, a robust universal healthcare apparatus. And public health experts, on their part, cannot afford to neglect putting in place strong alliances with community-based, politically active individuals and groups. For it to materialize in a meaningful way, UHC needs to stop being just a top-down expert recommendation and turn into a bottom-up grassroots demand.
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P.S: One such example of a bottom-up demand action, happening on Dec 11th in Belagavi, Karnataka, was brought to my attention recently in a post by Dr Akshay S Dinesh.
