India’s health system: No lessons learned
Sunil K Pandya
Published online: August 30, 2017
K Sujatha Rao, Do we care? India’s health system. New Delhi: Oxford University Press, 2017. 479 pages, INR 850 (hard cover), ISBN–13:978-0-19-946954-3
Ms Kanuru Sujatha Rao studied post-graduate history at Delhi University. She has a Master’s Degree in Public Administration from Harvard University. She joined the Indian Administrative Service in 1974 and belonged to the Andhra Pradesh cadre. She has dealt with health and family welfare in the Government of Andhra Pradesh and in the Government of India. She won plaudits as the Secretary, Department of AIDS Control and Director General, National AIDS Control Organisation (NACO). Some of her work there is described in Chapter 4 (pp 201-297).
She was appointed Secretary, Union Ministry of Health and Family Welfare in September 2009 and retired from government service on November 30, 2010.
The Preface sums up the contents of the book.
The question asked in the title of the book under review can only be answered with a resounding NO!
Had we cared, we would have ensured that the slogan “Health for all” pronounced in the World Health Assembly in 1977 and accepted internationally as the stated objective of all governments would not have remained an unrealised dream in India. Health was supposed to be within the reach of every citizen by 2000. Education, hygienic housing, potable water supply round the clock, the elimination of malnutrition and ignorance on matters pertaining to health, the lowering of neonatal and maternal mortality to international standards, access to facilities for treatment of illness and gainful employment remain beyond the reach of vast numbers throughout our country seventeen years after the deadline set in 1977 has passed.
Ms. Rao voices such a feeling herself at the start of the book. She informs us that the title of the book was suggested by a leader of the transgender community. “I cannot but agree to the title proposed as, sadly, from the viewpoint of the deprived and discriminated population groups living at the margins, India’s health system just does not care for them.” (p xxv)
The book attempts a discussion on why this dismal state of affairs persists.
Her analysis of the manner in which the government in Delhi and those in the states allocate funds shows clearly the lop-sided priorities that follow political expediency, exertion of pressure by interested groups and corruption. Add to this the complex “processes, procedures and systems for releasing funds in India” and the fact that “in an environment of scarcity, low utilization determines (lower) future allocation despite the fact that allocated budgets have not been released in the first instance” and a vicious cycle is set in motion (p xiv).
Governments and bureaucrats have often resorted to taking refuge under the phrase “want of resources” when faulted for failures in the health sector. Is it not strange that these same groups can come up with funds for “politically sensitive” but practically senseless steps costing crores of rupees? In the state of Maharashtra we are witness to such allocation of funds for building a statue to Shivaji in the ocean adjoining south Mumbai and the creation of expensive memorials to the departed leaders of two political parties. This conclusion is validated by Ms Rao when she states, “Non-availability of resources for health has more to do with the mindset and political priorities… Resource allocations have been guided more by political pragmatism than national welfare.” (pp 42-43)
Several factors contributing to the present sorry state are analysed in the six chapters that constitute the book.
- Expectation that the creation of grandiose institutions such as All Institutes of Medical Sciences (AIIMS) will solve the major health problems of the nation. Dr C G Pandit, one of the advisors to the government when the first AIIMS was being planned in Delhi, reviewed its functions after a decade or so of its existence. It had been intended to produce teachers with a broad understanding of the principles and practice of modern medicine who would go out to populate smaller medical colleges in the country and raise the general standards of medicine. Instead, he found that most of its graduates migrated to lucrative pastures abroad. Hardly any populated smaller colleges as professors. This lesson has not been learnt and we continue to see more such institutes being set up.
- The general approach in governments has been to ‘adopt a techno-managerial approach… rather than undertaking the more difficult but sustainable policy of tackling the causative factors and linking diseases with the social conditions that produce it…’ This system encourages sitting in air-conditioned offices, holding meetings and making ex-parte pronouncements rather than moving around in villages and towns, meeting local citizens, officials and health personnel and learning first-hand of the problems experienced and solutions suggested by and acceptable to those living and working there.
- Long term planning of health policies was left to the Planning Commission. The Commission was subject to pressure from its political masters. It was habituated to form committee after committee, often made up of the same individuals and often at cross purposes with officials in the ministries of health and education. Strategies were formulated on directives from “the High Command”, personal whims and questionable data. Means for impartial monitoring and ensuring punishment for wrong-doers were either not built into their programmes or not utilised. Critics of such strategies were ignored. The Commission achieved little long-term benefit for the country in return for the huge sums allocated and squandered.
- The attitude of several states towards ensuring health for their citizens remains pathetic. High rates of maternal and infant mortality, malnutrition in children and women, the spread of debilitating diseases such as tuberculosis and the absence of clinics and hospitals where the poor can receive good quality medical care are common in these states. Ms Rao provides two examples of the horrendous events that are “disturbingly routine” in such states: a ten-day infant dying from rodent bites in the intensive care unit of a teaching hospital and snakes wandering around the operation theatre (p xvi).
- Doctors in service are permitted to carry on private practice to the detriment of their duties to their patients in primary health centres, district and public sector tertiary care hospitals. The absence of regulatory oversight to ensure that there is no conflict of interest has engendered a sense of impunity.
- Inconvenient doctors are transferred. “As a rule, transfer policies are non-transparent and arbitrary and constitute the most lucrative source of rent-seeking… Postings and transfers are lucrative, a source of power and patronage and control over doctors besides being the biggest source of indiscipline in the department.” (pp 153-4)
- Salaries account for 50% and drugs for 10% of the total spending. Surely infrastructure, purchase and maintenance of vital equipment and drugs needed for the care of patients should gain overwhelming priority over salaries. The present system ensures that doctors while away their time in clinics without drugs and equipment or, worse, set up private clinics which poor patients must, perforce attend and in which they must pay for what should have been provided free of cost (pp 62, 68).
- In times of financial stringency, it is the salary component that is safeguarded and budgets for drugs or maintenance often slashed.
Ms Rao discusses the privatisation of healthcare in some detail.
Privatisation received a big boost when the governments in Delhi and the various states decided, in the 1960s, to follow economists in the US advocating that “health is as much a marketable commodity as any other, making way for markets in the health sector.” (p 15) Blind adoption of measures proposed by the World Bank and the World Health Organisation, without consideration of the implications of such steps in India further worsened the situation. (pp 21-22)
Our “political system colluded with the private sector to the disadvantage of the public sector.” (p 95)
More reprehensible still, “public resources were used to strengthen the private sector” (p 23). The voices of protest against such an approach in India, where vast numbers are abjectly poor and where the public sector was crucial to ensure their care in primary, secondary and tertiary health care centres, were drowned out. “By 2004, the private sector accounted for three-quarters of outpatient treatment, 60% of inpatients and three-quarters of the specialists and technology” (p 16).
Aggressive promotion of private medical colleges without enforcing quality and high standards in them has accompanied neglect of reputed and well-established colleges in the public sector. No systems are in place to ensure transparency, accountability and professional oversight. It is unlikely that they will ever be formulated. “The emergence of the nexus between the political system and financial investors, who in many cases were connected to politicians as relatives, proxies or funders for their elections” will ensure this (p 150).
Private sector clinics and 5-star hospitals now dominate not only in metropolitan centres but also in the smaller towns. Poor services in public sector clinics, district and tertiary hospitals drive even the lower middle classes to these expensive clinics with disastrous consequences to the economic status of their families. 32 million were pushed below the poverty line in their attempt to restore health to a sick person, 22 million of these were in the rural areas (pp xiii, 20, 38)
“Julian Hart refers to the phenomenon of the inverse care law that relentlessly subordinates human values to pursuit of profit…”
The real tragedy lies in the fact that when India gained independence, ministers, senior bureaucrats and the upper middle classes sought and were provided medical care of the highest standards in our public sector teaching hospitals! These hospitals and their attached medical colleges led medical advances in the country. Shakespeare’s words, uttered in a different context, are applicable here:
O, what a fall was there, my countrymen!
Then I, and you, and all of us fell down,
Whilst bloody treason flourished over us.
(Julius Caesar, Act 3, scene 2)
In most of the above instances, bureaucracies have failed to form rules and regulations and, more important, to ensure that they are followed scrupulously.
And as regards bureaucrats, Ms. Rao notes: “If policymaking is the business of politicians, the administrative and technical bureaucracies have the responsibility of forming rules… instituting processes, implementing policies and managing the contradictions. India’s record in this aspect has been woeful.” (page xvi)
In many instances, bureaucrats have been found to lack any sensitivity towards the problems of those working in the field. I shall never forget our meeting with a Secretary in the Ministry of Health, Government of Maharashtra. When we pleaded for the purchase of vital equipment for the Sir Jamsetjee Jejeebhoy Hospital in Mumbai, run by the Government, he burst out, “You are always wanting this and that. You are a drain on the economy. You never give anything!” To say that we were stunned would be an understatement. We were full-time employees of the Government, earning far less than he did. We treated the poorest of poor patients in the hospital. What could we give him? What did he expect from us?
Ms Rao understates the issue when she says: “Over the years, the institution of bureaucracy is beginning to show signs of weakening. With the emergence of interest groups, policy inputs are increasingly being sourced from extra-constitutional authorities…”
She has rightly blamed the health crisis on the absence of sustained leadership at the political, administrative and technical levels and on the general erosion of values. “We have never had a minister resign for preventable deaths or a secretary in government sacked for failing to achieve the targets that have been laid down.” (p xix) In doing so, she has highlighted what is probably the chief cause for our present state. When inefficient and corrupt ministers and bureaucrats can be shielded again and again, there is a general loss of morale amongst public-spirited individuals and groups.
The advent of the government in New Delhi nominally headed by Dr Manmohan Singh worsened an existing nightmare. “Health policy had to be formulated in this maze of layered power centres – diffused political power, multiple interest groups… along with the formal systems of governance… and the institutional trappings of democracy…” (pp 300-301). “The National Advisory Council (NAC) had no real power but it had the prestige that proximity to Sonia Gandhi gave it. Following from that, it had access to all policies and authorities to lobby for people or ideas.” (p 381)
Then there is the game of badminton played between the central government and state governments. Those in power in Delhi argue that health is a state subject and wash their hands of all deficiencies in this sector. “When pushed, the tendency is either to leave it to the states… or to postpone indefinitely by constituting committees…” (p 132) The states, on the other hand, point out that the central government has the funds they need for adequate health care and these are not released in adequate quantities and in an efficient manner. “…The centre has power without responsibility and the states have responsibilities without resources…” (p 133).
States find it easier to badger the government in Delhi for additional funds than making their own efforts at raising resources.
Consider also the reasons why some states have remained backward after seventy years of independence. When such backward states are politically important on the national stage, the situation is fraught with peril. The total lack of accountability under our democratic system cannot but lead to a perpetuation or worsening of our present sorry state. Ms. Rao provides an interesting example. “Seven states were provided Rs. 58.87 billion for health… But these transfers turned out to be ineffective as the conditionalities were too complicated.” Ms. Rao does not name these states nor does she provide details on these complicated conditionalities (p 47).
Cudgels can be taken up against some of the statements made by the author.
Ms. Rao errs when she states that the British “argued on the basis of empirical science and observed data when they imposed modern medicine upon a reluctant people” (pp 6, 7). Let me just provide one example to refute this argument. When Sir Robert Grant, Governor of Bombay, considered setting up a medical college in Bombay in the 1830s, he got Dr Charles Morehead and other medical experts to carry out a survey throughout the Presidency. A questionnaire running into several pages was prepared. It was sent out to all medical officers in the Presidency, vaccinators and native Indian individuals and groups who could contribute information on medical education and practice then in vogue in cities, towns and villages in the Presidency. I quote from just one of the responses to this questionnaire. Bal Gangadhar Shastri Jambhekar, founder-editor of the Marathi newspaper Bombay Durpun stated: “We have every reason to believe that vast numbers die on this island for want of proper medical attendance and due to the ignorance of the native medical practitioners to whom, in general, the native inhabitants are obliged to resort when overtaken by sickness… Our object, however, is to suggest to some of our own countrymen to study medicine according to the European system and by that means, while they secure a livelihood for themselves, contribute to the savings of the lives of numbers who for want of regularly brought up medical men are obliged to entrust their lives to inexperienced practitioners…”. This and other similar findings of the survey culminated in the formation of the college posthumously named after Grant. The success of this government medical college, those in Calcutta and Madras, and subsequent colleges in other parts of the country are testimony to the stellar role they played in creating a cadre of excellent Indian physicians and educationists. The college in Bombay was especially noteworthy as it was, from its start, intended to produce full-fledged doctors who would cater to their fellow-countrymen.
Ms Rao is also inaccurate when she bemoans the lack of attempts at stopping the privatisation of health or handing over of medical education to profiteers (p xix). Were she to read editorials and essays published in the Indian Journal of Medical Ethics, the Economic and Political Weekly and the publications of the Medico-Friends Circle – to name just three sources – she would have seen evidence of several such protests.
The sorry fact remains that the brute force and apparently unlimited funds at the disposal of governments for judicial battles and the pathetic state of our over-burdened judiciary provide favourable conditions to render any protest infructuous. Add to these the fact that several private medical colleges are the brain-children of extremely powerful political figures and ex-ministers and you can see that individuals and small groups stand no chance of effecting change.
Ms. Rao is also unusually gentle in her criticism of the government when she states that “strengthening the private sector in secondary and tertiary care markets … reflected the government’s confused and ambivalent thinking.” (p 24) Many believe that privatisation was a coldly calculated step taken to benefit coteries close to and even within the government.
Ms Rao is right when she points out that powerful organisations of medical professionals such as the Indian Medical Association have maintained a studied silence and turned a blind eye to developments that have wreaked havoc in our system of medical education and care of poor patients. These organisations and agencies such as the Medical Council of India and the state medical councils have colluded for mutual benefits. These malpractices too have been highlighted again and again in journals such as those referred to above, but to no avail. It is obvious that writers and editors lack the means, power and stamina for decisive battles.
Ms. Rao comments on the role the judiciary and media must play in safeguarding patients’ interests and in making the government the providers of care. “They are the only institutions with that capacity.” (p 132). I beg to disagree. The primary change must come from within the Government itself. Ministers, bureaucrats, the Parliament and the Legislative Assemblies have the principal responsibility to promote health and the welfare of citizens. The judiciary, the media and the public at large can only play secondary roles.
Despite seventy years of independence we have no means for ensuring that states put the development of the infrastructure needed for the health of their people at a high priority. Thus, Telangana may choose to focus on building temples and Andhra Pradesh on building a capital.
Despite spending two decades in the health sector in various capacities, it appears that the principal causes for our substandard healthcare system became apparent to Ms. Rao only in 2012, when she “was struck by the remarkable absence of political, administrative or technical leadership in the health sector.” (p xxiv) As with some other senior retired officers of the Indian Administrative Services (IAS), she gained “the citizen’s perspective of public policy… after my retirement…” Could it be that the subservience shown to such senior officers as herself by all those in lesser positions blinds them to the realities faced by the common Indian?
Some sections of the book appear to have brought out the bureaucrat in her. “Not achieving improved health is not a question of a lazy government or insensitive doctors but a reflection of the relational power balances between the political and economic forces at play, competing priorities, implementational capacities of public institutions, the extent and strength of the prevailing structural inequalities, and the effectiveness of public policies in addressing them, and so on.” (p 5) Such reasoning detracts from a consideration of the precise means for effecting a cure.
At times, her explanation appears contradictory. Describing the poor conditions of our public facilities and the “… iniquities and disparities that characterize India’s development story…” she disavows the claim that lack of resources, indifference of caregivers or an apathetic bureaucracy are to blame. Instead, she blames the migration of the middle classes to the private sector and their reluctance to bear the increase in taxes for building a public health system (pp xviii – xix). Yet, again and again, throughout the book, she points out that the allocations by governments in India for this same public health system have been pathetically low and that the migration to the private sector has been out of necessity born of the poor quality or absence of public health facilities. Funds generated by taxes have, ever so often, been frittered away on political expediencies or stolen by those in power.
Ms. Rao offers several gloomy truths in the course of her text.
- Health is not a much-sought-after ministry as it has measly resources, poor policy attention and low priority in the eyes of the prime minister.
- Most state government systems are abysmally deficient.
- Bureaucracies dislike true empowerment of people and prefer dependence and being “in control”.
- In India, policymaking and priority-setting regarding financial, administrative or technical matters related to health care are centralised and operate in a closed-door system with limitation on entry.
- The bane of governance in India is the non-implementation of most laws.
- The attitude of finance officers treats each release of funds as a favour and not a responsibility. There are instances where the finance department approves sanctions and promptly calls up the district treasury officer not to release funds.
- PPP (public-private-partnerships) can just become another way of privatising profits and nationalising losses.
- The health sector is but a reflection of the governance model system set up by the political system.
- The key (to success) lies in laying systems that ensure that ensure coordination and foster participation and an ethos of sharing responsibility (and working for the common good). India has singularly failed in this regard.
Ms Rao also refers to basic truths that have been cheerfully discarded by governments in India over the past seven decades:
- Far more than the bricks and mortar, at the core of the health system are the values that drive it.
- It is imperative that morality determines politics and economics.
- Ideas and strategies might be sound. The difficult and often neglected part is the building of systems and institutional mechanisms to implement them.
- Substituting prevention with treatment is a more costly and unsustainable option.
Ms. Rao makes the point that deep reforms are required for resetting priorities.
How are these to be implemented?
“Ultimately it is the people who will have to assume responsibility,” says Ms Rao.
The toiling masses that are unsure of their next meal have more pressing tasks on hand. The middle classes and the rich have decided that instead of wasting time and effort on legal battles that may last years and decades and are almost certain to fail, it is wiser to come to terms with reality and seek medical care in private facilities that will meet their immediate requirements.
Editors and authors writing in journals such as Indian Journal of Medical Ethics, The National Medical Journal of India, Medico-Friends Circle Bulletin, Economic and Political Weekly had done their best over decades without making a dent on policies.
Ms Rao refers – without naming persons – to the incident when Mr Keshav Desiraju was unceremoniously shunted out of the Union Ministry of Health and Family Welfare in order to facilitate the re-entry of Dr Ketan Desai into the Medical Council of India (MCI) (p 111). On this and subsequent pages she discusses the charges of corruption against Dr Desai and acts of the Government of India that must, forever, remain a blot on its reputation. Ms. Rao rightly emphasises, “The MCI is largely responsible for the deterioration in the standards of medical education and the enormous corruption associated with it.” (p 165)
Ms Rao discusses the policy of arbitrary transfers of efficient and effective officers in the health sector to posts in ministries, such as those concerned with textiles and personnel, which cannot use their expertise. The health sector loses invaluable skills acquired over the years at the stroke of a pen (p 127). The reader would have benefited had Ms Rao described steps taken by successive Chief Secretaries and Health Secretaries to ensure that such transfers do not take place.
Ms. Rao describes the three “critical fault lines” that permit blatantly detrimental political acts: a) yielding to politically powerful individuals; b) inability of constitutional authorities to check such abuse of power; c) the moral void and corruption permitting political expediency to override the rule of law. There is a fourth fault line, especially evident in the transfer of Mr Desiraju: the failure of the general body of bureaucrats to rise en masse in support of their colleague who had done no wrong and was, in fact, doing his best to prevent a corrupt person, convicted in a court of law, from entering a body entrusted with ensuring ethical medical education and practice in the country.
Ms Rao has listed seven elements of good governance that have been flouted (pp 135-6) I wish she had placed the last item at the top of the list as without ethics and the elimination of corruption, none of the other six will work.
In the final Chapter 6, Ms Rao addresses the future. She discusses five areas that deserve attention. Some of these have already been discussed in earlier chapters. She points out that reforms are painful processes but need to be undertaken. She concludes that such reforms are only possible “if our governments care and rise above partisanship and political squabbling.” Once again, a quotation from Shakespeare is appropriate: “Ay, there’s the rub.” (Hamlet, Act 3, Scene 1).
When the stables of King Augeas were filled with the urinary and faecal outpouring of thousands of cattle, sheep, goats, and horses and had not been cleaned in 30 years, it required a Hercules to cleanse them.
Do we have to await a similar Hercules?
Or can we hope for a miraculous change in the characters of our ministers and bureaucrats – blessed as they are with means and power – to bring our healthcare system out of its present morass and in line with those in the enlightened countries that put the welfare of their peoples as their prime responsibility? We would also need a similar miracle in the minds of each and every one of us. Ms Rao rightly notes, “Society as a whole seems to have lost its soul in its blind pursuit of money.”
This volume embodies many facts, most of them conducive to dismay. Even so, it needs careful study. for only an awareness of our faults and shortcomings can help us emerge with constructive solutions that may improve matters.
The volume would have gained much from the addition of details of what Ms Rao did to change the situation for the better during the years when she influenced events pertaining to healthcare.
Additional accounts of how some of her efforts were stymied or even countermanded by those above her and how such frustrating situations were overcome by her so that the intended good from her efforts was effected would have encouraged and helped younger officers in her service.