Decoding the twisted concepts of welfare capitalism
Published online: December15, 2018
Purendra Prasad, Amar Jesani, Editors. Equity and access: Health care studies in India. New Delhi: Oxford University Press; 2018. 418 pages, INR 1195, ISBN: 9780199482160.
As a public health practitioner in rural central India, issues of access to healthcare as well as cost, quality and equity issues have always interested me. Yet my day to day work has brought only a few aspects into sharper focus. This book caught my attention due to the interesting title and the promise by the editors that the book traces the role of the state and market forces in worsening health inequities. Working in a small part of the country where health inequities abound, I was curious to get a wider perspective on this. My hopes were fulfilled and I enjoyed reading this volume and learnt much from it. I would like to give the reader a quick tour of the book.
Both editors are public health scholars who have impressed me with their incisive analyses of health issues over the years. What attracted me most about the design of the book was the political economy approach to the issues that all 17 papers in this compendium take.
The first section on the role of the state and the market in shaping the healthcare system has some sterling contributions. Two chapters on medical education which stand out elucidate how commercial pressures have determined its direction. Anand Zachariah points out that the structural problems in medical education are related to the orientation of medical knowledge, a divorce of medical education from healthcare, and its privatisation. Both Zachariah and Neha Madhiwala offer specific advice on how to mitigate this maldevelopment through changes in pedagogy and content.
Purendra Prasad explains how the economic reforms of the last three decades have fostered increased costs and inefficiency besides reducing regulation of quality and access to health systems; and accelerated the development of an unregulated private healthcare market. He points out three trends which exemplify it – decline of the secondary and primary government health services, excessive growth of corporate and private healthcare and significant rise in people’s out of pocket expenditure.
His scathing criticism of the agenda of healthcare reforms of the last decade in the name of greater accessibility and social justice is spot on. He argues that such individual or household level protection for curative procedures distorts the priorities of the public health agenda of preventive and primary healthcare that primarily benefits the poor people. Social protection, he argues, is not only curative or surgery-based interventions, but prevention and control of diseases as well. He shows how clearly such social protection strategies are boosting health insurance markets and leading to commodification of health services.
Ritu Priya in her article presents an evidence based and very lucid argument of how welfare capitalism has twisted all the concepts of primary healthcare to suit its needs.
The second section on pharmaceuticals and medical research is very educative and has clear take-aways for building a better healthcare policy for the country’s people. That we can’t ensure healthcare for our people without proper state intervention in drug pricing, licensing and provisioning is asserted very emphatically by Srinivasan, Malini Aisola and Amit Sengupta in their contributions. The authors effectively argue that price regulation / control of drugs by the state is essential because of market failure in this arena. They also lament the dilution of key flexibilities in the country’s patent laws as unnecessary and regressive, and done at the behest of the big pharmaceutical lobby They further caution that opening the country to international trade might undo the tremendous progress made in the domestic drug industry over the last four decades.
The entrenched economic and social inequity in our country makes it very difficult to develop ethical standards or to ensure compliance with them, thus making the conduct of equitable and ethically sound experimental research almost impossible. The article by Sarojini and Vrinda explains how the new markets in biomedicine (of renting and selling body parts) throw up provocative questions of autonomy, reproductive justice and outright oppression. I think these provide illuminating thoughts for all those interested in equity issues in public health, including those involved in clinical medicine.
The third section explores equity concerns along the more traditional axes of gender, disability, social group, violence and other forms of marginalisation. How the medical- health bureaucracy and legal state apparatus perpetuate inequity in healthcare quality and access is something I learnt from the four articles in this section. Even though the purported concern of the state is to benevolently plan and intervene in the lives of communities through its bureaucratic structures, the caste, class and gender bias remains an underlying factor.
It made sense that the papers that would look at potential solutions were the strongest part of this volume. Here it is clear that the paper written by Srinath Reddy and Manu Raj Mathur makes a strong case for need and viability of the concept of Universal Health Coverage (UHC). Another paper by Sunil Nandraj and Devaki Nambiar writes about the pilot projects in Kerala with hope. But these papers were at least two years too late to affect the National Health Policy 2017. They say very clearly that UHC is not merely a technical redesign and infusion of larger funds but is, rather, a political battle that has to be fought through with objectives of health justice and social solidarity. These papers offer not only a theoretical framework for the path that the country should take but also talk about the nuts and bolts of UHC implementation.
Arguably, the best in this collection is Ravi Duggal’s lucid note on the potential and problems for financing UHC – based on projections for one large state, Maharashtra. While arguing for the need to minimise out-of-pocket expenditure and regulate private and public health services, the author emphasises the importance of a strong political leadership with conviction enough to neutralise the opposition of the medical industry. He says the state has to be ready to reorganise healthcare under an autonomous decentralised health authority, with strict budgetary provisions, and also enable citizen participation. He draws from the experience of UHC in other countries.
Another sterling contribution to this section explains what it entails to make the “right to health” meaningful. The authors – Kajal Bharadwaj, Veena Johari and Vivek Divan, all lawyers – caution that the Right to Health is a deeply contested space and the path from drafting bills to enacting laws and issuing policies is a long one that will be played out in the judicial arena. I enjoyed reading this one a lot.
I wish those who framed the National Health Policy 2017 had read this book. The publication of the book has been delayed as the papers here are drawn from a consultation held in early 2015. Even so, I think this book remains relevant, for perspective building, if not for direct inputs into health policy framing. I hope the editors also upload the book on an online site for wider access. As presently priced, this handsome volume is a tad too expensive at INR 1195.