Historical analysis of the development of healthcare in India is a fascinating subject but the literature is limited, as related to Eastern India. So, at the outset, kudos to Amrita Bagchi for writing this book, which is based on her doctoral thesis.
In the Introduction, Bagchi specifies that “the aim of this work is not merely to trace the increase of private healthcare sector in Kolkata but to explore the changing pattern of the entire healthcare sector, which has transformed itself into a profit-making industry in the last two decades” [p 2]. And for this, the author poses certain key questions that she will try to answer through this book:
• What was the state of the public healthcare system in Kolkata after 1947? Was it inadequate to meet the need?
• What was the nature of private healthcare in post-1947 Kolkata? Was its development independent or linked with the public sector?
• Is there any paradigmatic shift within the periphery of the private healthcare sector and in the policy documents in the post-liberalization era?
• What are the factors responsible for the growth of private healthcare in Kolkata?
• Why and how did the welfare state accommodate the influx of corporate capital in the health sector?
• How did the transformation of healthcare from a service to a commodity jeopardise common people’s access to healthcare? [p 3]
The book has five chapters. The first chapter “Promises and Commitments: The Development of Healthcare Policies and Plans in Independent India” follows the usual route, beginning with the Bhore Committee Report and tracing subsequent developments through the various Five-Year Plans and the National Health Policies. It points out that space was left for the private sector’s unregulated growth by keeping investments in public health grossly inadequate, with a segmented approach instead of a comprehensive primary healthcare perspective.
Chapter 2 “Changing Paradigm in the Health Sector” focuses on the retreat of the welfare state in accommodating policy shifts post-liberalisation, wherein the state proactively supported pro-private sector policies in healthcare and created the base for entry of corporate capital into the heath sector. The author rightly indicts the World Bank for this sharp policy shift that moved the character of healthcare from being a public good to a marketable commodity.
In Chapter 3 “Public Health Sector and the Development of Nursing Homes in an Eastern India Metropolis”, the author dives deep into the “transformation” process which is the key focus of this book, describing how smaller private hospitals or nursing homes began to emerge, while public health facilities began to degenerate through state neglect, fuelling the massive private sector expansion in healthcare.
Chapter 4 “Changing Profile of Private Healthcare Sector” further discusses how the neglect of the public health system contributed to the emergence of corporate interests in healthcare and strengthened for-profit healthcare in a neo-liberal frame of development.
Chapter 5 “The Metamorphosis of Private Healthcare” deals with structural changes within the healthcare sector creating a now dominant private health sector and a declining public health system. In the concluding section, the author advocates for another paradigm shift to reclaim healthcare as a public good within a rights perspective, and for strengthening the public health system towards universal access to healthcare for all. The author outlines how schemes like Pradhan Mantri Jan Arogya Yojana (PMJAY) create inequities through an insurance-based healthcare system and are not a solution.
Given the above overview of the book, let us look at how effectively the author has dealt with the questions she had laid out at the beginning.
The first question relates to how the public health system in Kolkata evolved post-Independence in terms of meeting the needs of the people. Like elsewhere in the country the public health system in Kolkata suffered under investment, leading to overcrowding of the district/urban hospitals and a simultaneous waste of precious resources wherein specialists at hospitals were treating primary level cases in the absence of a referral system and of adequate primary healthcare services closer to where people lived.
The Bhore committee recommendations, which were available to post-Independence planners, were completely ignored in the Five-Year Plans. Further, as mentioned earlier, given the inadequate budgetary resources made available. they resorted to a fragmented or segmented approach wherein selective programmes for malaria, tuberculosis, family planning, etc were identified for implementation during each plan period, through the public health system. This was completely against the comprehensive primary healthcare approach which the Bhore Committee had recommended. The author also mentions the influence of the Beveridge Report, but this is factually incorrect, because both the Bhore Committee and the National Planning Committee of the Congress preceded the Beveridge Report. In fact, if the author had looked deeper into the Bhore Committee Report, she would have found the strong influence of the Soviet health system.
Her questions two, three, and four pertain to the post-independent development of the private health sector in Kolkata and the paradigmatic shifts in health policy towards privatisation. Here again, the author finds that — as elsewhere in the country in the first four decades after Independence — the state was the dominant provider for institutional services, albeit inadequate in numbers, and private practice (including private practice by doctors employed by government) dominated primary level care wherein general physicians (GPs) operated unregulated in the market. However, the latter had, until then, functioned more in the petty-bourgeoisie mode of production rather than a capitalist mode, that is as independent self-employed professionals through their clinics and small nursing homes. The seventies saw huge growth in private nursing homes due to the increasing number of specialists being produced in the country, who would certainly not work as GPs. So, they either went abroad or set up nursing homes which catered to their specialties. In later decades, with the pharma industry coming of age and the entry of insurance and larger corporates, the political economy of healthcare in India got transformed completely into a commodified system where the “public good” character of healthcare was completely undermined.
The author has explained this transformation quite well from the early influence of bilaterals like the United States Agency for International Development (USAID), the Department for International Development (DFID), etc and private foundations in various health programmes through the Five-Year Plans to the major structural changes post-SAP (Structural Adjustment Programs), post 1991, commandeered by the World Bank and other multilaterals. The inadequate initial investment in public healthcare coupled with these major changes eased the entry of corporates into the health sector that brought in the larger multi-specialty hospitals to the fore with the support of insurance-based financing.
In chapter 3, which is the heart of the book, the author has painstakingly documented the historical evolution of public hospitals in Kolkata as well as of the early private hospitals and nursing homes. Since getting information on private hospitals is a challenge, she has conducted interviews with those associated with these hospitals and built a database of select private hospitals which in itself provides insights into the development of the private health sector. Perhaps the story in other parts of the country too is quite similar, but there is one dimension of the evolution of private hospitals that the author has failed to capture. Perhaps Kolkata did not witness that? This is the dimension of philanthropy in healthcare since colonial times and the role of seths (merchant capitalists) in setting up the early private hospitals to cater to native communities since the state hospitals initially catered only to the military and civil lines. This we see clearly in Bombay and even Delhi where seths set up hospitals, even provided annual grants and handed them over to Municipal or provincial governments. In Bombay, many of the larger charitable hospitals took this route [1] and are today the main public hospitals there. My sense is that some of the public hospitals in Kolkata, including the R G Kar Hospital, Campbell Hospital, etc, may have had similar antecedents.
The last two questions posed by the author, ie question 5 about the retreat of the welfare state and the entry of corporate healthcare with state support and question 6 on the transformation of healthcare from a public good to a commodity with reduced access for common citizens, are dealt with elaborately in the final two chapters of the book.
Following the structural adjustments, economic reforms also impacted the political economy of healthcare in India, especially across states which received World Bank assistance for health sector reform projects. West Bengal was one such state and was forced to make changes within the public healthcare system, like the introduction of user fees/charges, outsourcing of services and even direct privatisation. This had a huge adverse impact on the public health system which was already degenerating due to neglect by the state, that was gradually withdrawing from direct provisioning of health services to supporting private hospitals through the PMJAY kind of schemes. On the other hand, the private sector arm of the World Bank, the International Finance Corporation (IFC), was providing support to corporate hospital chains to penetrate the health market and establish themselves. Further, health insurance was given a fillip through increased tax incentives so that the middle and upper classes, mostly those in the organised sector, could afford the corporate hospitals through their health insurance plans, and the poor (bottom 30%) could access these services through the PMJAY scheme. That left about 60% of the population, which could not afford the health insurance premiums and were not poor enough to be covered under PMJAY, to the mercy of the markets under a political economy where healthcare was becoming increasingly commodified. In West Bengal, the poor did not have access to the PMJAY as the state had rejected the scheme; but had alternately set up the Swasthya Sathi scheme, and in 2020, announced that it would cover the entire population of the state. What the status of this is at the ground level is anybody’s guess, but the insurance companies are raking in profits.
Finally, the author concludes that such a health system will lead to greater inequities in access to healthcare as well as widespread negligence, malpractice and corruption raising ethical issues in provisioning of healthcare services within the marketplace. This would lead to replacing the social construction of illness by corporate construction of disease so that profits could be maximised. If Universal Access to Healthcare for All has to be achieved then all these policies will have to be reversed and health as a public good would need to be established under a rights framework, backed by legislation mandating these rights. To begin this process, comprehensive primary healthcare has to form the foundation for reclaiming health as a public good.
Some errors identified in the book:
Page 18: Death rates are per 1000 population and not per cent
Page 23: Total villages 650,000 and not 65000
Page 91: Beds in West Bengal should read 0.7 beds per 1000 and not 7 beds per 1000.
Notwithstanding these minor flaws, the book is a very useful contribution to the literature on the history of medicine in India and worth having in your collection if the subject is of interest to you.
Author: Ravi Duggal (rduggal57@gmail.com), Independent Sociologist and Public Health Researcher, Mumbai, INDIA.
To cite: Duggal R. Historical growth and transformation of healthcare services in Kolkata. Indian J Med Ethics. Published online first on February 17, 2025. DOI: 10.20529/IJME.2025.013
Manuscript Editor: Sanjay A Pai
Copyright and license
©Indian Journal of Medical Ethics 2025: Open Access and Distributed under the Creative Commons license (CC BY-NC-ND 4.0), which permits only noncommercial and non-modified sharing in any medium, provided the original author(s) and source are credited.