Health matters, a documentary by Shikha Jhingan. DVD, 60 minutes, 2005

Campaigns to promote health care access and accountability, such as the Jan Swasthya Abhiyan (People’s Health Movement), have gathered momentum in India in recent years. Such campaigns, critiques and demands for reform of the Indian health care system call attention to the neglect of justice and equity concerns. Shikha Jhingan’s documentary Health Matters highlights these concerns through the interweaving of narratives and statistics describing the state of the Indian health care system.

In the course of 60 minutes, Jhingan brings to the fore a range of systemic problems such as the non-functioning of the primary health care system, the resultant overburdening of public tertiary health care facilities (primarily concentrated in urban areas), and the rapid expansion of the private sector and medical tourism. Even relatively less-well off individuals, we learn, prefer the private sector. As Nirmala, a domestic worker in Delhi, states in the documentary: “What’s the point (of going to a public hospital)? …one has to run around…it’s such a hassle.” However, while out-of-pocket expenditures for private sector primary care are considerable, tertiary care costs are prohibitive, leaving many relatively less well-off individuals (such as Alimuddin, a former loader of plyboard) at the mercy of the vast but crumbling public tertiary care system. We watch as Alimuddin doggedly pursues medical care at a large tertiary care public hospital in East Delhi where over 5,000 individuals seek out-patient care daily. Through the experiences of Nirmala, Alimuddin, and Gajanan Pulekar, a mill employee, Jhingan illustrates the meaning of statistics such as the decrease in public expenditures on health from 1.3 per cent of GDP in 1990 to 0.9 per cent in 1999 and the exorbitantly high proportion of expenditures on health (70 per cent) that are out-of-pocket.

As the film contrasts images of a public tertiary care facility with those of a private hospital, it asks whose concerns are being met by the Indian health care system. Health Matters illustrates how private hospitals are now being established with an explicit mission to serve not the local community but the nation and the world at large. The private sector aspires to meet “international standards” and offer state-of-the-art technologies such as prosthetic aids and organ transplants. Thus, the film illustrates the manner in which health care services are advertised, treating health and health care as a commodity. It demonstrates the links between health care technologies, standards of care and health care costs. All these issues, hotly debated at the First National Bioethics Conference in 2005 (1), emerge as critical points for further reflection and discussion.

Jhingan goes on to highlight how the private sector has reneged on its commitments to provide subsidised care to those in need while having received and benefited from considerable government subsidies (such as land in prime urban areas). Research has shown that gender and other social inequities in health have worsened in India since the 1990s and are linked to the expansion of the private sector and the concomitant neglect of the public sector (2). However, the documentary does not explore the particular challenges faced by disadvantaged and vulnerable groups such as women, nor the worsening of urban-rural differentials in health care access and outcomes.

Other ethical issues raised in Health Matters include the practice of fee-splitting, the limited sense of accountability on the part of health-care providers, flaws in the informed consent process in medical settings, and the conduct of inappropriate procedures. In conclusion, Shikha Jhingan provides a comprehensive overview of the contemporary Indian health care system. Given the documentary’s focus on issues of justice and equity in health care availability and access, it will prove to be particularly useful for health activists and teachers.

Shikha Jhingan can be contacted on shikhaj@vsnl.com