Neoliberalism siphons off the state from the economy in tremendous ways. The social sector is the easiest target for advocates of neoliberalism to cut off from state finances. The two most adversely hit sectors due to neoliberalism and privatization are education and health. Siphoning off the state from the social sector is one thing and making profits out of healthcare is another. Healthcare in India has been looked at something to be made profits from in the past decade. Federation of Indian Chambers of Commerce and Industry (FICCI) in 2008 said that ‘Health care infrastructure should not just be viewed as a social good but also as a viable economic venture with productivity’.
WHO defines health as a state of complete physical, mental and social well-being and not merely the absence of disease. Such a definition encapsulates a broader understanding of health and not just focuses on the medicinal aspect of health. Healthcare can be divided into two broad categories – medical services and public health. Public health is a public good that assures the good health of the population and is aimed at reducing the population’s exposure to disease through sanitation, food safety, vector control, monitoring waste disposal, and water systems and promoting health education. Further, LS Chauhan defines public health as “Art and Science of protecting and improving the health of a community through an organized and systematic effort that includes education, provision of health services and protection of the public from exposures that will cause harm”.
Public health should not be mistaken for Public sector healthcare, though both of them are in bad shape in India. Public sector healthcare could also neglect public health and focus on high-end medical services. Public health largely deals with preventive measures while medical services deal with curative measures. The aspect of public health remains significant because it has been witnessed in the past that certain diseases have been curtailed from affecting thousands of people before their cures could have been found. Tuberculosis is one such example.
With the existing literature on the health sector, one can conclude that public health in India has been adversely hit by policies, approach, functioning, and organizational structure. The approach towards the public for healthcare overpowers the approach towards the public for public health as far as the Indian healthcare system is concerned. The underlying message in the previous argument is that the ‘public’ in public health has been neglected by the Indian state. The approach towards the public for healthcare in India has been asymmetric. The healthcare system in India has turned a deaf ear to public health and has favoured medical services. The implementation of basic public health regulations has been neglected. The approach of policies towards public health has been discomforting as earlier public health services were merged with medical services and when India was close to eradicating malaria, priorities shifted to family planning. Investment in family planning rose from 15% in the 6th five-year plan to 35% in the 8th five-year plan of overall spending in health. Both health and education suffered in the second five-year plan as industrialization was preferred over the social sector.
The approach towards the public for public health in India also depends on who constitutes the notion of public. The public is defined and transformed by state action. The approach towards the public is quite problematic as public health measures have been used to remove or control the movement of sections of the population considered undesirable. An anti-public approach was also seen at the time of emergency when thousands were sterilized as a result of coercive action by the state. Despite being a signatory to the WHO Alma Ata declaration of 1978 which emphasizes the egalitarian distribution of resources between rural and urban areas, things haven’t changed much in India.
While medical services have been preferred over public health, the status of public health and the approach towards the public for public health is also dismal in India. For example, Swachh Bharat Abhiyaan has been the most recent initiative taken by the state to provide public health services. It has failed not only at planning and implementation by building cupboard sized toilets in rural India* but also the context of social inclusion as many workers belonging to the lower castes have lost their lives due to inhaling toxic gases while cleaning sewers. The biggest problem in our health system is that it does not acknowledge social determinants. Another social problem with public health has been seen in the policy of the population control program. The program has a solitary focus, a single solution – that is, women’s fertility and sterilization. It does not observe the multifaceted relations between livelihoods, social security, education, employment, and infant mortality, but continues to view sterilization of women as the only target. Public health has been ignored as a result of bad politics and, ironically, a government employee in the health sector receives a fat salary while the government ignores the deaths of thousands due to lack of basic services such as clean water. Amartya Sen’s concept of ‘missing women’ could also be seen from a public health perspective as the girl child is more likely to survive than the boy child given equal health treatment but we still witness lopsided sex ratios and also ‘missing women’ as argued by Amartya Sen.
Concerning budgetary allocation, the problem is again two-fold. First, very little is allotted to health (also education), and whatever is allotted, mainly channels into the tertiary sector leaving primary sector out. The total health expenditure in India is just 6% of the GDP. Out of the total 6% expenditure, 5% is out of pocket expenditure and 1% is public expenditure. The National Family Health Survey III shows that 70% of expenditure is out of pocket expenditure by households. Out of the little public expenditure, most funds are spent on high end tertiary medical services which coincide with the interest of the high and middle classes and divert from the provision of public health services. The rich and middle classes have the luxury of basic public health services and the reason for mortality in these classes shifted to non -communicable diseases way back. For the same reason, public health can be said to be pro-poor as it targets diseases that are to be found in the lower strata of the class hierarchy. Growing income inequality and an increase in the size of the middle-class lead to the shifting focus on high-end medical services instead of public health. This shows that the service sector, when unregulated, will cater to the demands of the classes which are on top of the class hierarchy. The introduction of technology in medical sciences (antibiotics for example) has served many but has also reduced the importance of public health. Public health should be seen as a pre-requisite for anti-biotics as was in the case of the western countries rather than something to be completely replaced by antibiotics as in the case of developing countries. It has served the western world and has rather proved to be anti-poor in third world countries such as India. The Western world completed its public health revolution before the introduction of antibiotics and eliminated epidemics through public health measures. The role of anti-biotics in serving the people of the third world countries such as India is insignificant as they worsen the situation by providing temporary relief to the suffering and allow the underlying causes for the epidemic to go untreated. It has been proved to be anti-poor in the sense that the living conditions of the poor are not questioned and a surface solution like antibiotics is offered. The reason for this surge in medical services can also be attributed to democracy and its institutions as a technologically advance surgery is a headline but eradication of diarrhea is not. Further, public health efforts in India sees medicine as a solution to all problems. It did not encapsulate political, educational, social, engineering and economic inputs as in the west. Also, the approach towards the public for public health was debilitated, to begin with, as health was put in the concurrent list of the Indian constitution.
A multidimensional approach is required to tackle this problem. Variables other than health per se can also influence public health, for example, education. The state should start by generating awareness among people. Policies other than health policies, for example, labour laws can also increase the level of public health by ensuring safe working conditions. Public health requires the intersection of various streams but the approach it has taken in India has been linear and one-dimensional towards medicines. The approach that the Indian state must take forward should be inclusive and focus on social determinants of public health. It should focus on malnutrition and the ‘diseases of the poor’ rather than catering to the needs of the extremely powerful class minority.
This dual neglect is very problematic, as firstly public health is neglected and then public in public health is neglected. It is imperative to focus on public health as it provides a life with dignity to all the citizens of a country. The aspect of public health should be treated as a top priority as it comes under Article 21 of the Indian Constitution. The underlying argument in the article relates to the highly unequal health system in India rather than a highly inefficient health system. Access to basic healthcare is a right of every citizen of the nation and is guaranteed by the constitution of India.
The significance of public health intensifies in the times of epidemics and pandemics especially when there’s no vaccination. The current global situation shows how important public health is when almost 8 million people have been infected and lakhs of people have died as on 13/06/2020 because of ‘coronavirus’ which has been declared a pandemic (worldometer).
I would like to conclude the article by quoting a phrase from Laurie Garrett, “Focusing on clinical services while neglecting services that reduce exposure to disease is like mopping up the ﬂoor continuously while leaving the tap running” and it is a never-ending exercise. Thus, the growth of public health is the need of the hour and especially in times of epidemics and pandemics.
*Cupboard sized toilets were to be seen in Kesla, Madhya Pradesh(village for our field trip) as an initiative of the Swachh Bharat Abhiyaan.
Author info: Sarthak is a postgraduate in Development Studies from Ambedkar University, Delhi (2018-2020) and excited to build a career in the development sector. He can be contacted at firstname.lastname@example.org, his LinkedIn profile or his Twitter handle.