Deteriorating healthcare system

By Jyotshna Pandit

The impact of the structural economic reforms of the 1990s on human development in India has been a subject of controversy from the start. But while there has been a fair amount of public debate on whether we need to improve our general health and education levels if the economic reforms are to be successful, there has been less discussion on the actual impact of the reforms themselves. In a country with so much poverty and economic insecurity, riven by severe inequalities between rich and poor upper and lower castes, women and men, the extent to which health services are affordable and equitable is crucial to the well-being and indeed survival of the disadvantaged.

At Independence, the Health Survey and Development Committee (Bhore Committee, GoI 1946) was emphatic that comprehensive healthcare should be universally accessed by all regardless of their ability to pay. Despite this, progress in health over the intervening decades has been very uneven. Worse still, the pace of improvement in key health status indicators appears to have slowed down and even stalled in some cases in the past decade. The pace of decline in infant mortality has been very slow in the 1990s, and preinatal and neonatal mortality have not fallen. In its review of the working of the 9th Plan, the Planning Commission has expressed concern at the drop in routine immunisation of children. The recent second round of the National Family Health Survey (1997-98) showed that maternal mortality is still extremely high. Health inequalities across States, between urban and rural areas, and across the economic and gender divides have become worse.

Three aspects of the economic reforms of the 1990s may have played a role in this : stagnating Government health expenditures, the skyrocketing prices of drugs and rising cost of health services, and increasing unregulated privatisation of the health care sector. Between 1990-91 and 1994-95, the real value of Government (Centre and States) health expenditures remained stagnant at around Rs. 33 per capita. Thereafter, there was a modest increase, but no significant infusion of funds until 1998. As a result, public expenditures on health stagnated at under three per cent of total Government expenditure, and were only 0.86 per cent of GDP at the end of the decade.

A second set of policy changes that had a crucial bearing on the quality and costs of health care in the 1990s was the systematic deregulation of drug prices. The effects of industrial deregulation on drug prices began to be felt in the 1980s, and these continued and accelerated in the 1990s. The result was spiralling costs of drugs, and the continued absence of a regulatory list of essential drugs meant that the market continued to be flooded with irrational drugs. National Sample Surveys from the mid 1980s and 1990s point to significant increases in the cost of both in-patient and out-patient health care in rural and urban areas. Drug costs and rising fees for different health services undoubtedly played a major role in this. These cost increases affected both private and public health services, and in fact the cost of public in-patient care came closer to the cost of private care. Rising cost of care is a critical concern for poor people. A review done in the mid-1990s showed that the proportion of household spending on treatment by the poorest income groups in five major States was higher than the average for all income groups. The rising cost of health care can have a range of possible impacts on the poor. These include cutbacks on outer consumption such as food which directly impacts on health status; increased indebtedness; growing untreated illness; and growing gender biases in health seeking behaviour.

A third aspect of the reforms of the 1990s was the growing support for private health care providers. This included a variety of subsidies for corporate hospitals, such as urban land in prime locations in exchange for their providing a proportion of their services free to the poor. There is increasing evidence of non-compliance with this condition by major private hospitals in metropolitan areas. Furthermore, as corporate hospitals have come to set the standard for medical technology and interventions, there is reason to believe that they have contributed to the increases in health costs overall. Given the poor quality of care and the low labour productivity in the public sector, not all attempts to increase the role of the private sector are necessarily inequitable. However, the overall impression is one of rapid privatisation with little accountability to patients, while public health services have continued to deteriorate.

Until the mid-1980s, public hospitals were still the dominant providers of inpatient care especially for the poor, even though patients increasingly resorted to the private sector for out-patient services. Although this varied considerably across States, public hospitals provided an important alternative to the private sector and at significantly lower cost.

By the mid-1990s, there is clear evidence that the private sector had become dominant in terms of both out-patient and inpatient services, and that the average cost of all care (and particularly of in - patient care) has gone up significantly. Untreated illness among the poor has clearly increased. Inequity by economic class appears to have worsened, and the divide between rich and poor in terms of untreated illness and expenditures on health services, as well in the use of both public and private health care institutions, has grown. The rich are now the major users of not only private but also public hospital !

A comparison based on the National Sample Surveys provides sobering evidence of the worsening situation. NSS data from the mid-1980s already showed striking differences across the economic class spectrum and by gender in the extent of untreated illness, as well as in expenditures on in-patient and out-patient care. Already in 1986-87, untreated illness was 15.21 per cent higher among women and girls. This figure does not include the reservoir of untreated sexual and reproductive illness that these surveys do not capture. Inequality by household expenditure groups for untreated illness was highly significant in both rural and urban areas.

The poor were less likely to get treated for their illnesses than the rich, and this was worse among women than men. When the poor did get treatment, they tended to spend less on both outpatient and in-patient care.

In the 1990s, we found even greater inequality across economic classes in the extent of untreated illness, and in health expenditures for both women and men in urban areas and for men in rural areas. The conclusion that health care is becoming increasingly difficult for poor people to access is borne out by the reasons that people gave for untreated illness. Compared to 1986-87, the proportion of those who said they were unable to access health care because of 'financial reasons' went up significantly in both rural and urban areas. So did the proportion who said that there was no medical facility available.

Gender inequity, particularly in untreated illness, remains severe. However, the worsening of inequality in the extent of untreated illness, and hospital utilisation has been somewhat sharper for men. This relative worsening of access for poor men even though they continue to be better off in absolute terms than poor women, may imply that poor households are now really stretched to the breaking point in terms of access and affordability of health services. There may be so little left to cut by way of women's access to health services that poor households are now forced to cut on the men.

This may reflect the worst kind of 'catching up' in terms of gender equality.

The overall impression is that, unless significant steps are taken to make health care affordable and accessible, India's already abysmal performance on human development is likely to get worse. INAV

The Dravidian-Hindustva alliance

By Jayant Muralidharan

Till the other day, Tamil Nadu was one state where the advent of the Sangh parivar was considered unthinkable. An impregnable ideological barrier was presumed to encounter the Hindutva brigade. The supposedly deep roots struck by the Dravidian ideology in Tamil Nadu, it was taken for granted, would not let the alien plant, even a grafted version of it, grow. It was the pleasures of a facile presumption ! Why has the proposition not survived the test of time ?

The most striking proof of the Hindutva politics that has entered Tamil Nadu’s political soul is that the BJP today enjoys the status of the second position in a major front, headed by the DMK, which has an anti-Hindutva record and is avowedly anti-Hindu, even anti-theist. Political expediency alone does not explain this particular transformation of Tamil Nadu.

It is true that Tamil Nadu’s rulers, of the regionalist variety in particular, have always preferred an alliance with the power-wielders at the Centre. The alliance, by which the DMK has given the BJP a mile where the AIADMK has allowed it an inch, is more than analogous to the AIADMK-Congress pact of the MGR/Jayaallitha-Rajiv past. Dravidian vesteran M. Karunanidhi has conducted himself earlier as a satrap of the Centre under prime ministers as politically varied as Indira Ganhi, V. P. Singh and Inder Gujral. But his role as a votary of Vajpayee and his government raises questions that politics of merely routine convenience would not.

The sad fact is that no Dravidian party has resisted the temptation of a profitable tie-up with the BJP. It was the AIADMK that gave the BJP a toehold in Tamil Nadu. Now, when Karunanidhi scoffs at the anti-BJP camp’s talk of ‘communalism’, he sounds quite the same as a Hindutva hardliner castigating ‘pseudo-secularism’.

Even more unblushing is the adoration of the BJP by the Marumalarchi DMK (MDMK), which claims to be the ‘real’ DMK. It is more a ‘I-am-pro-BJP-than-thou’ slanging match that has been taking place between the MDMK and the DMK.

The commonality between both the ideologies consists in the basics upon which either envisages popular mobilisation. The Hindutva camp seeks to mobilise its constituency on communal or majoritarian lines. Dravidianism aims to do so on caste lines. Neither of them is for mobilising the people on either a compositely national basis or on class lines, as either Indians or a socio-economic interest group.

Guru Golwalkar, arch-ideologue of the RSS, in his Bunch of Thoughts, openly declared communism as one of the three main enemies of the RSS (the other two being Islam and Christianity) because that unholy and alien ideology was against mobilising Hindus as Hindus. The Dravidian ideologues may not have been as candid in their ornately alliterative rhetoric. But they were no different in the chauvinist mobilisation of their own variety.

The Dravidian movement, while being anti-communist in its formative period, borrowed bits and pieces of Left radicalism and tried to make these a part of its own baggage. The disguise was intended to help it disarm what them appeared its natural enemy. Tamil Nadu’s political history is proof that the trick has paid off. Before the undivided DMK replaced the Congress in 1967, it had replaced the Left as the main opposition. It is for the Left and the liberals to ask themselves : were not the unchallenged ideological claims behind the unchecked advance of Dravidianism ?

The core of these claims is that the Dravidian casteism is actually social reform. To question this claim even mildly today is to enter a fiercely contentious territory. Questioned, however, it must be, if the Dravidian-Hindutva compact is to be comprehended.

What is wrong with Dravidianism is not its origin in anti-Brahminism, neither as opposition to the decadent values of Brahminism nor as a challenge to the social dominance of the Brahmin community. This was the natural starting point of a social reform movement here as in many other parts of India. Even nationalist poet Subramania Bharati and the Hindu’s founder-editor G. Subramania Iyer, who condemned the precursors of Dravidianism as compradores, set themselves against Brahminism when they espoused the cause of wide-ranging social reforms, especially women’s emancipation.

The early Dravidian movement degenerated for a time into crude Brahmin-bashing, and its excesses (like the forceful cutting of individual Brahmins’ sacred threads and tufts) hardly endeared the avowed cause to the peace-loving majority of the Tamil people. The rationale of anti-Brahminism, however, remained, though it may not have lost all of its ideological relevance even today. For, a set of socio-cultural values upheld by the upper crust or castes still remins to frustrate a reborn Bharati or Subramania Iyer. This set of values has lately acquired a new sanction at the national level. And it is the Drvidian camp that has brazenly tied up, time and again, with the all-Indian party of opperessive Brahminism.

The uninterrupted rule of anti-Brahminism has not de-Brahminised Tamil society. It has only created new Brahmins. The intermediary castes, empowered by anti-Brahminism, have only gone on to emulate their erstwhile social superiors and provide today an expanding base for the BJP and even the more rabid of its relatives in the parivar. It is under rulers spouting Dravidian rhetoric about a casteless society that Tamil Nadu has seen increasing caste conflicts and a steep decline in the status of oppressed Dalits.

All this only shows a degeneration of Dravidianism, once the ideology of a crusading social reform movement. Chronicles of the movement reveal that it bore within itself seeds of its own Brahminisation and its historic compromise with Hindutva.

Narendra Subramanian, in his insightful study of the Dravidian movement Ethnicity and Populist Mobilisation – Political Parties, Citizens and Democracy in South India (OUP, 1999), says : "Despite Periar’s (Dravidian ideologue E. V. Ramasamy Naicker’s) critique of religion and Hinduism, a section of Tamil Hindus (BCs) occupied the core of Periar’s vision of the Dravidian community, while other Hindus and non-Hindus were relegated to the margins. Besides, Periar viewed his movement as primarily engaged in an effort to reform Tamil Nadu’s Hindu society. These features of the early Dravidianist vision made it possible to find common ground with Hindu revivalism."

Subramanian recounts : "When both Hindu and Muslim religious leaders denounced a DK (Dravida Kazhagam) campaign to break idols of the Hindu Pillayar (Ganesh) deity, Periar warned Muslims not to impede a movement that had arisen from within the Hindu community. Following this definition of his movement, he instructed Muslim party members to keep away from the agitation. Further, he threatened that DK activists would play music in front of mosques if Muslim leaders did not withdraw their objections to the agitation, reaching down into the bag of tricks Hindu chauvinists had assembled well before."

The Dravidian ideology, thus, could never have been Tamil Nadu’s reliable bulwark against the saffron brigade. A sustained Left-liberal ideological struggle against Dravidianism, on the contrary, could have prevented the growth of this unholy alliance that had irrationally been presumed to be impossible. INAV