Medicare? Who Cares?

Smarajit Jana

Coming out from a long hibernation World Health Organization (WHO) at last (in July 2017) pronounced the call 'Access to Medicines for all by 2030'. The strategic framework talks about how to ensure availability and accessibility of essential medicines, vaccines and other health products to every child, man and woman across countries. This strategy is linked with the sustainable development Goal (SDG) and specifically with the Goal no 3. But why the call is restricted only to medicines and not to the Medicare services in its totality? Well, to get the answer it is  essential to go back into the history of health development with a view to comprehend the role of SDG's and WHO in promoting health and well being for all.

Back in 1978, the leader of more than 100 countries assembled at Alma-Ata in the erstwhile USSR at the call of (WHO) and championed a slogan - "Health for all by 2000"(HFA). It did raise lot of hope and aspiration among many that it would help reduce death and human sufferings from illnesses and would help improving quality of life. To achieve the goal, technical experts set up several indicators to measure the progress at country level. The strategy to achieve the target e.g. to reduce infant mortality, maternal mortality, and to put check on birth and death rates was based on the improvement of primary health care services. There was one more important underlying issue i.e. making drinking water available and accessible to all, the target was to make drinking water available to every household within a walking distance of 15 minutes from their residences. Needless to say that not much has been achieved by the end of 2000, though there were some progress in the initial phases but the early gain achieved though expansion of primary health care infrastructure and services in India sooner got compromised for various reasons.

After the completion of HFA 2000, the United Nations raised a new slogan—'Millennium Development Goals' (MDGs). It included a number of health indices. MDG does include issues of HFA, but expanded the arena of health interventions beyond mother and child health care. MDG includes control of three major epidemics, namely Malaria, TB and HIV/AIDS-and put stress on universal access to essential medicines. The important shift from HFA to MDG was to place the health development program on a broad framework of poverty eradication, environment protection and universal education. Eighteen of the 48 indicators set forward by MDG's were related to health.

The term of the Millennium Development Goals came to an end by 2015. Followed by the same consortium of Global bodies brought its new Avatar, called Sustainable Development Goals or SDG's. A new set of goals were introduced in 2015 keeping the same framework of development with the addition of gender equity and peace. Health was positioned as the heart of development. It also reinforced almost all issues articulated in MDGs. The mission of SDG further widened the scope of health development drawing few more newer areas of interventions. The signatory countries pledged to fulfill all those indicators of health development by 2030. In addition to health interventions mentioned in MDG, the new charter calls for interventions of neglected tropical diseases which are predominant in developing countries, Hepatitis is one of them. It incorporated control and management of non-communicable diseases which includes mental illnesses too. The charter also sets standards to reduce physical damage and death due to road accidents. It talks about reduction of deaths and diseases due to wide-spread use of harmful physical and chemical products manufactured and used in industrial production process and what in turns pollute (air, water and land) working environment including human habitat. It lays down benchmarks for the prevention and treatment of many important diseases including cancer and heart diseases. Not only that, what sort of inputs are required at country level to attend and achieve standards set forward by SDG's was made clear in the document. Improvement of public health care services through substantial increase in Government spending in health sector became an integral part of the document with indicators specified therein. More importantly, the charter lays equal stress on building social security related infrastructure and services for the poor and weaker sections of the population whose access to health care services are limited. In theory the approach and strategies adopted in SDGs' appear more inclusive and grounded on the macroeconomics of the country in question. However none of these Global institutions and platforms dare to articulate Health as one of the fundamental rights of citizen. The same is true for the WHO's present slogan i.e. medicines for all by 2030,.As a result of which everything is left to the 'good wishes' of the policy makers of individual countries, as it is not binding to signatories of this charter.

What has been achieved so far in health development arena and where India stands in comparison to other countries by the end of MDG’s speak volumes about the ground reality? Out of 193 countries who all have provided data for health measurement indices; India scored 'centuries' in all these parameters [based on the ranking among countries] for example, IMR (Infant Mortality Rate), MMR (Maternal Mortality Rate) Mortality under 5 years of ages India stands at 143, 124 and 145 respectively and in terms of India's position in Public Health Care spending it is at 184. Had there been more countries in the comparison table, India could have done 'double century' at ease. This is not just a dismal story about India's health development; it is pathetic when India compares itself with countries like Bangladesh, Srilanka and some other poorer countries in Africa. It would be painful and worst of its kind if one disaggregates data according to class, caste and gender. Question is : why India is unable or uninterested [?] to tackle all these preventable death, treatable diseases and morbidities affecting millions of citizens?

One broad response to this question could be summarized in one sentence that is health is not a priority issue to the policy makers. It has never been a political issue in India what has happened in the western world including in USA. One may recall the recent past voting at the Senate[in USA] over health care where a good number of republican senators voted against their own party and the President to keep running the so-called 'Obamacare' to ensure accessibility of health care services to poor and marginalized. This has happened as because health is a public and political issue as well in their country and everyone knew that whosoever once enjoyed health care services will jealously guard it for good, so some of the republican senators did not like to antagonize their voters.

Here lies the difference in India. As per the NSSO data the percentages of physical ailments (who should have receive treatment) 'not treated' rose to 24% in 2004 which was less than 15% in 1987.As per WHO globally 1.3 billion people can't afford and access to health care services. Keeping in view the existing trend one can guess what could be the present state of affair. Though there is no dependable data to project the percentage of Indian citizens who have never or hardly ever enjoyed fruits of modern health care services could be anything in between 30% to 50% of total population. This section of population may not be knowing what modern Medicare services mean to their life and what possible changes could have been made through use of Medicare services in their families. This section of the society is unlikely to rise their voices for something what they have not tasted before. They will mostly remain invisible in official discussion and in policies. Even though SDG spoke about health for all in reality the development of health policies and processes in India has systematically forced a section of citizens out of the existing Medicare system. Policy makers finding no pressure from within the country left the health sector development to market forces at the expense of (ruining] public health care delivery system in the country. Privatization of primary health care services was started in late eighties through distributing Govt run health care centers to NGOs and corporate sector to run in line with the broad economic and political strategies for National growth and so called development pursued by the successive Govts.

One of the underlying reasons could be tracked in the approach and process of 'Depoliticization' of health. As most people believe that health is a social sector where politics does not play any role but in reality it is just the opposite. The great thinker and the social scientist Virchow even in eighteen century [1849] commented that ''Health is a social science and politics is medicine in large scale" to help open up intricacies of social and political control of medicine and vice versa.

It's interesting to see how the politics of health operates in this era under the garb of so-called "apolitical" agenda. Drawing every health slogan 'for all' is no doubt a good gesture but without specifying strategies armed with budgetary allocation for different sections of population and communities ostensibly reinforces existing inequities and inequalities in health while reducing the very slogan more as an arbitrary and superfluous one. Lumping of health statistics at national or at best at provincial level essentially helps 'cover up' of the true health scenario and of health development practices in the country. The dismal story of public health care expenditure which is just around 1% of GDP and what remained stagnant over the years is the true depiction of the politics of health. Even though policy makers made lot of promises the budget has not been increased even after all these noises of progress and development they made in the country and abroad. They know well how to play with the gallery. The charter of SDG's recommended raising of public health care spending at least to the tune of 5% of GDP. In reality India's public health expenditure trend could be seen as declining provided one tracks the actual annual expenditure of the Govt Dept and incorporates factor of inflation. NSSO in 2007 revealed that Citizens of this country spend three forth of their health care expenditure out of their pockets and the trend is ever increasing. As per the report of the World Bank [2014] the Health care market in India is equivalent to 4.7% GDP of the country. It is the flourishing private sector what contribute the remaining 3.7% of GDP, the growth of which is projected to the tune of 15% for the financial year [2016-2017].At present on an average citizens of this country spent more than 78% of health care expenditure out of their pockets in comparison to UK which is just 18%. But who really can afford the cost of Medicare services? And who will be the worst sufferers in the 'game plan' of policy makers? Undoubtedly those who have no other alternatives but to knock at the doors of Govt run health centers and hospitals. They will admit their kids or family members even paying bribes and more likely would face the similar fate what happened in Govt run medical colleges and hospitals in Gorakhpur or in Farrukabad in the recent past. Nonetheless this is part of the Global agenda to privatize health care sector through diluting the states' responsibility to ensure health for its citizens in one way or other.

To comprehend how politics operates in health sector the example of classifying 'life style diseases' could be a another one. The coinage already finds its place in the text book of medicine. But what does it mean? It says that people are responsible for their illnesses; as if all individuals have the power and privilege to act based on their decisions and create their life style independently and of its own. This is a myth created over the years. The life style of an individual or groups of individuals are intricately linked with the family and social background, nature and contractual agreement in the job and the work organization, type and nature of stress, autonomy in the job, earning capability, available space for recreation and so on so forth - what essentially create and recreate one's behavior and practices. How many citizens in any country whatsoever have the access to healthy diet free from chemicals, pesticides and trans fat? What social and support environment could be ensured and for how many citizens of the country to adopt healthy practices? Choice is a social construct. Perhaps Modi or Ambani has access to innumerable choices and they can act based on their likings and disliking but not the commoners. Whether an individual is capable of preventing socio-economic disposition which is constantly pushing them into a rat race, forcing human biological system beyond the limits of its adjustment and compensatory mechanism. Is the fatal competition what has distorted human relationships in the family, in the society and in the workplace is compensable? Could it be rectified through Yoga or brisk walk in the morning? Is it possible for an individual to revert this 'mad' production system and the market dynamics that force-feeds kids and promote varied kinds of unhealthy practices through alluring them into addictive tools and technologies? If the objective would have been to classify diseases based on the etiology then all these illnesses should be defined as 'Market Induced Diseases', and not life style diseases. In fact a decade back nomenclature of all these health problems was clubbed under 'diseases of development'. The terminology of 'life style diseases' is a value loaded classification and here lies the politics of health. It blames the victims for his or her illnesses and gives an ample justification to the State to absolve its obligation to provide requisite health services to affected individuals and communities.

The other underlying issue is linked to the psyche. Indians are not only fond of 'living in the past glory' but wish to live in the past that often distorts basic issues and challenges with special focus to health and health care services. Some even love to bring back Ram Rajjya, some love to recreate practices of Charaka and Susruta and some others keep faith in Patanjali and so on so forth. There is no debate that they are all great scientists of their era and their contribution has helped growth and development of modern medicine. But one needs to recognize that people of India have crossed over few hundreds to thousands of years down the line and during this period lot of things have changed in all aspects of life as well as our society. The impact of tremendous growth of science and technology that has brought revolutionary changes in life as well as in thinking can't be reverted back. However there are exceptions to the rule and a section of Indians still live in that 'time zone'. The very mindset could be diagnosed as Time and Space Avoidance Syndrome[TASAS].However this is a syndrome that has affected primarily a section of educated, urban middle class and elites only. This has yet to infect the minds of Am Admi [common people] of the country. Even in early seventies Professor D Banerjee of JNU through an extensive study across rural India revealed that 96% of rural population will opt for modern medicine if options are given to them to choose in between modern and traditional medicine [Ayurveda, Siddha, Unani etc].This is more so important at this juncture when the Union Minister of health as part of the new health policy[2017] unfolded his grand strategy to bolster AYUSH [which includes all varied kinds of traditional medicine including Yoga, Naturopathy etc] through establishing 3600 hospital across the country. There is nothing wrong in the strategy so long it does not replace proven interventions for diseases with something else which are not verified and are of questionable efficacy. Secondly it should not siphon off meager funds available for the established Medicare delivery institutions and system which are already in dire straits. Public health care system is disintegrating slowly but steadily over the years due to lack of support from successive Govts.

The health minister also has declared that to expand the culture of Yoga and to promote healthy behavior among the masses the present network of so-called 'illness treatment centers' that falls under the primary health care system would be transformed [to begin with 1.5 lacs of SHC or Subsidiary health centers] into wellness centers. Maybe he is one step ahead of the Prime minister as he believes that good days are already here,[as opposed to good days are coming] there is no disease or illnesses to be treated in rural India, so there is no need to keep these centers open for treatment. Henceforth the poorer sections of society won't be able to get even a pain killer or tablets for treatment of respiratory tract infection or other minor ailments .They would be shunned from the slightest touch of the modern medicine. Perhaps this is the last nail being thrust into the coffin of the primary health care system in the country. As per the grand design of NITI Ayog district hospitals will be handed over to corporate.

Against this backdrop one may look into the other part of the story, what really is happening to the other sections of the society who do not romanticize traditional medicine and are determined to procure modern health care services from the market, as hardly any other options are left to them. This is a sizable section of population. As mentioned earlier 78% of health care expenditure comes out of pockets and the very process shall and will ruin their families including the household economy of millions. This is part of the global phenomena. As per the estimate of WHO more than 150 million families every year face 'catastrophic health care cost' [when it goes above 40% of the household expenditure] and in the process no less than 100 million families are pushed below the poverty line. As per the study report of the Harvard University the principal cause behind individual bankruptcy in USA is the medical debt. The share of medical debt in bankruptcy rose to 62% out of all bankruptcy cases in 2008 from what was 50% in 2001. The charter of SDG was forced to focus this aspect of 'pauperization' resulting out of health care spending by the poor and disadvantaged communities across countries. Keeping in view the worst scenario of public health care expenditure in India one may dare to guess what could be the possible figure in India and how the process of pauperization is being steered by the 'designed effect' of the government's health policies and practices with the 'Midas touch' of the private health care sector. The volume of health care industry in India as projected would reach around $280 billion by 2020 and with an annual growth rate of 15% how it would be lucrative to corporate houses does not require much explanation. But all these users of Medicare services are the potential 'power house'  who could be the future of the health care movement in the country. Out of grudge against the system some of them are involved in vandalism and violence in absence of proper guidance and initiation of the process of mobilization that was the forte of left intelligentsia once upon a time. Whereas the ruling Govt cleverly enacts legislations to douse people's sentiment and anger hiding their politics to sell out Medicare services to private enterprises. The volume of global Medicare industry was around $6 Trillion [2010] with a growth rate of 10% to 12% per annum it likely has crossed the figure of ten or more Trillion Dollars. Neither Trump nor Modi would be able to resist their desire to offer this gift to Corporate.

This is indirectly fueled by the ideological bankruptcy of the progressive sections of the health intelligentsia including the policies of the left. In one hand they have a very fixed notion about prevention, which is very narrow and restrictive in nature and secondly they often make the mistake by putting prevention against the Medicare services. There has been a major shift in the concept and practices of prevention services. It is no more restricted to water, sanitation and behavior change communication only. As part of the prevention strategy community mobilization including the ownership building of the infected and affected communities has come up as an integral part of prevention strategies and practices. The dichotomy between prevention and treatment has also been narrowed down significantly. In fact there are levels of prevention practices. Prevention and treatment are complimentary to each other and one can't be placed against the other. To develop clarity on the issue take the examples of three major epidemics namely TB, Malaria and HIV/AIDS. In case of TB the cornerstone of prevention is centering around early detection and treatment of TB cases to prevent transmission of infection, in case of Malaria again detection and treatment is the primary strategy of prevention and in the case of HIV/AIDS treatment does play a significant role in preventing transmission of the disease.

Secondly, all known diseases are not preventable, at least the present development of medical science and understanding says so. For example take the common illnesses that are known to nonmedical people also. People have no idea how to prevent formation of stones in the gall bladder or in kidneys. People can't prevent enlargement of prostate in males and ovarian tumor in females, cataract in the eyes, Polyp in the nose or in the intestine etc. One doesn't know what specific health practices could prevent from acquiring many other common diseases be it migraine, appendicitis, tonsillitis and so on . Then there is very little knowledge to find out who are prone to diabetes and how to prevent it. Lot of research has been undertaken centering around coronary heart diseases and on cerebral thromboses [what lead to paralysis of one side of the body]. Some 'risk factors' for these illnesses have been identified such as high blood pressure, presence of diabetes, lack of physical exercise, obesity etc. Those who are having these problems are  more likely  suffer from coronary heart diseases or from cerebral thromboses (clotting of blood in the arteries in brain). But none of these risk factors could establish cause and effect relationship. Considering these risk factors all together, one can at best explain 25 to 30 percent of the causes behind Coronary heart diseases. Also, there is very limited knowledge about why some people suffer from high blood pressure. There are few identified risk factors (like high salt intake, social and economic stress, personal traits, etc.) but these are not enough to explain the full context of the said illness and no causal association could be established. So how to prevent rise of blood pressure and who would suffer is more of a conjecture. Similarly, modern medicine is unable to prevent depression in this societal culture. There are many such common illnesses which are not preventable and the list could be unending. But what medical science knows in connection with these illnesses is that how to diagnose these diseases and what sort of treatment could be provided to heal or to reduce sufferings with great certainty. This is why people aspire for treatment for remedies and for all counts it should be considered as an appropriate demand for health development agenda. If one starts talking about cancer (which has become very common) one would face even more complex challenges. Numerous harmful substances (chemical, physical and biological) manufactured in industrial process as well as used in food products have become part of people's day to day practices. Many of these chemical or physical agents have been identified as cancer producing substance. Now the governments have been expanding nuclear power plants that essentially push all living creatures including human beings to the exposure of ionizing radiation, Radiation adversely affect health and human life including the future generations to come. The question is what sort of health seeking behavior could be suggested in order to avoid such harmful substances. The fact remains that it is beyond the capacity of any individual. This also applies to mental depression and many such diseases which are grinding human lives. Orthodox prevention strategies do not work in all these circumstances.

Also, the changing demographic profile of the country must be taken into account; many have not noticed that the average lifespan of India's men and women has increased considerably. Now it is nearly 67 years. About 20 percent of the population would be over the age of 50 years by 2020. With the increase of age our biological system will start deteriorating with special focus to muscular skeletal system, eyes, lungs, kidneys etc. The chances of diseases impacting these systems will go up according to the law of nature. One can't prevent those changes to happen in biological system, through adopting so-called healthy behavior and practices, at best one can delay the process of degeneration of organs to a certain extent. These degenerative illnesses are going to affect the quality of life of twenty percent of population who will be needing treatment for various ailments and palliative care services. It's unfortunate that a section of academicians and intellectuals still believe that preventive care can solve all health problems. There are intellectuals who argue on the ground that treatment has become very expensive in developing countries, so one should not ask for Government spending beyond primary health care services. Their view is that by supporting Medicare services pressure would be created on the existing primary health delivery system. As a result of which Medicare services have become the 'soft target' both by the left and right wing intelligentsia and politicians alike who disapprove public expenditure in treatment and care services.

The changes occurred in the mortality profile of the country since last 40 years must be noted. In 2012, about 20 percent of the deaths occurred due to infectious diseases whereas 26 percent deaths occurred due to coronary diseases, 13 percent death is accounted for chronic lung ailments, 7 percent death is due to cancer and 12 percent due to various other non-communicable diseases and 2% for diabetes. In total, 60 percent of all deaths occurred in the country due to non-communicable diseases that further strengthens the requirement of Medicare services for all these non-communicable diseases. It is difficult to understand the mindset of these health analysts and political activists who still refuse to push public health care expenditure in Medicare services, perhaps they fail to comprehend the transformative changes that the medical science has brought forward including its enormous impact in people's life and health.

The role played by the Left politicians are even worse. The enactment of RSBY [Rastriya Swastha Bima Yojona] could be sited as a case for examples. The legislation was meant for the unorganized labor sector with an objective to protect their health through this insurance scheme and interestingly enough it was enacted by the ministry of labor. When India had one of the best, if not the best pro-people legislation in the country i.e. ESI act. How the leftists   forgot this ongoing program and allowed [who were sharing power in the center] it to happen is a mind-blowing issue. As mentioned earlier people in this country spend 78% of health care expenditure out of pocket but how they spend? The NSSO data [2007] pointed to the fact that out of their pocket expenditure 3/4 expenditure goes to buying outdoor services which include cost of investigation, medicine and professional fees. Which insurance would provide these outdoor services? And of course not the RSBY. This is one aspect of the story but the other important issue one can't ignore is the uniqueness of the ESI scheme is that in addition to Medicare services it provides sickness and disability benefit. The insured member under ESI is entitled to receive 50% of his or her average daily wage when they are not able to work due to illness  under the provision of sickness benefit and insured labor similarly can  claim wages for disability out of work related injuries as par the disability benefit provision, All these components  has a political dimension altogether. By a single stroke of RSBY the policy makers could successfully divert the discourse on intricate political issues related to workers' health rights. And we probably lost one more opportunity to initiate health movement of and by the working masses in the country. This incident could be written in the history as 'the greatest deception of the millennium to the working masses’.

People get agitated when appropriate Medicare services are kept beyond their reach. And quite naturally one can't reject the demand for appropriate Medicare services for the citizens of the country and that should come from the Govt's coffer. Health workers and activists who are committed to work on health agenda need to engage into deeper analysis and discussion on development and distribution of health care services including creation of 'values' and culture pertaining to it. Looking from the people's and political perspective of health development in the country one can't ignore the policies and programming of Medicare services what deserve much serious attention.

Frontier
Autumn Number
Vol. 50, No.12-15, Sep 24 - Oct 21, 2017