Following the large scale macro-economic reforms introduced in many countries since the 1990s, there has been a shift in the provisions of public goods, including health and education. Certain Asian and Latin American countries have opened up the medical care market for privatization and introduced the concept of user fees in public health services. The concept of segmented medical care was given in the World Development Report itself- offering private, market-oriented better quality care for the rich. By comparison, the public health facilities look woefully inadequate. They were widely criticized, and the government expenditure on health declined sharply.
This change in the health care sector where private players have started treating it as a flourishing business is premised on the view that the public sector is unable to act as a sole provider of those services within the backdrop of shortage of resources. Even when there is no recession, the capital need to be deployed in several other sectors mainly industry, agriculture and infrastructure so that health care falls short of funds. It is now being realised that greater competition is the only option for better quality services and improvement in the overall efficiency of these services.
The advocates of reform hold that the state should undertake only minimal interventions in the economy, and for health service it should provide only the essential service. This view totally overlooks the issue of incompatibility between public welfare and private provision. More importantly, this approach does not address the problems of poverty, inequality among social classes, religious groups and gender aspects. The poor and socially backward classes depend on public provision of health care almost entirely.
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The system of health care as it is present in most of the developing countries is that while the poor would go for the public care for essential clinical services, the rich would prefer high-tech private medical care. Consequently, consumer choices of health services remain restricted to only those who can afford to pay for services in highly expensive private hospitals and clinics. The ‘willingness to pay’ is often equated with ‘ability to pay’. But some studies have shown that in some family’s highly expensive treatment of serious diseases like heart ailments, cancer, nervous system disorders have lead to erosion of family assets, high indebtedness. Some families have known to resort to inadequate diet, drop out of school children, especially girls.
This is known as medical poverty trap. This takes place so often and in every region of our country that we have no reason to accept that the government should provide only the essential clinical services. They need medical care against diseases like respiratory infections, renal problems, intestinal disorders, vitamin deficiencies, arsenic poisoning, fatal accidents, mental disorders, etc. Under gross economic equalities, the application of market system and sticking to the segmentation of health services will pass on the benefit only to the rich.
In India the post-reform era shows a gross neglect of the health scenario. Investment in health sector yields only long-term gains which seem to be at odds with short term political gains which our politicians always tend to seek. Under the Structural Adjustment Programme funded by IMF-World Bank, the government’s share in total health has not shown a commensurate rise with the increase in population. Due to poor access and quality of service, the rate of utilization of public facilities has in fact shown a decline over the years as per report of the National Sample Survey Organisation. It has also been observed that whatever public facilities are available they are utilized more by the rich sections.
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The share of richest 20 per cent for in-patient bed days is about 6 times more than that of the poor. In monetary terms, less than 10.2 per cent of total government investment on health service goes to the poor and to 31 per cent to the richest by comparison. It is clear that the poor spend disproportionately higher per cent of their incomes on health service.
More than 30 per cent of their income goes for treatment for minor ailments, infections and communicable diseases. The neglect of preventive health care in public health policy is the chief cause of this situation. Out of the total government expenditure, only 13 per cent is spent on primary care, 25 per cent on public health research and a hopping 60 per cent for the secondary and tertiary health care. Due to this, 55 per cent of rural primary care is sought from the private practitioners, of whom many are unregistered and another about 24 per cent from private clinics or nursing home. In this backdrop, the issues of traditional medical systems and their usage appears to be of great importance in India.
Another unexpected trend needs to be mentioned. Although market-based reforms in health care are advocated in almost all the developing countries, the state continues to play a major role in the delivery of health care services in developed countries, especially in America, West Europe and Australia. However, the degree of commercialization of health care services as measured by the spending of the private individuals varies from country to country.
The results of commercialization of health care, considered generally, and not with specific reference to India have not been very encouraging. The observations made in this regard show that countries with better health outcomes, have significantly lower commercialization in health care services; better care at birth is associated with more of GDP spent by the government on health, but not with more private health spending to GDP; higher commercialization at primary health care is associated with greater exclusion of children from treatment when indisposed.
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It is quite evident that the introduction of private competition and user charges in public health discriminates against the sick and the poor. The condition of health care system in all big and small cities in India shows that the poor have no or little access to health care facilities. The public hospitals are all full of patients; beds are not available wherever we go. The medicines are always short in government hospitals. The situation in remote areas of the country and most of the villages leaves much to be desired. On the other hand, the rich have access to the health care everywhere. In cities, private clinics, hospitals and diagnostic centres are in every part. They welcome patients who can afford expensive treatment.
Commercialisation of education is certainly against the policies of social equalities which India aims to bring. It has also led to many undesirable practices. Private clinics often subject the patients to conduct many tests which are not necessary. They admit patients who do not require admission. This is done to earn more money. Operations are performed at times when they are not required or are bad for the patient’s health. However, some hospitals and clinics keep a strict code of conduct and do not adopt such unscrupulous practices. Their high charges are justified because of high cost of inputs.
The fact cannot be denied that the commercialization of health care has supplemented the public facilities in this regard. It has rather helped the government to maintain a high level of health care in the country. In all major and small cities and towns, private health centres are open day and night and are ready for any emergency. They are saving the lives of thousands every day. The private hospitals and clinics have provided employment to lakhs of doctors, nurses and other staff across the country. The government is earning huge revenue in the form of taxes.
These clinics, diagnostic and treatment centres have also created a huge demand for health care products, instruments and medicines. This industry has flourished to become the fourth largest health care industry in the world. The economy owes a lot to this commercialization. Today, India has a strong and sophisticated tertiary health sector where people from outside the country come for medical tourism. Given this situation, India can take advantage of its indigenous medical system to ensure cheap, accessible and capable medical care for her population, particularly the poor. India has many systems like Ayurveda, Unami, Siddha, etc. which it has developed since the ages. These systems need to be expanded and exploited for improvement of general health of the people.