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Health care in independent India was originally imagined as a comprehensive three-tier system of primary health care, (including public health and preventive medicine), secondary level care in the district hospitals, and advanced tertiary medical care in government hospitals in cities. This imagination of health care was first stated in the Bhore committee report (1946). For nearly two decades after, the hope of the people was that health care should be provided by the government. Primary health centres (PHCs) were set up, partially manned and provided with minimal supplies of essential drugs. Very soon, cost benefit analyses privileged national programmes like small pox, tuberculosis and malaria control programmes, etc., at the cost of curative health care in the PHCs. [1] The PHCs were gradually appropriated by the national programmes.
Meanwhile, the mid-1960s saw one of the worst famines in the country that led to food aid from the USA with conditionalities that India would push family planning (FP). The family planning programme was now implemented through the PHCs and targets were set for each government employee, regular sterilization camps were held and new devices and contraceptives were introduced, some of them at the level of clinical trials. This was accompanied by propaganda which convinced the nation that birth control was the solution to the nation’s problems. The allocations for the FP programme were as large as the allocations for the health sector as a whole. They were centrally administered with strict accountability. [2]By the 1970s the primary health centres thus became non-functional under the sustained onslaught of the centrally driven targeted family planning programme. This led to the withering away of all the national disease control programmes, resulting in a resurgence of malaria, which had almost been eliminated. All earlier programmes like those to control tuberculosis and malaria were abandoned. Thus the utopian dream of the Bhore Committee was extinguished. In practice, there never was any significant and truly effective curative care for those among the poor afflicted by serious ailments.
By the 1980s there was an uneven, urban biased, erratically growing network of corporate hospitals and nursing homes dotting the landscape. The elite had moved on to the private sector (the small nursing homes and hospitals) and the mission hospitals. Some government hospitals survived providing services to the poor in towns and cities. The rural areas bore the brunt of this transition. [3]Apollo and Owaisi hospitals were the earliest of the corporate hospitals that began to mushroom in Hyderabad. Studies in the late 1980s confirmed that 80% of the health care needs were being accessed in the private sector. There were many who used other systems of medicine provided by skilled practitioners of Unani, Ayurveda, Siddha, nature cure, bone setters, etc., [4]of whose contribution to health care there is no record.
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Today, the nation spends around 6% of its GDP on health care, of which the government pays a meager 1%. The balance of 5% expenditure is being paid out of the pockets of the patient. [5]On the aggregate 60% of this private expenditure is on diagnostics and medicines, while 40% is incurred on hospitalization, most of which is in the private sector. This is a catastrophic burden on low-income families often leading to perennial indebtedness and pushing them below the poverty line. This condition, which has become worse today, is characterized by near autocracy of private hospitals, no protocols or audits to assess their practices, irrational treatment and medical bills that depend on the whims of the hospital industry. The government hospitals are still the last resort for patients who have been turned away from the corporate hospitals for inability to cover bills, and have exhausted their money to pay for visits to different specialists, diagnostics, transport, and high costs of living in the city.
In this situation, there has been since about 2000 a renewed interest in medical care. One of the factors leading to this interest has been the corporate agenda of expanding the market. Another driving factor has been the appearance of dismally low health indicators on several fronts in a nation otherwise projecting a rosy picture of economic development. One such initiative was stimulated by the high maternal mortality rate, which has led to the establishment of the National Rural Health Mission, in 2005, in order to increase institutional deliveries. Another has been the establishment at the national level of the Planning Commission’s High Level Expert Group (HLEG) on Universal Access to Health Care led by Dr. Srinath Reddy. This initiative looked at health care as a national responsibility.
At the same time, the Rockefeller Foundation, the World Bank, international capital and the top government officials were overjoyed that the resultant expansions in the health sector would contribute to the second phase of growth of the Indian economy. To this end, the Planning Commission announced that it would double its health care budget from 1% to 2% of the GDP, which is yet to be fulfilled. Their expectation of the HLEG report was that it would recommend fully privatized insurance based health care. Such a recommendation would provide an expert vindication of the privatization of the health care responsibility of the state. Corporate and governmental concern seems thus to be more interested in the growth and profitability of the medical and health care industry than the well being and health of the people of India. It is another matter that the HLEG report has recommended that health care administration be retained in governmental control and private providers are used where necessary to meet the gap in capability.
Andhra Pradesh had stolen a march on the health care front with the establishment of the Aarogyasri state funded insurance programme in 2006 by the then Chief Minister Dr. Y.S. Rajasekhar Reddy. This programme, which has been designed to provide the most advanced form of tertiary care free to those below the poverty line, has two distinctive public profiles: a profile that is admired and acknowledged by many including the World Bank as bringing together the needs of health care and corporate interests; another profile where the poor see Aarogyasri as a programme that provides them life support in times of need. It marks on the one hand the emergence of health care on the political agenda of many political parties; on the other hand, its structure is characteristic of ineffective, badly prioritized, lop-sided orientation of advanced medical care that furthers the wealth of corporate hospitals through specialized medical and surgical procedures.
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These procedures are performed on patients, who come to these hospitals in a desperate condition with little or no medical support during the early stages of their ailments, no preventive care, and no emphasis on promotion of good health through nutritive food that meets the metabolic need of working bodies. It is almost as if the complete abandonment of the general health of the population by the government acts as a system that feeds patients to corporate hospitals so that they may access government funds. Today Aarogyasri covers over 950 specialties that are available in large corporate hospitals, but does not cover blood pressure, malaria, dengue or diarrheal diseases unless they lead to advanced, life threatening complications that need tertiary care. This programme of insurance driven medical care has been attractive enough for other states to emulate (Maharashtra, Tamilnadu, etc.)
The fragmented health care system as it emerges in India today between the governmental efforts to manage its health indices and to turn medicine into the engine of economic growth has some bemusing results. For example, a person on the street has to remember a) she needs to go to a government dispensary for common illnesses like colds and coughs; b) the Janani Suraksha Yojana for healthcare during pregnancy and childbirth; c) the national programme for TB care; d) the Women and Child Welfare department for nutrition during pregnancy and six months after delivery; e) use the school lunch programme for food for her school going children; f) access Aarogyasri for her tertiary care procedures; g) and use her RMP to guide her through this labyrinth.
Rizwana’s story illustrates one aspect of this chaos in health care. When her husband who worked at Airtel had tremors and seizures, she took him to a traditional practitioner who gave him an elaborate regimen that did not provide relief. She then took him to the government ESI hospital, which promptly saw him as a case of alcohol withdrawal and delirium tremens (apparently all workers who come to that hospital are first treated for alcohol addiction!). It took an unofficial consultation with another doctor outside the system to ensure that he was referred to a corporate hospital, which resulted in a diagnosis of brain tuberculosis now under treatment. Fortunately he was covered under ESI, and his payments were up to date. He got paid leave for three months and it helped him buy eggs and milk. However he had to go to the TB centre to collect his drugs! This is a result of the completely chaotic, un-coordinated, system of health care in India today. It is extremely likely that without the outside intervention and their networks in the city Rizwana’s husband would have died.
The essays in this broadsheet are a small attempt to examine some symptoms of the crisis of health and health care in Andhra Pradesh in the above context. There are papers dealing with Aarogyasri, interviews with health professionals and politicians and studies of different mechanisms of health care provision. It is hoped that this collection of analyses and information will enable the reader to ask the question where we go from here, and participate in the emerging politics of health care in India.
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A Note on Primary, Secondary and Tertiary Care
Primary Health Care
Primary care is the term for the health care services which play a role in the local community. It refers to the work of health care professionals who act as a first point of consultation for all patients within the health care system. Such a professional would usually be a primary care physician, such as a general practitioner or family physician, or a non-physician primary care provider, such as an ANM, ASHA worker, etc. Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care.
Primary care involves the widest scope of health care, involving preventive and promotive care along with basic curative health care. The beneficiaries include all ages of patients, patients of all socioeconomic and geographic origins, patients seeking to maintain optimal health, and patients with all manner of acute and chronic physical, mental and social health issues, including multiple chronic diseases. Consequently, a primary care practitioner must possess a wide breadth of knowledge in many areas. Continuity is a key characteristic of primary care, as patients usually prefer to consult the same practitioner for routine check-ups and preventive care, health education, and every time they require an initial consultation about a new health problem. A health system with a strong primary health care system is the most cost-effective mechanism of investing in health and can handle almost 50% of the health care needs of the population.
Common chronic illnesses usually treated in primary care may include, for example: simple viral and bacterial infections, diabetes, asthma, etc. Primary care also includes many basic maternal and child health care services, such as family planning services and vaccinations.
Secondary Care
Secondary care is the health care services provided by medical specialists and other health professionals who generally do not have first contact with patients, for example, medical specialists, surgeons, obstetricians and gynecologists, orthopedists, ENT specialists, ophthalmologists, dermatologists, etc.
It includes acute care: necessary treatment for a short period of time for a brief but serious illness, injury or other health condition, such as in a hospital emergency department. It also includes skilled attendance during childbirth, intensive care, and medical imaging services.
The term “secondary care” is sometimes used synonymously with “hospital care”. However many secondary care providers do not necessarily work in hospitals, such as psychiatrists, clinical psychologists, occupational therapists or physiotherapists, and some primary care services are delivered within hospitals.
Depending on the organization and policies of the national health system, patients may be required to see a primary care provider for a referral before they can access secondary care. In India, the weakness of the primary care network results in most people directly accessing and over burdening specialists for their illnesses. This leads to inefficient utilization of health system resources from the medical perspective and to an expensive form of care for patients.
Tertiary Care
Tertiary care is specialized consultative health care, usually for inpatients and on referral from a primary or secondary health professional, in a facility that has personnel and facilities having superspeciality services, such as a medical college or medical institutes. Examples of tertiary care services are cancer management, neurosurgery, cardiac surgery, plastic surgery, treatment for severe burns, advanced neonatology services, palliative, and other complex medical and surgical interventions.
The All India Institute of Medical Sciences, Christian Medical College and Hospital Vellore, and most medical college hospitals are tertiary care institutions. Corporate hospitals in Hyderabad, especially those who have their specialized procedures empanelled in the Aarogyasri programme are tertiary care hospitals. In Andhra Pradesh, as argued in other contributions in this broadsheet, the dominance of tertiary-care hospitals and the absence of a well-regulated primary care network have resulted in a lop-sided, expensive and sometimes unnecessary form of medical care.
Other systems of Health Care in India
In the Indian context, the modern system of medicine was introduced during colonial rule and is paralleled by other traditional systems and practices of health care that are utilized by different people according to their needs and assessment of the situation. Thus for example, Ayurveda, Yoga, Unani, Siddha, Homeopathy and traditional bone setting are forms of knowledge and practice that are available through skilled practitioners in different parts of the country. These practitioners are accessed at all the three levels mentioned above, and in addition, they are often also put to use in palliative care.
Much more can be said about this subject, but for an introduction this should do!
