The health section of the 12th five year plan is irrefutable proof of the structural hegemony within the country. It shows unequivocally that Indians do not intrinsically believe in equality. We honestly believe that one group of people are different from another, that resources CANNOT be shared equally, and that one group must give up – ensuring the happiness of another group. This belief is so entrenched that it is shared by those to stand to gain as well as those who stand to lose from this systemic arrangement. For a country that has been steeped for centuries in a web of cultural, religious and social inequity, concepts like equity, fairness and justice are uneasy bed-fellows that have been borrowed from societies unlike our own.
The health plan is clever. It uses semantics, it throws words around. This playing with words, more than anything else, shows how little the people in power care about the needs of large sections of the country. PriceWaterHouseCoopers in 2007 did an in-depth analysis of healthcare in India as an ‘emerging market’ in terms of revenue and employment. It estimated the value of the sector in India to be $40 billion in 2012 translating to more than 6% of the GDP.
The Planning Commission on the other hand talks about needing to increase health sector related resources to 2.5% by the end of the 12th plan, and this would include provision of clean drinking water and sanitation as one of the principal factors in the control of disease! It just simply means that India is willing to give more than 6% of the GDP to the private healthcare market but unwilling to spend on public health.
PWC sees the Indian economy thriving due to more disposable income which ‘maybe a fraction of what the US peers earn, but is equivalent to more than $100,000 per year when adjusted for purchasing power parity’. Numbers of women entering the work force and the ability of Indians who can afford to buy Western medicines is seen to be rising. It takes no account of the fact that many of these women are the first generation to break out of rigid gender hierarchies, who struggle to ensure that their children receive meaningful health, education and nutrition, who are wearing themselves out taking care of their homes and jobs. It sees these women as ‘potential spenders’ – as a market, and that too on Western medicines !!
The report also states that infectious diseases and chronic degenerative diseases are rising in India with some communicable diseases that were once thought to be under control through the public health systems such as dengue, viral hepatitis, tuberculosis, malaria and pneumonia have ‘returned in force’ or are ‘developing a stubborn resistance to drugs’. They attribute these squarely to sub-standard housing, inadequate water, sewage and waste management systems and a crumbling public health infrastructure. The also gleefully point out that India is grappling with emergence of AIDS, food and water borne illnesses and lifestyle diseases such as hypertension, cancer and diabetes as ‘Indians live more affluent lives and adopt unhealthy western diets that are high in fat and sugar”.
The market analysis looks at the pharma industry as one of the fastest growing in terms of sales especially because of the OTC (over the counter) market. The report sees the proposed pharmaceutical policy for price control as ‘adversely impacting foreign pharmaceutical firms that want to bring business in India’.
They also point out that of the 15,393 hospitals in India in 2002, 2/3 were public, but after ‘years of under-funding, most public health facilities are inefficient, inadequately managed and staffed and have poorly maintained medical equipment”. The report talks about the healthcare divide and the fact that there exists ‘two Indias: the country that provides high quality medical care to middle class Indians and medical tourists, and the India in which the majority of the population lives – a country whose residents have limited or no access to quality care’.
It proudly states that a google search for ‘India medical tourism’ throws up more than two million results leveraging the country’s ‘well-educated, English speaking medical staff, state of the art private hospitals and diagnostic facilities at less than 1/10th of that incurred in the US. This industry alone was estimated to reach $2 billion in 2012. The government is also supporting this initiative on 43 acres of land in Gurgaon, Delhi at an estimated cost of $493 million. This, apart from the lower import duties, higher depreciation rates on medical equipment and expedited visas for overseas patients.
In absolute stark contrast stands a Muslim mother from a slum in Bangalore who needs a below poverty line (BPL) card to claim Rs. 5000/- that she has spent by taking a loan, on her ill child. She has been paying bribes and shedding tears before different officials. “I feel ashamed begging like this’ she says ‘ but I need the money for my child’s treatment. The government tells us not to have more children. How can we not, when they do not protect those children we already have?”
PWC has indeed identified the pitfalls within the healthcare system, but rather than suggesting that the rich poor divide be narrowed, pharmaceutical industry be regulated, public funding for health and other social determinants be increased and income of the newer workforce (including women) be used more appropriately, the report goes on to elaborate different strategies to maximize profits.
PWC has also identified private health insurance, telemedicine, health care infrastructure expansion, medical equipment, pharmaceuticals and clinical trials as areas of maximized profits.
In this backdrop, the 12th five year plan reads very well. It starts with the rhetoric of people being poor in the country but goes on to make its position clear when it says that upper income groups may “opt out of public services”. This is essentially the crux of the downfall of the public system. The public is the ‘other India’ – the one that is anyway dying. The deaths in this other India are not incidental, they are not an accident or an aberration in a society that is trying to better itself. The deaths are planned. They amount to willful extermination and elimination. The health chapter of the 12th five year plan draws up elaborate strategies that ultimately benefits the private sector – be it insurance, or tertiary hospitals, medical education or diagnostics. The ‘partners’ of the government in policy making are international bankers, investors and money lenders wearing the innocent garb of researchers, academicians, policy makers and experts . The policy is to facilitate the rich India – to ensure that businesses and industries maximize their profits. A health activist said “India is one of the few countries where people do not hesitate to steal food from the mouths of dying children’. The cost of profit for a few is the death, degradation and ill-health of many.
For a country that is steadily moving towards a “unified nation”, ethnic cleansing takes new forms. Why would the country need its slum dwellers and rural poor? The middle class stand to gain by entire sections of society being wiped out. The middle class do not want to drive down an up-market street in the country only to find a miserable street urchin begging at one’s window, one doesn’t want to see the filthy street vendors chocking up foot paths, one does not need slums that require water, housing and electricity – resources that one would rather save for oneself. What earthly gain would the Schedule caste colonies in every village offer to the upwardly mobile India? They bring down our statistics, they make us look bad in international fora, they demand reservation for benefits that we very intrinsically believe is strictly for our own family and community. This is the truth of the Indian ethos. We do not want the poor, we do not want to see them or hear them or speak to them. They make us look bad. The choice of governments that we have now is either right wing or extreme right wing.
The move then is to eliminate!! The process of elimination is slow but definite. One cannot do it suddenly because it means having to deal with it legally. A day will come when India really will have no poor people, our populations would be stabilized and showing a declining trend, our infant and maternal mortality rates would be greatly improved, we would have adequate water, electricity and nutrition. We would have hounded out those who we believe need the fewest resources but consume the most – the adivasis who gather a few berries and logs for their day to day sustenance are the ones we suspect are depleting our natural resources, the muslims, who we think are all terrorists and need to be exterminated, the Christians who shake the social eco-system by offering education and health to the poor, the schedule castes who are more and more difficult to control and becoming more and more demanding – all these are perceived as a threat to the order of things. The plan is to cut off their access to every basic resource – education, health, water, nutrition, law and daily wages. The Muslims and Christians, if they are not poor, can just be made into hate targets, after which the people will take care of the issue on their own.
The constitution, in that way, is an aberration because it did not emerge from the social institutions that were well established in the country even as it was being made. When the constitution talks about equality and liberty, it borrows heavily from other sources. If equality and liberty were real values – on paper and in spirit, then the voice of the 19 year old woman from a slum, who asked me in despair “What is the government doing for the poor people in the country?, is as likely to be heard as that of a Narayan Murthy or a Devi Shetty. Her concerns are real and she is not a lone voice, but the voices get drowned by the din of welcome we offer the profiteerers and marketers, the money lenders, the traders, the bankers and the investors.