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On the occasion of World Health Day, on 7 April 2017, Jan Swasthya Abhiyan (JSA), Public Health Resource Network (PHRN) and PSI organised a panel discussion “People over Profit: Countering the Privatisation of Healthcare” and released a booklet series published by PSI called “Non Standard Work in the Healthcare Sector in South Asia”. The panel addressed issues related to the direction of healthcare policies, the expansion of the private sector in healthcare provision and the informalisation of conditions of employment of the healthcare workforce.
Speaking to the National Health Policy published a few weeks ago, Amit Sengupta from Delhi Science Forum, highlighted that the aims and targets of the policy are grossly inadequate.
“The targets are modest at best in several cases.” He elaborates, “The target for achieving a life expectancy of 70 years by 2025 has been exceeded by two of our neighbours, Nepal and Sri Lanka. The target for 2.5 per cent of GDP to be spent on health by the government is half of the global average and of what the World Health Organisation recommends.”
Sengupta also stressed that while there is no concrete direction to strengthen the public sector, there is a worrisome shift in emphasis for the government’s role to become that of a purchaser of services, instead of a provider.
“The experience of such a model is almost uniformly negative, both internationally as well as in India”, he concluded.
Researcher at Center for Women Development Studies, Bijoya Roy, confirmed this last point and stressed that the experience of engaging the private sector through Public-Private Partnerships (PPPs) has not responded to the expectations that it would allow to expand the provision of healthcare services.
“In most cases, private sector providers end up pulling out of their contractual agreement with the government, and the government finds itself having to provide the services the way it would have in the first place, but with a delay of one or two years and a waste of public resources that have been transferred to the private provider in the course of this process,” Roy said.
In the discussion, it was proposed that instead of PPPs, the government should turn to Public-Public Partnerships in which organisations representing the community that receives the services (the public) are taken on board to ensure the accountability and responsiveness of specific facilities while the government steps up to its role as a provider of healthcare services.
A very worrisome trend is that of the development of the private healthcare sector, as highlighted by Indira Chakravorty, independent researcher associated with Jan Swasthya Abhiyan.
“On the one hand, companies in tertiary speciality and super-speciality care are consolidating by creating hospital chains across the country, raising venture capital and private equity funds, and expanding their operations outside of India into South Asia, Africa and the Gulf. On the other hand, foreign healthcare multinational companies are increasing their presence in India, and India is becoming an important contributor to their revenues, such as is the case of Columbia Asia and IHH Healthcare Berhald.”
Columbia Asia is a US owned company, incorporated in that operates 1,200 beds in 11 facilities across the country. India accounts for 45% of its global revenues. Malaysian-Singaporean company IHH Healthcare Berhad is the world second largest healthcare group (in terms of capital) and operates 10 hospitals in India under the brand names of Gleneagles, Global Hospitals.
“The nature of the Indian private healthcare sector is changing from a highly fragmented and diverse sector towards an organised health care industry”, Chakravorty warned. “We have to understand the implications of this change for the healthcare system, for patients as well as the healthcare workforce,” she concluded.
Speaking for Public Services International, Susana Barria said that as private hospital presence in the capital has increased, the strategies of informalisation of the workforce have intensified and affected more and more job categories.
“Unskilled and semi-skilled workers involved in support services in hospitals, such as laundry, housekeeping and security were affected first and saw the security of tenure vanishing as fixed term contracts were increasingly used. But by the early 2000s, unskilled and semi-skilled workers in hospitals under the Government of the Nation Capital Territory (GNCT) started being through contractors, at lower wages and without any social protection. In this period, health professionals such as nurses and technicians start getting affected as they are now taken on fixed term contracts too. In the last 4-5 years, contract work has become the norm for unskilled and semi-skilled workers and it is now starting to affect nurses and technicians too.” Barria concluded by saying that “Informalisation is but one more piece in the process of weakening public healthcare institutions and therefore weakening the role of the public sector in the country’s health system.”
Speaking of the experience in the autonomous speciality hospital under the GNCT Institute of Liver and Biliary Sciences (known as the ILBS), Anil Lamba, from the ILBS Employees Welfare Association, shared the condition of the 600 workers of the hospital that are all either on fixed term contracts, or hired through contractors, in both cases without security of tenure.
“We raised our voice to denounce scams within the hospitals, but instead of taking action, the management of ILBS is targeting the whistle-blowers who are also the representatives of our association.”
Irregularities in the accounts of the institute have also been raised by the Comptroller and Auditor General of India. As an instance, The CAG report of the 2008-10 accounts of the institute show that ILBS paid more than Rs 37 lakhs to French food company Sodexo for providing a service that is income generating, leading to an illicit drain of public money. On a more regular basis, doctors use brand names when writing prescriptions, and generic names are only rarely used, leading to higher cost to patients.
“Now we do not know if the leaders of our union will see their contract renewed later this month. We have been victimised for raising issues that affect workers and patients”, Lamba concluded.
As a conclusion to the panel, Amitaba Guha, from Center of Indian Trade Unions (CITU) gave a concrete instance of the way the pharmaceutical industry and manufacturers of medical equipment and devices shamelessly take advantage of people’s ill health to increase their profit margins.
“Huge unethical mark ups were charged at each stage in the supply chain of coronary stents resulting in irrational, restrictive and exorbitant prices,” said Guha. This was the prevailing situation despite that stents are on the national list of essential medicines since July 2016. “We demanded that the price be fixed base on the production cost, and not on the average price of a failed market system as was the case. The fact that this process resulted in a cut in prices of 85%, from an average price for bare metal stents of Rs 45,000 to Rs 7,623, gives an idea of the audacity of the companies involved”, Guha concluded.
Vandana Prasad, from PHRN who chaired the panel, concluded that public health and trade union activists need to ally to exercise the required pressure on the government so that the public sector is strengthened, as this is the only effective way to regulate the private sector and provide healthcare for all with equity.
The meeting was attended by more than 30 activists in public health, trade union representatives and researchers. PSI South Asia Sub Regional Secretary R Kannan released the booklet series.