Waning visions of equity: Healthcare privatisation in India and its many discontents

THE BHORE COMMITTEE REPORT OF 1946 charted a course for public health investments and infrastructure for the emerging nation state. Its recommendations were manifold, all with the aim of making healthcare equitable and universal. Among them, some key ones included a vision of a healthcare system that had – 

1. three levels – primary health centres (‘PHCs’) at the village level, secondary health centres (hospitals) in districts, and tertiary level hospitals in metropolises 

2. a focus on preventive health, over curative services; free and universal healthcare and,

3. investment in human resources for health through medical and nursing education at scale.

Vitally, it recommended a significant proportion of the government’s budget – 15 percent – to be dedicated to health. Its vision included a thirty year timeframe within which all these components were to be fully realised.

What is visible today is, at best, a partial implementation of these recommendations, and a healthcare system which is the opposite of the egalitarian and humane approach that the Bhore Committee espoused. Over time inequity in Indian healthcare has become further entrenched. Although a three-tier system was implemented, reporting reveals the abysmal state of much primary healthcare, the shambolic condition of district hospitals, and increasing number of poorly resourced government tertiary health institutions due to lower financial outlays for public health. 

While certain preventive programmes such as immunisation, maternal and child health services, and sanitation have been put in place, a large emphasis of healthcare in India has historically been around curative medicine. And, the shortfall in human resources for health in rural India has been abundantly recorded. Finally, the Union government’s budgetary commitment to health has reached nowhere near the figures envisioned by the committee.

There are many reasons why quality healthcare in India has skewed in favour of those who can afford it, making it one of the many starkly unequal sectors in India. One of them has been the stepping away of the government from being the primary provider of healthcare. Indeed, one of the better-known appalling facts about financial precarity in India is that out-of-pocket expenditure (‘OOPE’) on healthcare is the chief reason that drives families and individuals into poverty. This is because with the shrivelling or under-resourcing of government healthcare provisioning, most turn to a largely unregulated private sector to seek care, where expenses lead to severe indebtedness.        

Policy trajectories

In 1983, as the Indian government issued the first National Health Policy (‘NHP’), a path which increased the role of the private sector opened up. Simultaneously, the public exchequer’s contribution towards provision of healthcare remained stagnant. While the NHP 1983 envisioned a larger role for private providers to alleviate the burden on government, the introduction of user fees in public healthcare during the Eighth Five-Year Plan (1992-1997) demonstrated another step in the commodification of healthcare. To be sure, neither of these policy moves were devoid of welfare-oriented instincts. The NHP in 1983 spoke of decentralising healthcare to move resources closer to needy communities, and of cost-effectiveness that elevated affordable healthcare solutions. Planning in the 1990s, around the time of liberalisation of the Indian economy,  was pre-occupied with how to generate revenue for a resource-constrained health sector, while also acknowledging the need to encourage greater use of public health services, and improve access for the poor. User charges were seen as a panacea for this, with a push coming from the World Bank of its Health Systems Development Project. Many states implemented this approach in the next decade.