New Delhi: In a recent report, the Times of India examined 24 recurring topics from Prime Minister Narendra Modi’s speeches in March. Out of 24 topics, defence was the most mentioned. Health was down at the 21st place.
But a large survey of what voters want, carried out by the Association for Democratic Reforms, showed that health centres and hospitals were the second most important issue, after jobs. Access to drinking water, which directly impacts sanitation and health, was the third most important issue for voters.
There seems to be a surprising disconnect between what voters may want and what the BJP is keen to promise.
It has not always been this way. Over the last five years, healthcare has featured prominently in the BJP’s policy and legislation. In fact, it has said and done much less about the other social sector heavyweight, education.
However, some of the party’s most widely-marketed schemes were not cast as healthcare programmes, when they in fact were. The Swachh Bharat Mission, the Ujjwala scheme and the Jan Aushadhi scheme, for example, all attend to healthcare needs but were not funded by or run by the health ministry.
All these schemes were started by the previous Congress government, but boosted by the BJP.
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“While health was largely neglected in the current government’s initial years, it has since been able to consolidate gains from the previous government’s work and make a creditable future plan,” says Oommen Kurian, head of the health initiative at Observer Research Foundation.
He called the NDA’s performance on healthcare over the past five years a “UPA-3 Act”. He added that their promises in the 2019 manifesto sound a lot like “UPA-4”.
He’s not wrong. The budget speeches in 2014, 2015 and 2016 reveal that the Modi government was largely silent on any substantial new measures on healthcare.
In the 2017 budget, the Centre announced that India would eliminate kala-azar and filariasis in the same year and leprosy by 2018. (These targets were not met.) The government also announced that measles would be eliminated by 2020 and TB by 2025. It introduced a health insurance cover of Rs 1 lakh for families. (This never took off.)
The 2018 budget then announced Ayushman Bharat, the two-pronged government scheme to extend health insurance and uplift sub-centres and primary health centres. The 2019 budget flushed Ayushman Bharat with Rs 6,400 crore.
But India’s healthcare story is not just about budgets and schemes. It is also about persistent injustice to people who are unable to access their right to healthcare.
Major tragedies from the opening act
The Modi government’s health story opened in 2014 with the tragedy of sterilisation deaths in BJP-ruled Chhattisgarh. In November 2014, 13 women died after undergoing illegal sterilisation operations at a government health camp in Pendari. About 83 operations were conducted there in a span of just about six hours.
Investigations into the deaths found that unsterilised equipment was used on these women, who were also given spurious medicine.
Justice to these victims and families has not been forthcoming. The block medical officer who conducted these 83 operations, R.K. Gupta, was acquitted after the state government refused permission to prosecute him. The owner of the private pharmacy did go to jail.
As The Wire reported, the deaths have not changed anything. Official data shows that the burden of sterilisation is still on women in India. About 35.7% women undergo sterilisation, according to NFHS 2015-2016. This has remained stagnant over a period of ten years. Figures for male sterilisation have in fact dropped, from 1% to 0.3% in 2015-2016. Last mont, a report in The Hindu Business Line said women agricultural workers in Beed were getting their uteruses removed because contractors are unwilling to hire menstruating women.
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The next major tragedy was in BJP-ruled Uttar Pradesh, in August 2017. About 23 children died during a crisis over oxygen supply in the government-run BRD Medical College in Gorakhpur.
The UP government denied that any of those deaths were due to oxygen shortage and tried to peddle a narrative that the deaths were routine, from encephalitis, which is endemic to the region. But most children who died were not afflicted by encephalitis. In an interview with The Wire, the state’s health minister argued that there was no shortage of oxygen, only a “disruption”.
An investigation by The Wire also showed that while the government claimed all the deaths were “natural,” the hospital had raised the possibility of the oxygen supply being cut. During the months before the tragedy, at least 30 letters were written to government officials, saying the oxygen supplier’s dues stood at Rs 63 lakh and thus the supply might be cut off. This eventually happened.
As in the Chhattisgarh case, the UP government has carried out virtually no prosecutions, even though a number of employees and doctors would need to be investigated here.
Private sector is as uncaring as the public sector
If the public sector has failed patients, so has the private sector. The past few years saw a rash of cases of alleged medical negligence and over-pricing by private hospitals.
In September 2017, seven-year-old Adya Singh died while she was being treated for dengue at Fortis hospital in Gurugram. Her family alleged medical negligence. The case received media attention, yet a chargesheet was filed only a year later.
In November 2017, another seven-year-old died during dengue treatment at Medanta in Gurguram. This time, the family was from a less privileged background and could not get even an FIR filed.
Medanta finally paid them “hush money” to withdraw their case – brokered by the health ministry, as reported by The Wire. This betrayed a larger culture of pay-outs to buy the silence of patients and victims.
The bereaved parents in both cases kicked off an alliance with other patients who are fighting cases of medical negligence.
In November 2017, another frightening incident came to light. A woman gave birth to two babies, but the Max Hospital told them that one was dead. The family was allegedly given the dead infant in a plastic bag. The infant was still alive. A few months later, the Delhi Medical Council said there was “no negligence”. The Delhi government partially shut down the hospital as a reaction to public outrage, and promised to clean up the sector.
These cases eventually managed to whip the bureaucracy into motion. By February 2018, the NPPA analysed hospital bills and found that private hospitals were making profits of upto 1,737% on drugs, consumables, medical devices and diagnostics.
Corruption at the roots of Indian healthcare
How does Indian healthcare manage to fail patients in both the public and private sector? The answer might be in its origins – medical colleges.
A major scandal in medical colleges broke in 2017, with links right up to the higher judiciary, and even the chief justice at the time, Dipak Misra.
In 2017, an FIR was filed against a retired judge of the Odisha high court, and others, for allegedly influencing the rigging of medical college permissions. Former Justice I.M. Quddusi was even arrested. Meanwhile, The Wire reported that health ministry officials were colluding with journalists to do the same. In a third case, an inquiry committee recommended the removal of Justice S.N. Shukla of the Allahabad high court, over alleged involvement in a medical college scam.
It was this ‘MCI bribery case’ against Quddusi that kicked off a long period of chaos in the Supreme Court, and clouded the tenure of Chief Justice Misra over the issue of the ‘master of the roster,’ culminating in various quarters even moving for Misra’s impeachment.
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In 2016, the Supreme Court decided it would be a good idea to appoint an oversight body above the government’s oversight body of the MCI. The court appointed former Chief Justice R.M. Lodha to look into the MCI – such as files on private players seeking permissions to run colleges, or colleges that had lost permissions over deficiencies.
While the MCI issues or cancels permission after physically inspecting institutions, Justice Lodha’s three-member team only checked their websites, along with affidavits the institutions provided about their facilities. Some of these colleges were shell structures, not fit for classes or medical procedures.
The government has also tried to replace the MCI with a new body called the National Medical Commission. The parliament needs to vote on that change.
Medical devices: A new scam
At a number of public events in 2017, Modi boasted of cutting down the price of cardiac stents. The fact is the price caps had come about because the Delhi high court ordered the government to look into high prices.
Still, the National Pharmaceutical Pricing Authority (NPPA) announced price regulation on stents in February 2017, a bit of refreshing news for Indian patients. A year later, the NPPA slashed prices further.
But months of backlash followed from trade lobbyists for multinational corporations, who were the ones selling the stents at heavy marked-up rates. The US Trade Representative spoke at several forums against India’s decision to regulate prices of stents. Apart from back-room lobbying, their first public comments was reported by The Wire in April 2018.
In August 2018, Teena Thacker covered the plight of patients implanted with “faulty” hip implants from Johnson and Johnson. It sparked months of reporting, ultimately leading the government to direct the company to pay compensation to the patients. By October 2018, the government devised a formula for upto Rs 1.2 crore in pay-outs.
Some of the government’s efforts here are an eyewash because there are no direct provisions in Indian law to financially penalise a company for a poor-quality medical device. Johnson and Johnson is anyway opposing this in Indian courts, even while simultaneously paying millions of dollars to litigants in the US over the same faulty implants.
According to the International Consortium of Investigative Journalists, which tied up with the Indian Express to report on faulty implants in India, India’s regulatory system is so poor it “effectively doesn’t exist”.
Government patronises private healthcare with Ayushman Bharat
While all of these issues occupied the Indian health community for the last five years, the government has now put all its resources and focus on Ayushman Bharat. The scheme does intend to improve primary healthcare, but what has been given the most attention is the government’s proposal to cover 100 million families with an insurance coverage of Rs 5 lakh per family. This is estimated to cover about 500 million Indians, leaving out about 700 million. Despite this massive exclusion, the government boasts of this as “the world’s largest health care programme”.
As The Wire reported, the government also plans to pump public money into the private sector and has promised to provide “viability gap funding” and land to private players to build health infrastructure which will also be hopefully used by India’s poorest under the Ayushman Bharat.
All this patronage comes even as healthcare in the private and public sector has been marred by corruption and inefficiency, over pricing and medical negligence, while the government has failed to regulate it effectively.
A wide range of other health issues
TB and immunisation were taken up in “mission mode,” and the government introduced new vaccines in the universal immunisation programme. While the global deadline to “eliminate TB” is 2030, Modi announced India would do it by 2025. India has the world’s highest burden of TB, with 26% of the world’s cases.
India is home to a wide array of tropical diseases and in 2017, the World Health Organization announced that India had a few cases of the Zika virus. The Indian government had failed to disclose this until then. As The Wire reported, India used technical loopholes to avoid reporting the cases to the WHO or to the public. The Wire also reported that India’s disease-surveillance portal was not counting cases of Zika at all.
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Indian policy-making has still been fighting the war between science and pseudo-science, fact and fiction. A prime instance was the government’s push to ban the production and sale of oxytocin, a life-saving hormone for pregnant women. The government claimed oxytocin is being abused on cattle, which the Delhi high court called “unscientific”. All the same, the government is pushing ahead with this ban.
‘Death by breath’ became a frequent phrase in the Indian media. In October 2018, the WHO said the deaths of at least 60,987 Indian children under five were linked to their exposure to PM 2.5.
India has also been trying to figure out its stand on the new and complex issue of e-cigarettes. So far, the government’s various wings have favoured clamping down on the sale of these products due to insufficient evidence on their claimed benefits.
Small improvements, big impacts
India made a few improvements on health indicators. While they may seem small, given the scale of India’s struggle with many of these issues, even small improvements impact large numbers of people.
India’s maternal mortality rate (MMR) has dropped by 22%, to 130 (per lakh of live births). The WHO called India’s decline “groundbreaking”. The Sustainable Development Goal target for MMR is 70, by 2030. India believes it will achieve this target by 2022 and not by 2030.
Odisha has also seen a significant drop in malaria, improving India’s overall score on malaria and bringing India up many notches on the global scale too. The WHO said, “only India showed progress in reducing its disease burden.”
