What ails our public hospitals?

World-wide the historical precedents of hospital care were invariably in public domain. In India even during pre-colonial times going as far back to the Ashoka and Maurya period hospitals were run by the State and this was seen as a critical public responsibility. Somewhere around the 15th/16th century when modern medicine emerged and capitalism became the order of the day health care was still seen as a public good and the entry of private players (merchant capitalists and the rich bourgeoisie, and institutions like the Church) was within the charity/philanthropy framework. The Mughal Sultanate and the colonial regime in India also honoured this. Even today in most countries which have provided universal access to health care to its citizens hospitals are either in the public domain or are financed through the public exchequer.
In India until the early eighties an overwhelming majority of hospital care was via public hospitals run by governments or municipal bodies but around that time public health policy was being turned on its head. Curative care was increasingly being seen as a private responsibility and public investment in hospitals began its downward trend. In the mid-eighties public health expenditure reached its peak of 1.5% of GDP with a massive injection of investment in rural health infrastructure like primary health centres and rural hospitals. But having built this infrastructure the State retreated and sucked out resources from public health budgets to the effect that by the time India went into structural adjustment, public health spending was down to 0.9% of GDP and continues to be the same today despite high economic growth and the National Rural Health Mission.
It is this stifling of resources within the public health budget that has led to the current scenario of ailing public hospitals. Until the eighties public hospitals were robust, vibrant and leaders in establishing new technologies/therapies. Public Hospitals in metros like Mumbai, Delhi and Chennai attracted patients from all over the country and treatment was given efficiently and free of cost to the patient. There were certainly resource constraints but public hospitals met most demands made on them without burdening patients. In the nineties with a clear liberalisation, privatisation and globalisation mandate of the Indian economy public health services were deprived resources as evidenced in declining public health budgets post-1991, and this led to the collapse of the public health system, especially the hospitals.
The resource withdrawal precipitated other consequences. The patients began to lose faith in public hospitals because they would not get the medicines they needed from the hospitals because medicines were being prescribed for external purchase, diagnostic tests were increasingly being denied because of poor maintenance of equipment and poor supplies of consumables. With dissatisfied patients, the doctors and nurses got frustrated and began their exodus from public hospitals. In such a situation it is unfortunate that the best talent leaves. Many went abroad to greener pastures and others joined the corporate hospitals that had emerged in the nineties and were catering to the insured elite and globally the medical tourists. This sounded the death knell of public hospitals. In the meanwhile governments responded by introducing user fees in public hospitals and as a result, the very poor who were still visiting these poorly equipped and managed public hospitals also moved away. Such is the situation across most of India.
Couple of years back, I visited a number of public hospitals, health posts and maternity homes across Mumbai and interviewed doctors, nurses, managers, bureaucrats, paramedics, municipal councillors and patients and across the board I got very negative responses. The providers complained of complete frustration about the working environment and lack of resources, the managers expressed helplessness and said that they had no decision-making powers and financial control, the councillors said that the municipal administration did not pay heed to their demands and the patients said that despite having to pay for services they didn’t get proper treatment and ended up with prescriptions for medicines and diagnostic tests. And the bureaucrats were the icing on the cake. They said that curative care and running hospitals is not their responsibility and all this should be privatised. So this is the mindset that we are up against and the Mumbai Municipal Corporation (atleast the bureaucrats) is abdicating responsibility for provision of health care to its citizens despite the legal mandate of municipal law that municipal corporations should devote one-third of their budget to public health services – this the BMC was doing in the seventies but from eighties the down trend began and they now spend a mere 14% of their budget on public health services (including medical education). Maybe its time for a public interest litigation to get the Municipal Corporations to obey the law!
In rural India and the small towns the situation is even worse. In many states our politicians have assured that rural hospitals and primary health centres are constructed as per norms specified in health policies. So the physical infrastructure is there because the politicians and/or their cronies get the contracts for constructing them and make money, but the same politicians do not exert the political will to assure that these health centres and hospitals are adequately resourced and provided for so that they can deliver the services they are supposed to. In rural hospitals vacancies of specialists is between 60–75%. In PHCs (Primary Health Centres) too vacancies of doctors and nurses is huge. Human resources is just one aspect, supplies like medicines, bandages, x-ray films, reagents etc., are also grossly deficient. Government’s own facility surveys repeatedly highlight these deficiencies and nothing is done about them. Often money is not the constraint, though we need to invest much more, because even what is allocated is not spent fully. Infact the recent NRHM audit by CAG and the Appropriation Accounts shows that overall the NRHM was grossly underspending the allocations and therein too there were lot of problems.
However, good public health care is not as yet totally extinct in India. There are a few good examples. Mizoram, spending over 2% of its SDP, has a reasonably vibrant public health system atleast providing good primary and first level referral care. Under NRHM in a few states one does see some positive trends, especially Tamil Nadu. This revival is happening because more resources are being pumped into the public health system, adequate investments in hospital infrastructure is happening, management capacity has been improved, human resource policies have been reshaped to attract and retain staff and more transparent procurement policies have improved supplies. Most importantly these states have also debunked user fees and returned to free care.
The above assessment clearly shows that there is a complete lack of political will to support public health services, the declining budget commitments to public health have harmed even the little that has been built, the performance of public health facilities because of starvation of resources has been brutally affected and as a consequence the credibility of and the faith of the people in the public health system has suffered tremendously.
If the ailing public health system has to be revived the actions needed are not alien to it. The NRHM mission document and its various guidelines provide atleast some of the necessary framework. But the political will is lacking to implement that. Infact, what is needed is both a constitutional amendment that makes health care a right as well as a national legislation that provides the framework for protecting and fulfilling that right. If this is done political will, required finances and investments will fall in place.

The writer is a Senior Trainer and Analyst at the International Budget Partnership and an activist of the People’s Health Movement.

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