Wednesday, 29 August 2012
Friday, 24 August 2012
Programa de las Naciones Unidas para el Desarrollo
Sala de Prensa
05 de octubre 2007
Amartya Sen: Poverty, evil and crime
Exactly one hundred years ago, George Bernard Shaw argued that "The greatest of evils and the worst of crimes is poverty." Shaw wrote this in the Preface to his brilliant play, Major Barbara, published in 1907. The tragedy of poverty is, of course, obvious to all - whether in Latin America, or in Asia or Africa, or in Europe and the United States. The calamity of deprivation and penury can hardly be missed by those who have bothered to think about the subject, no matter whether they are themselves poor or not. Lives are battered, happiness stifled, creativity destroyed, freedoms eradicated by the misfortunes of poverty. But Bernard Shaw was not talking, on this occasion, about the hardship of poverty, or the misfortune that goes with it. He was commenting, in a rather unusual way, about the causation and consequences of poverty - that it is bred through evil and ends up being a crime.
If poverty is indeed an evil, not to mention "the greatest of evils" (as Shaw puts it), then there must be some wickedness, or at least some culpability, behind poverty - some wrong-doing that allows such human tragedies to occur and persist. This raises the immediate question: who, then, are the wrong-doers?
Is that the right question? In thinking about strategic issues, as we are trying to do in this meeting today (both about eliminating the prevalence of poverty and about minimizing its terrible effects), we cannot but go into the question of culpability and the failure of duties and obligations. We certainly have to ask: how can things be done differently so that the evil of poverty is ousted? We certainly have to identity the nature and genesis of the wrong-doing that is responsible for the affliction. That is not, however, the same thing as trying to identify the wrong-doers: who, in particular, are responsible, personally, for the evil of poverty?
The identification of wrong-doers is not really our task. This is partly because we and the United Nations - or for that matter, Rebeca Grynspan or Bernardo Kliksberg - are not in the business of catching evil-doers for punishment and penalty (though I must add, since I have known Bernardo Kliksberg for many years now, that Bernardo would not be averse to making one or two "citizens's arrest" if he felt that it would materially improve matters for the underdogs of society). But the main point here is that trying to identify the evil-doers is not the right strategy at all, since the responsibility for creating an evil is very widely dispersed in the society. We have to see how the actions - and indeed inactions - of a great many persons together lead to this evil, and how changing our modes of actions - our policies, our institutions, our priorities - can help to eliminate poverty. Our focus definitely has to be on removing evil-doing, as part of our strategies and programs, rather than going on the wild-goose chase of catching the hugely dispersed collectivity of evil-doers who may not even fully understand how their actions can be seen as part of an evil state of affairs.
The widely dispersed nature of wrong-doing is, in fact, important to recognise even in identifying the policies that would be sufficient to eliminate the most talked about manifestations of poverty and exploitation. This is, in fact, why such good strategies as closing sweated labour factories in poor countries, or arresting those who employ children in the making of carpets, if separated from a general economic and social program, would fail to eliminate the poverty of the victims. There are, of course, a minority of cases in which the labouring employees are forced into their jobs, and when that is the case, removing the enforced indenturing of labour would itself make a huge difference. Indeed, in those cases, I would indeed like Rebeca Grynspan and Bernardo Kliksberg to arrest the evil-doers straightaway (making sure that they do not get bail). But in the vast majority of cases the employees are there in those terrible jobs because they have very few options - none that are particularly good. The failure of the state and the society to create opportunities for decent employment is the main culprit here, which makes it possible to recruit labour to do terrible jobs, for the alternative may be unemployment and starvation.
That is why exploited labourers are led to soul-destroying work today in the poorer countries, and that is of course also why similarly soul-destroying work was taken on by labourers in Britain or France, when they were sent down into gruesome and hazardous coal mines or imprisoned in airless and grisly factories in Europe, a century or two ago. The evil of omission is as big a part of this terrible story as the evil of commission. Closing down sweated-labour factories without giving the victims alternative opportunities for employment or education - the latter is extremely important in the case of child labour - is not an adequate solution to the problems and predicaments of the precarious poor. There is, of course, moral merit in restraining the pursuit of profit of businessmen through exploiting vulnerable and freedom-less labour, but a fuller solution can emerge only through positive opportunities of alternative employment and occupation, and that demands societal action. So the first strategic issue in dealing with poverty in these types of cases is the expansion of employment opportunities, and in the case of child labour, arrangements for good and supportive facilities for schooling.
My argument so far has been based on seeing poverty as lowness of incomes. It works well enough when we are dealing with emergencies like famines or other disasters where some people have to starve because they have no income with which to buy food. The priority there is to recreate income for the afflicted victims, and once they have the income with which to buy food, they do not have to succumb to starvation and famine mortality.
But how do we go beyond these rather obvious cases? Is employment with income a full solution to all problems of poverty? To believe that would be to underestimates vastly the complexity of poverty, particularly the nature of persistent poverty. Indeed, in dealing with endemic poverty, we cannot at all stop at the most elementary thought that poverty is no more than deprivation of income, since a great many critically important problems would remain unaddressed if we based our anti-poverty policy only on that rudimentary understanding of the many-headed hydra that is called poverty. Strategic examination about eliminating poverty, or even reducing its burden, has to go more deeply into the nature of poverty. I fear this makes it necessary to examine and scrutinize the concept of poverty itself.
Talking about concepts in a meeting for practical strategies is not always easy, since it sounds so academic to go into ideas that may look abstract. Many of our so-called "men of action" have no time for conceptual questions, or for that matter, for unobvious instrumental connections. But that is, of course, also why men of action often go so badly wrong. The heroic John Wayne perfected the art - at least in the cinema - of preventing harm being done by the nasties through outsmarting and outgunning them, but he evidently never quite figured out how much harm he could quietly do to himself and to others, in real life, by the simple act of smoking and by leading others to famous brands of cigarettes, through being the picture-boy of cigarette producers: many of the recruits perished, I fear, with John Wayne in a cloud of smoke, from similar diseases. No, in our search for practicality and for strategies that can guide us to fruitful and effective actions, I fear we have no way of avoiding difficult - and apparently distant - connections.
So what is poverty? The identification of poverty with the lowness of income is, of course, a well-established practice, and there is some obvious and earthy sense behind this diagnosis. But there is, by now, quite a substantial literature establishing beyond reasonable doubt the serious inadequacies of this way of understanding poverty. Poverty is about the inability to lead a decent - minimally acceptable - life, and while low income does make it difficult to lead a life of freedom and well-being, an exclusive concentration on seeing poverty as lowness of income misses out a great many important connections.
This is because people have different opportunities of converting income into characteristics of living, and the relationship between income and deprivation is instrumental and contingent. Rowntree, a pioneering leader of poverty research in Britain, noted more than a hundred years ago - in 1901 - an aspect of this problem by referring to "secondary poverty," in contrast with "primary poverty" defined in terms of lowness of incomes, and he focused specifically on influences that affect a family's consumption pattern, which can make the elimination of undernourishment and the care of the children that much more difficult, even with potentially adequate income. But the Rowntree point about unfavourable consumption patterns is only the top of the iceberg of problems that take us beyond the perspective of incomes.
Incomes can certainly help the enhancement of the quality of life and the freedoms that people can enjoy, but the conversion of income into living is itself a hugely important problem. There are, in fact, diverse types of contingencies leading to variations in the "conversion" of incomes into levels of living. Let me comment here on four important sources of variation.
Personal diversities and capability handicaps: People have diverse physical characteristics for a variety of reasons, and these variations also link with disability, illness, age, and gender, making the needs of different persons quite disparate. For example, a disabled or an ill person may need more income to do the same elementary things that a less afflicted person can do with a given level of income, and some disadvantages may not be correctable even with more expenditure on treatment or prosthesis.
I should point out here that the magnitude of the global problem of disability in the world is truly gigantic and its huge dimensions are often not fully realized. More than 600 million people - about one in ten of all human beings - live with some form of significant disability in the world today. And more than 400 million of these 600 million disabled people live in developing countries. Furthermore, in the developing world, the disabled are quite often also the poorest of the poor, in terms of income, within those countries. There is here a "coupling" of two handicaps in the case of the disabled. Their incomes are low partly because of the disabilities themselves, but in addition their need for income is greater than that of able-bodied people, since they need money and assistance to try to live normal lives and to attempt to alleviate their impairments. Their difficulties in income-earning ability - what we may call their "earning handicap" - is reinforced and much magnified by what can be called their "conversion handicap": their problems in converting incomes and resources into good living.
And what is patently obvious and observable in the case of disabled people is widely present in more diffused form across the population. For example, people have different genetic vulnerability to illnesses. These makes their lives much harder and also their normal living more costly. There are, in fact, further problems in dealing with standard societal institutions. We can easily see why the people who are more disease-prone will have difficulties in getting adequate medical insurance if insuring is left to profit seeking firms, since it is in the interest of these insurance companies to identify the more vulnerable and to refuse them insurance or limit their coverage in one way or another. So an insurance system run by the state or by some other social support system, not by profit-oriented private firms, may be a necessary part of the elimination of poverty. This would take us well beyond income-based solutions to deprivation.
Environment and poverty: How far a given income will go will depend also on environmental conditions, including climatic circumstances, such as temperature ranges, or rainfall and flooding. The environmental conditions need not be unalterable - they could be improved with communal efforts, or worsened by pollution or depletion. But an individual may have to take much of the environmental conditions as "given" in converting incomes and personal resources into functionings and quality of life.
The environmental issue is, thus, an integral part of poverty removal, and there is no way of delinking the search for sustainable development from the perspective of poverty removal. Kofi Annan, the former Secretary-General of the United Nations, put his finger exactly on this connection in his speech in Nairobi last year when he argued, "the impact of climate change will fall disproportionately on the world's poorest countries, here in Africa." He went on the explain, "poor people already live on the front line of pollution, disaster and the degradation of resources and land." "For them adaptation is a matter of sheer survival." This focus on the poor brings us solidly into one of the most important connections - that between poverty and the environment - which deserves much greater attention right now. It is important to see why and how the perspective of poverty has to be central to environmental and ecological thinking, and on the other side, why environment and ecology are integral problems of policy against poverty.
Social conditions and personal capabilities: The conversion of personal resources into functionings is influenced also by social conditions, including public health care and epidemiology, public educational arrangements, and the prevalence or absence of crime and violence in the particular location. Aside from public facilities, the nature of community relationships can be very important, as the recent literature on "social capital" has tended to emphasize.
One of the limitations of seeing poverty in terms of lowness of individual or family incomes is that personal income does not take into account the social climate, nor the social initiatives to eliminate deprivation. Poverty was reduced in Europe as much through providing what are called "public goods" - epidemiological care, educational facilities, shared legal protections and other such common resources - as through the generation of personal incomes and private goods. Any strategic understanding of the demands of poverty removal would be badly handicapped if it did not take this huge connection into account. The understanding that poverty is not only - or even primarily - about low private income is badly needed across the world today, not least in Latin America.
Differences in relational perspectives: Established patterns of behaviour in a community may also substantially vary the need for income to achieve the same elementary functionings. For example, to be able to "appear in public without shame" may require higher standards of clothing and other visible consumption in a richer society than in a poorer one (as Adam Smith had noted more than two centuries ago in his Wealth of Nations). The same applies to the personal resources needed for taking part in the life of the community, and even to fulfill the elementary requirements of self-respect. This is primarily an inter-societal variation, rather than an inter-individual variation within a given society, but the two issues are frequently interlinked. There is much more research to be done in this field, especially in integrating cultural characteristics into the analysis of poverty, and given its rich variety of cultural background, I expect Latin America will be a major source of new research in this field.
It is important to emphasize that focusing on the quality of life, rather than on income or wealth, or on psychological satisfaction, is not new in economics. Indeed, the origin of the subject of economics was strongly motivated by the need to study the assessment of, and causal influences on, the conditions of living. The motivation is stated explicitly, with reasoned justification, by Aristotle, but it is also strongly reflected in the early writings on national accounts and economic prosperity by William Petty, Gregory King, Francois Quesnay, Antoine Lavoisier, Joseph Louis Lagrange and others. While the national accounts devised by these pioneers established the foundations of the modern concept of income, the focus of their attention was never confined to this one concept. Nor did they see importance of income to be intrinsic and uniform, rather than instrumental and circumstantially contingent.
Even if deficiency of income is retained as the main view of poverty, that deficiency would have to be defined with respect to the level of income a person, given her own characteristics (including disability, age, proneness to illness, etc.), would need to lead the kind of life that the poverty line income is meant to provide. The criterion of poverty then becomes inadequacy of income, rather then just lowness of income defined absolutely. While much can be done by using parametrically variable poverty line cut-offs, it is of course much more straightforward to concentrate directly on seeing poverty as inadequacy of capabilities, than as lowness - or even inadequacy - of incomes, since income is only one variable among many that influences our ability to live minimally decent lives.
I have so far concentrated on one of the two connections about which George Bernard Shaw spoke - that between poverty and evil. What about the other connection also touched on by Shaw - the connection between poverty and crime. In the remaining minutes of this talk I am going to talk a little about the need for some sophistication in understanding the nature, reach and form of that connection. Recently, much focus has been placed on the case for poverty removal based on the causal connection of poverty with crime. There is, of course, some immediate plausibility in emphasizing this connection. Poverty can certainly make a person outraged and desperate, and a sense of injustice can be a good ground for rebellion - even bloody rebellion.
Furthermore, it is not uncommon to presume that an enlightened attitude to war and peace must go beyond the immediate and to seek instead "deeper" causes. In looking for such underlying causes, the economics of deprivation and inequity has a very plausible claim to attention. The belief that the roots of discontent and disorder has to be sought in economic destitution has, thus, been fairly widely favoured by social analysts who try to look beyond the apparent and the obvious. This approach has another usefulness: it is available for use in the humane political and moral advocacy of concerted public action to end poverty.
Those trying to eradicate poverty in the world are, naturally enough, tempted to seek support from the apparent causal connection that ties violence to poverty, to seek the support of even those who are obtuse enough not to be moved by nastiness of poverty itself. There has, in fact, been an increasing tendency in recent years to argue in favour of policies of poverty removal on the ground that this is the surest way to prevent political strife and turmoil. Since generic physical violence seems to be more widely loathed and feared, especially by well-placed people, than social inequity and the deprivation - even extreme deprivation - of others, it is indeed tempting to be able to tell all, including the rich and those well-placed in society, that terrible poverty will generate terrifying violence, threatening the lives of all. Given the visibility and public anxiety about wars and disorders, the indirect justification of poverty removal - not for its own sake but for pursuing peace and quiet - has become, in recent years, a dominant part of the rhetoric of fighting poverty. Given the co-existence of violence and poverty, it is not at all unnatural to ask whether poverty kills twice - first through economic privation, and second through political and social carnage.
Is this connection as robust as would be needed for powerful use of this approach to advocate poverty removal because of its criminal connection. I fear we have to recognise that the picture is rather murky in this respect, at least at the level of immediacy that is sometimes presumed in these causal reasonings. The claim that poverty is responsible for crime and violence draws on an oversimplification of empirical connections that are far from universal. The relationship is also contingent on many other factors, including political, social and cultural circumstances, which make the world in which we live far more complex.
Let me give an example. When, a few months ago, I gave the Lewis Mumford Lecture in this city, at the City College of New York, entitled "The Urbanity of Calcutta," I had the opportunity to comment on the rather remarkable fact that Calcutta is not only one of poorest cities in India - and indeed in the world - it so happens that it also has an exceptionally low crime rate - indeed absolutely the lowest crime rate among all the Indian cities. It occupies an extreme position, by a very substantial margin, in the lowness of crime rate among all the Indian cities. This applies by a long margin to the incidence of murder. The average incidence of murder in Indian cities (including all the 35 cities that are counted in that category) is 2.7 per 100,000 people - 2.9 for Delhi. The rate is 0.3 in Calcutta. The same lowness of crime can be seen in looking at the total number of all violations of the Indian Penal Code put together. It also applies to crime against women, the incidence of which is very substantially lower than that in every other Indian city.
If this appears to us to be an unfathomable conundrum, given Calcutta's poverty, that may be a reflection of the limitation of our thought, rather than a paradox of nature. Calcutta has a long distance to go to eradicate poverty and to put its material house in order. It is important to remember that the low crime rate does not make those nasty problems go away. And yet there is something also to celebrate in the fact that poverty does not inescapably produce violence, independently of political movements as well as social and cultural interactions.
Explanation of crime is not an easy subject for empirical generalizations, but there are some possible connections that seem suggestive. Calcutta has benefitted, I have been inclined to argue, from the fact that it has a long history of being a thoroughly mixed city, where neighbourhoods have not had the feature of ethnic separation that some cities - in India as well as elsewhere - have. There are undoubtedly many other social and cultural features that are relevant in understanding the relation between poverty and crime. For example, it is clear to me in trying to understand the high rate of crime in South Africa, which I visited in April, that some of it is connected with the legacy of the apartheid - not just the inheritance of racial confrontation, but also the terrible effects of separated neighbourhoods and families that were split up for economic reasons, which went with apartheid policies. But it would not be easy to explain why the belated attempts to generate mixed communities have also had the immediate effect of fostering crime committed within the newly mixed neighbourhoods.
I do not think we know enough about the empirical relations and their fragility and robustness to be confident of what the exact causal connections are, and I am acutely aware that there is need for humility that social sciences invariably invite and frequently do not get. And yet it is absolutely clear that the tendency to see a universal and immediate link between poverty and violence is hard to sustain. To see this danger is not the same as denying that poverty and inequality can - and do - have far-reaching connections with conflict and strife (more on this presently), but these connections have to be investigated and assessed with empirical strongmindedness. The temptation to summon what we can call "economic reductionism" may be sometimes effective in helping what we may see as a right cause, particularly in getting support even from the ethically dumb who are unmoved by poverty of others but are scared of bloody violence affecting their own lives as well.
There is certainly a more complex picture that lies behind the alleged straightforwardness of the poverty-violence connection. It is not hard to see that the injustice of inequality can generate intolerance and that the suffering of poverty can provoke anger and fury. There is clearly much plausibility in seeing a connection between violence and poverty. For example, it would be hard to think that the outbursts of political violence in France in the fall of 2005 had nothing to do with the economic and social deprivation of some people living in parts of the country, often in the outskirts of Paris and other cities, who felt badly treated and neglected. And yet it would be a huge mistake to see that only as a poverty-related violence. The categories of the poor and the non-poor are separated by economic distinctions, but there is correspondence, in France, between these economic contrasts and the social and ethnic contrasts related to culture and immigration. It is extremely important for poverty research to pursue the congruence of different categories of distances - economic, social, cultural and ethnic. Adam Smith already set the ball rolling more than two hundred years ago by talking about the connection between social circumstances and the sense of deprivation that different segments of the society have. In our strategic thinking about poverty in Latin America, as in other parts of the world, we have reason to pick up that ball and complete the investigation.
So I end by affirming that George Bernard Shaw was right, a hundred years ago today, to point to the connection between poverty and evil and crime. The fact that this insight came not from an economist but from a dramatist and literary giant fits in well with my general thesis that the economics of poverty involves much more than just economics. Human lives in society are interlinked through economic, social, political and cultural associations. The nature, causes and consequences of poverty reflect the richness of those connections. We have no reason to be surprised by that elementary understanding.
Monday, 20 August 2012
warning! self-promotion.....a really good, new book is now out on global justice and health
Health Inequalities and Global Justice (Studies in Global Justice and Human Rights) [Hardcover]
Patti Tamara Lenard and Christine Straehle (eds.)
Edinburg University Press / Columbia University Press
Introduction: Health inequality as a concern for global redistributive justice, Patti Tamara Lenard and Christine Straehle;
Part 1: A right to equal health?;
1. Is there a human right to health?, Adina Preda;
2. What’s Wrong with Global Health Inequalities?, Daniel M. Hausman;
3. Ecological Subjects, ‘Ethical Place-making’, and Global Health Equity, Lisa Eckenwiler;
4. Health inequalities, capabilities, and global justice, Sridhar Venkatapuram;
Part 2: Who is responsible for remedying global health inequality?;
5. Reexamining the Ethical Foundations: Behind the Distribution of Global Health, Garrett Wallace Brown;
6. Global Health and Responsibility, Gillian Brock;
7. Outlining the global duties of justice owed to women living with HIV/AIDS in sub-Saharan Africa, Angela Kaida and Patti Lenard;
Part 3: Measuring heath or health outcomes;
8. Measuring Global Health, Kristin Voigt;
9. Exploring a Sufficiency View of Health Equity, Yukiko Asada;
10. Rating Efforts to Extend Access on Essential Medicines: Increasing Global Health Impact, Nicole Hassoun;
Part 4: Borders and health;
11. Justice and Health Inequalities in Humanitarian Crises: Structured Health Vulnerabilities and Natural Disasters, Matthew R. Hunt and Ryoa Chung;
12. ‘Illegal’ Migrants and Access to Public Health: A Human Rights Approach, Phillip Cole;
13. Medical Migration between the Human Right to Health and Freedom of Movement, Eszter Kollar;
14. Health Care Migration, Vulnerability and Individual Autonomy – The case of Malawi, Christine Straehle.
Thursday, 16 August 2012
From the Hindu, Business Line 12 August 2012S. Srinivasan
Essential health services should not be left to private players, as envisaged in the 12th Plan draft.
The idea of free medicines for all announced recently by the Government of India — that is, free for those availing of government health facilities — has been generally welcomed. The example of the Tamil Nadu Government, and subsequently emulated by the governments of Kerala and Rajasthan, is often cited. Free medicines are expected to bring back patients to public health services.
In a sense, it is true. The utilisation of public health services is very low in general. NSSO surveys tell us that out of every 100 persons who get sick in India, less than 20 use the public health services. In addition, 20 per cent of those who get sick in India do not ever access healthcare of any kind.
The rest, at least 60 to 70 per cent, negotiate their illnesses with private practitioners and private sector hospitals. (In Tamil Nadu which provides free medicines to a reasonable degree of efficiency in its public health facilities, the utilisation of public health facilities — if one goes by 2006-based NSSO estimates — is somewhat higher, but not more than 40 per cent.)
The fact that most people end up with private practitioners and private sector hospitals tells us why medical care is often the road to indebtedness and impoverishment for many, including the middle classes.
It is to offset such an imbalanced state of affairs that the Planning Commission-appointed High Level Expert Group (HLEG) had come out with recommendations on how free health for all can be achieved. Healthcare, and free healthcare, for all at that, is a public good in itself.
Public good is something the private sector is not interested in, unless it sees a way of generating profits out of it. Profit-seeking in healthcare often tends towards profiteering, with no thought given to how such high costs impact patients seeking treatment.
The HLEG report has recognised this truth, and therefore envisages that the State ought to be the primary organiser, provider and regulator of healthcare services.
However, the Planning Commission’s Draft 12th Plan strikes another note.
The draft Plan talks of delivering health services through ‘managed networks’. Managed care model has its genesis in the US — it sounds attractive in theory, but its effectiveness depends on who runs it.
If run by for-profit corporate groups, it is guaranteed to produce all-round resentment, as in the US where the general experience among consumer groups is that these for-profit networks are more interested in cutting their costs than servicing people’s health needs.
The managed networks envisaged by the Planning Commission draft plan would be funded by the government.
But they are to be run under some kind of an MoU between the government and the managed network for providing an ‘essential health package’ of clinical services.
In a country where corporate accountability is an oxymoron, public health experts feel that managed care in corporate hands would be a disaster.
The State, it is envisaged, will be essentially a manager providing some basic preventive services, such as immunisation. This means that, in effect, the clinical services will be handed over to corporate hospitals. Once corporates control clinical services, for the government to negotiate — forget controlling — costs of healthcare and standards will be difficult.
Even now, price setting of important procedures is benchmarked by corporate hospitals; and government schemes such as the CGHS, which allow government employees to access private hospitals, end up paying high costs.
For instance, a cataract surgery with intraocular lens should cost less than Rs 2,000 and is being done at these rates by some excellent groups with a world-class reputation in India. But the government allows cataract reimbursements up to Rs 25,000 because that is the “cost” decided by certain influential corporate health groups.
Likewise, the government’s Janani Suraksha Yojana, meant to encourage hospital-based delivery (which means largely in the private sector) has basically increased the cost of even ordinary deliveries, apart from bypassing the skills of traditional dais.
The managed network idea, especially when handled by for-profit corporate groups, and non-profit groups that are de facto for-profit, will likewise inflate the cost of healthcare — overpriced procedures will be the new normal, with taxpayer’s money paying for it.
Elsewhere, the experience of “purchased care” through the Rashtriya Swasthya Bima Yojana (RSBY) scheme at the national level and other such me-too schemes in different States, shows that costs of routine healthcare problems have gone up.
Many of us have had this experience — of the bill being inflated after the hospital comes to know that you have insurance.
More importantly, insurance schemes such as RSBY give the illusion of doing something for the poor by offering “packages”. Delivery of comprehensive, primary-level curative, preventive, and promotional services cannot be done by “package” peddlers.
The vision of the Planning Commission’s draft plan of Universal Health Care is a large-scale version of RSBY. It is a case of good money being thrown in — up to 1.58 per cent of the GDP is envisaged — for indifferent or poor health outcomes.
The idea of comprehensive free healthcare for all, especially for the poor, will be effectively buried. The draft Plan document talks of phasing out irrational medicines. That is good, but there is no time deadline mentioned. Nor is there a mention of price regulation of all medicines, a move that even the Supreme Court has directed.
The draft Plan rightly endorses the three-year doctor scheme — to be called B.Sc (Community Health). But it is silent on reversing the dangerous trend of privatisation of medical education. In the early 1990s, 80 per cent of medical colleges were government-run, whereas now in 2012, 80 per cent are in the private sector.
Private, for-profit medical colleges, with a few exceptions, are poorly regulated and are synonymous with purchasable MBBS and MDs, whatever your academic merit or aptitude.
“Investments” in such medical education runs into lakhs and crores, and therefore the sole aim of such graduates is to recover their investments by charging patients exorbitantly or joining hospitals that assure them of fancy salaries.
These hospitals, in turn, charge exorbitantly by resorting to all kinds of unethical practices in the name of quality care.
Not acting on privatisation and profiteering in medical, nursing and pharmacy education will undo any good intentions regarding healthcare for all.
Healthcare is riddled with market failures. For healthcare for all to become a reality, the State cannot sub-contract its responsibilities. It needs to strengthen state-owned health facilities.
(The author is associated with LOCOST, Vadodara, and Medico Friend Circle.)