Avoiding doctor-centric health solutions in India - Sujatha Rao

Op-ed by Sujatha Rao, former Minister of Health of India

Original page of The Hindu here

Avoiding doctor-centric health solutions

Sujatha Rao

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  The HinduUNHEALTHY: No country can be ‘shining’ or ‘incredible’ with a balance sheet that shows, among other things, productive lives being cut short by tuberculosis and other infections, and emergence of noncommunicable diseases. Photo: K. Ananthan
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  Scale * per 100,000 live births, ^^ per 1000 live births

It is creditable that Narendra Modi seeks inspiration for his growth model from China and Japan rather than the U.S., which is a high-cost, specialist-driven model

The old adage ‘health is wealth’ was given legitimacy by no less a personage than Professor Jeffrey Sachs, who in 2000, chaired the World Health Organization’s Commission on Macroeconomics and Health (CMH). The CMH report brought forth indisputable evidence of the link between health, development and wealth, arguing that neglect of health entails real costs to the economy — in terms of household expenditures incurred on buying drugs rather than nutritious foods, investments for hospitals rather than factories that generate jobs and impair growth due to reduced productivity and so on. As these impacts are not as easily perceptible as say the closure of a factory, they are routinely forgotten in policy dialogues in India.

Immediate concerns

The Bharatiya Janata Party’s stunning victory raises two immediate concerns: one, the focus on economic growth visualised in terms of physical infrastructure to the exclusion of the social sector, namely health and education; and two, the ideology of ‘minimum government and maximum governance’, so often stated by Narendra Modi in his election speeches. Such a formulation may be appropriate for economic sectors but in the context of health, it could imply a government reneging from its duty to provide primary health care, both preventive and curative, and universal access to public goods like piped water, nutrition and sanitation.

The economic growth and development dialogue needs to centre round the human capability dialogue — that it is the educated and healthy that create wealth, not the illiterate and sick. And given that health markets are plagued by failures due to asymmetry of information, state intervention becomes imperative for ensuring access to public goods. In other words, no country can be “shining” or “incredible” with a balance sheet that shows 40 per cent of its children malnourished, 69 per cent defecating in the open and less than 30 per cent having access to piped water in rural areas, productive lives being cut short by tuberculosis and other infections, and emergence of non-communicable diseases affecting the rich and poor alike.

There is little doubt that the nation’s health is in a critical state and needs immediate attention. The compulsions of earlier coalition politics resulted in soft pedalling on substantive issues that directly impacted outcomes. As each crisis loomed, a knee-jerk policy response was provided. While the United Progressive Alliance government can legitimately take credit for having finally eliminated polio, reduced by half the incidence of HIV/AIDS and accelerated the reduction in maternal and infant mortality, it failed to take hard decisions on two vital issues: the availability and quality of human resources in health and forging intersectoral linkages with social deteriments viz water, sanitation and nutrition.

Doctor-centric approaches serve vested interests in opening more medical colleges in the absence of systems that make them accountable to the quality of the product they produce. The manner in which the private sector is given easy passage to open medical colleges is no less a scam than the 2G — the “presumptive loss” to be calculated in terms of the consequences an unsuspecting patient could face due a poorly trained doctor. In fact, the recent report of U.K. removing from its rolls a large number of Indian doctors due to inadequate training hardly behoves well for India claiming its place in competitive global health markets. Achieving aspirational goals of Universal Health Coverage and the more immediate ones of arresting disease and bringing down morbidity will be dependent on initiating reforms related to assuring the quality of our doctors, our ability to paramedicalise primary care, the effective utilisation of technology and the active engagement of the lay public in the governance of health.

The new government has the onerous responsibility of making up for lost time. It is creditable that Mr. Modi seeks inspiration for his growth model from China and Japan rather than the U.S., which is a high-cost, specialist-driven model. China and Japan did not jump into health rights or health security for all without first attacking the causal factors responsible for ill-health. China started its “healthy China” narrative by first ensuring simpler and more basic services like access to water and toilets, good nutrition, access to public health at the community level and promotive health for forming sanitary habits like drinking boiled water, bringing to mind Mr. Modi’s call for instilling the values of cleanliness and hygienic habits in his thanksgiving speech in Varanasi. The difference in outcomes between China and India (in the table) will explain the importance of the paths we have chosen.

The question boils down to choices in resource allocations. Achieving universal access to the basket of public goods listed above requires an estimated Rs.10.8 lakh crore against which the Planning Commission has barely allotted 40 per cent during the 12th Plan period. Primary health care is itself underfunded — just meeting the National Rural Health Mission standards needs 3 per cent GDP against which hardly 1 per cent is being allotted.

The new government must undertake institutional reform to assign to the different layers of governance their functional responsibilities.

Highest priority must be accorded to resource allocation for public goods and implementation must be monitored at the Prime Minister level. Attention to water and sanitation alone will bring down morbidity and mortality by half and improve public health in a manner that doctors, medicines and hospitals may not be able to do.

Issues such as pricing, patenting, international agreements, quality control and regulation of drugs must be integrated and a cohesive drug policy formulated.

Multiple schemes related to nutrition — the Public Distribution System, food law, mid-day meal and Integrated Child Development Services programmes — must be revamped and integrated. This will reduce wastage and duplication.

The relationships between public and private sector in health, between the Centre and States, between the various hierarchies of human personnel such as doctors, nurses and paramedics, and between allopathy and other systems of medicine must be reworked through a broad and consultative process, which will reduce duplication and enable more cost-effective use of resources.

Finally, central funding must be provided to States (conditional to good governance) in terms of a State policy on human resources — training, recruitment and deployment and establishment of systems that ensure the synchronisation of all inputs.

India does not need any more reports. What is needed is sheer hard work to implement recommendations already available.

(Sujatha Rao is former secretary, Ministry of Health, Government of India.)

David McCoy: Lancet Commission on Global Governance for health should start over with reccomendations

The original blog and very interesting commentaries can be found here

David McCoy on the Lancet Commission

The Lancet-UiO Commission on Global Governance For Health Commissioners should withdraw their recommendations and come up with better ones.

The Lancet Commission on Global Governance for Health – co-organised with the University of Oslo – was established to examine the political origins of health inequity, with a focus on ‘global governance’. It was a good idea: we need better and more democratic global governance and a form of ‘globalisation’ that is equitable and sustainable. And we need the global health community actively engaged in making change happen.

But after more than two years, the outcome of the Commission can be summed up as: excellent in intent; good with analysis; but poor on recommendations. Importantly, having identified the need for systemic and radical change, the Commission ended up with, what one commentator described as, the tame recommendations of “a talking shop and monitoring mechanism”.

I was disappointed; but also perplexed. How did the Commissioners (supported by a secretariat and team of researchers) end up with such poor recommendations – especially after so much good analysis had been conducted? Before addressing this question, it’s worth examining the gap between the Commission’s analysis and its recommendations.

Some Good Analysis…

The Commission does not shy away from its core purpose. It hones in on the undemocratic and unequal distribution of power as an underlying cause of health inequities and of deficiencies in global governance. It names self-interested actors with too much power; and it points to governments, communities and households with too little power. It also describes how the current form of globalisation has liberalised markets and promoted economic integration, but without the accompanying institutions required to uphold human rights, promote equity and protect society from market failures.

It highlights the growth in power of finance capital and trans-national corporations (TNCs) and the harmful effects of global and international trade and investment agreements that are formulated without even “a minimum level of transparency”. It describes the “complex system of global rules and regulations” that protects wealthy elites and cross-border flows of finance at the expense of democratic institutions and the public interest, and which enables finance-corporate actors to sue governments for compensation in secretive international arbitration processes in the event that laws or regulations passed to protect human or environmental health might impinge upon their profit margins.

In contrast to the easy cross-border flow of capital, commodities and profits, the Commission notes the lack of freedom for ordinary people to migrate in pursuit of a safe and secure life, and it deplores the plight of undocumented migrants who are denied essential health care in spite of international treaties that are supposed to guarantee universal rights and entitlements.

Another aspect of the current model of globalisation highlighted by the Commission is the expansion of privatisation and property rights, including through an intellectual property rights (IPR) regime that commoditises science and knowledge, creates perverse incentives in clinical research, and sustains large market failures and inefficiencies across the pharmaceutical sector. This regime – which works for the few but fails for the many – was designed by powerful corporate actors, globalised by the World Trade Organisation, and then deepened by bilateral and regional trade agreements.

Dysfunctional political and economic arrangements are also shown to underlie the growing prevalence of hunger and under-nutrition in a world that produces excess food. This is linked, among other things, to: unfair trade arrangements (especially the 1994 Agreement on Agriculture); predatory financial speculation and food-price volatility; unregulated land markets; agricultural production directed towards profit maximisation rather than the meeting of rights and basic needs; and the displacement of local food production in developing countries by food imports from subsidised producers in the USA and EU. At the same time, the Commission describes how the rising epidemic of obesity and diabetes due to the increasing consumption of unhealthy soft drinks and processed foods is related to the “penetration of food markets in middle-income countries by multinational food corporations” and the concentrated market power of globalised food retail chains.

In its analysis of violence and conflict as “powerful and enduring threats” to health and wellbeing, the Commission similarly notes political and economic factors that increase the risk of war and armed violence. These include: high levels of unemployment; income inequality; economic instability; an unregulated small arms trade; and deficiencies in global governance (notably the “institutional stickiness” and “anachronistic” nature of the UN; the out-datedness of the Geneva Conventions; and the limitations currently placed on the International Criminal Court).

An absence of laws and regulations to promote public health is a prominent theme. But the Commission also notes that when appropriate laws and regulations do exist, states often lack the willingness or capacity to monitor and enforce compliance. Instead, elite, corporate and financial interests all too often subvert the capabilities and duties of democratic institutions to look after the general public interest; exploiting the gaps and deficiencies that exist within the international judicial system.

Importantly, the Commission notes that civil society efforts to hold powerful global actors to account by monitoring and publishing their behaviours (e.g. the Publish What You Pay initiative focused on the energy and mining sectors) or to promote “socially responsible investment” are no substitute for legal and regulatory mechanisms that can enforce sanctions when international norms, laws and standards are violated. Similarly, initiatives aimed at mitigating the negative effects of the IPR regime (e.g. the creation of patent pools, corporate donation programmes and public-private product-development partnerships) are deemed to be insufficient.

Poor Recommendations …

The Commission makes a clear case for a redistribution of political and economic power: for the strengthening of real democracy, including more transparency and greater accountability of powerful actors at the global level, and for the reshaping of the rules and laws that shape our current form of globalisation. In short, it calls for systemic, radical and transformative change.

But having done this, it then loses its way and retreats to the safe and apolitical territory of ‘governance’ by proposing the establishment of two new global structures as its primary recommendation: a UN Multistakeholder Platform (to share and review information, influence norms and opinions, and make recommendations) and an Independent Scientific Monitoring Panel on Global Social and Political Determinants of Health (to assess evidence and conduct research).

While both structures could provide some value in their own right, neither would redistribute power, nor alter the frame of existing laws, rules and systems. Furthermore, both would add to the already uncoordinated and crowded global governance landscape. Ironically, the Commission itself notes that a proliferation of international rule making, bodies and conferences has contributed to “regime complexity” and the blurring of obligations, responsibilities and lines of accountability.

A number of secondary recommendations are also made: make it mandatory for health equity impact assessments to be conducted by global institutions; create a regular forum for civil society organisations to present reports to the International Criminal Court on alleged violations by TNCs and other non-state actors; advocate more on the basis of existing human rights treaties; and promote the financing of global public goods through compulsory contributions made by all states according to ability to pay.

There is nothing bad about these recommendations. But some of them feel old and tired; and none of them are transformative. In fact the Commission admits that these secondary recommendations are not expected “to root out the very causes of persistent health inequities” but merely “remedy the effects of the inequitable distribution of health”.

As a consequence, trade agreements and investment agreements are left untouched (which the Commission repeatedly notes as being too difficult to reform or amend). And nothing is said about banking reform, corporate tax enforcement, global finance regulation, or mechanisms to redistribute wealth and assets (including reclaiming from the ‘one percent’, that which should fall under public stewardship or ownership). In terms of addressing hunger and food scarcity, the mention of social protection schemes and greater investments to strengthen smallholder farmers are also ameliorative solutions rather than anything transformative or structural. In fact under the current system, investments that support smallholders often benefit private finance capital and big corporations through corporate capture and buy-outs.

Although the call for countries to make compulsory payments to finance global public goods would mark a significant change from the current system of voluntary contributions, even here, the actual benefits are marginal, and would do no more than to make ‘official aid’ a little more generous and predictable.

Why did this happen?

The gap between ‘analysis’ and ‘recommendations’ is startling. The identified need for transformative change is abandoned in favour of a set of marginal changes. It is as though having ‘spoken truth about power’, the Commission wasn’t prepared to ‘speak truth to power’ when it came to making recommendations. What can explain this?

One possible explanation is that the Commission was being pragmatic and strategic – proposing a set of moderate and unthreatening recommendations but which might promote transformative change later on. For example, the Commission might have imagined that a new multi-stakeholder forum and an independent scientific panel would bring about a social and political mobilisation that would then lead to transformative equitable and democratic change.

A second possible explanation is that having described the political causes of health inequity, the Commissioners lacked agreement or a shared vision on what an alternative form of globalisation and global governance would look like. It is possible that social, political and conceptual differences between individuals led to differences in opinion which led to the formulation of moderate, ‘lowest common denominator’ recommendations that were acceptable to all.

Certainly, there is evidence of some ambiguity within the Commission’s report. For example, the Commission credits the global market system for having generated “ever greater flows of goods, people, money, information, ideas, and values” with the help of “privatisation, deregulation, and trade liberalisation”; and for having produced “unprecedented growth that has increased material prosperity for hundreds of millions of people and greatly improved their health and wellbeing.” It also notes how foreign direct investment “is widely regarded as an important vehicle to advance economic growth and development” and how TNCs also “yield enormous benefits by creating jobs, raising incomes, and driving technological advances”.

Both these claims contribute to a degree of ‘mixed messaging’ about globalisation and global governance. They also happen to be wrong. The trinity of privatisation, deregulation and trade liberalisation as currently structured, has done more to inhibit rather than encourage the generation and flow of knowledge, information and ideas (especially apparent in the pharmaceutical sector). Furthermore, it has hindered economic growth and development compared to other more pro-active approaches to socio-economic development. Similarly, there is no evidence that TNCs perform well in terms of job creation, raising incomes or driving technological advance (if anything, the evidence is negative).

‘Mixed messaging’ is also evident in the Commission’s discussion of the recent financial crisis and consequent austerity measures that governments have implemented. The focus was on how to respond to the financial crisis (i.e. whether counter-cyclical spending was better than austerity, and whether austerity could be implemented with less adverse health effects), but not on reforming and regulating the system of global finance, nor on how the vast amount of illegitimate and odious debt that has been piled onto governments and ordinary people could be annulled.

A third possible explanation is that members of the Commission were ‘censoring’ themselves – either consciously or sub-consciously. Promoting ‘transformative’ change that challenges power while seeking to redistribute resources equitably is discomforting and not without risks. One may want to avoid direct confrontation with power, and avert the risk of being labelled and then dismissed as an unrealistic or quixotic ‘radical’.

It is worth noting that the power and politics that shapes the global political economy also operates across the global health landscape. For example, TNCs are powerful and influential actors in global health who would positively welcome marginal changes in global governance (including the promotion of progressive norms, ideas and values), as long as trade and investment rules continue to be structured in their favour. And the Gates Foundation – a major source of funding for the global health community – is also a strong proponent of neoliberal globalisation and the prevailing undemocratic structures of global governance.

Importantly, the role of private philanthropy and official aid was not critically examined by the Commission, which instead praised the Gates Foundation by name and portrayed ‘global health’ and ‘aid’ as uniformly positive domains that counteract the negative effects emanating from ‘trade’, ‘national security’ and ‘finance’. The reality is more complex. While much aid and private philanthropy undoubtedly ‘saves lives’ and provides vital humanitarian assistance, their role in sustaining democratic deficits and disparities in power, and in shielding unfair trade and investment agreements and egregious market failures from reform was not even mentioned.

The Commission’s tendency to portray governments, civil society and corporate actors as separate and distinct actor groups that compete with each other for influence and power, also obscured the fact that power is organised horizontally across these three sectors. This links to another important contextual factor that was not examined by the Commission: the ‘public-private partnership’ paradigm which has come to virtually define global governance in the last two decades and which has enabled and legitimised the presence of powerful, undemocratic and self-interested actors at the heart of decision and rule-making structures and processes.

As I like to sometime say, the real occupy movement isn’t the one led by ordinary citizens on the streets and squares of towns and cities across the world: it is the occupation of governments, the UN complex and the media by the corporate sector and the wealthy. This occupation may also extend to universities and research institutions where changes to funding and management arrangements have shrunk the space for academic freedom and public-interest science.

Where is the Real Occupation?

The suggestion that the Commission may have censored itself will not go down well. But this is less an issue about individuals and more about how power and the dominance of neo-liberal ideology in mainstream social and political discourse influences what is generally considered to be politically ‘feasible’ or ‘acceptable’, and how words like ‘radical’ and ‘transformative’ are defined and given meaning.

There may be other explanations for the gap between the Commission’s analysis and its recommendations. And I hope this blog will spark some frank but constructive debate. Even better would be for the Commission to withdraw its recommendations and come up with better ones. This will almost certainly not happen, but I have written to the Commissioners to ask them anyway.

Moving forward …

A lot of the Commission’s analysis was good. But it didn’t go far enough. For this reason, the Lancet should also consider hosting a new Commission. It could be called a Commission on Power, Politics and Alternatives, and it would do three things.

First, it would deepen and broaden the analysis of politics and power conducted by the Lancet-UiO Commission. This would include: a) a better description of how power is structured and organised globally, and how it undermines democracy, equity and public health through the use of wealth, political influence, military force, laws, culture and ideology; b) a critical analysis of the role of aid and private philanthropy in global governance and the distribution of power; and c) an examination of the particular influence of the US corporate-military-government complex on global governance and the implications for the recent shifts towards a more multi-polar world order.

Second, it would work on proposals for an alternative development paradigm. We don’t just need better and fairer global governance; we also need a concept and vision of development which is ecological, sustainable and consistent with planetary health. Neoliberal globalisation isn’t working for the earth or most of the world. Only an alternative model would: a) construct development pathways that simultaneously address poverty and global warming; b) redistribute wealth and resources; c) ‘de-financialise’ the world economy and subjugate finance capital to greater social and democratic control; d) ‘de-globalise’ and ‘re-democratise’ economic and ecological policy; and e) break up monopoly power where it exists. These ingredients for an alternative model have received the attention of many serious scholars and thinkers: it’s time the global health community reaches out to such people.

Finally, it would develop the point made by the Lancet-UiO Commission about social movements “challenging undemocratic processes, or protesting against unfair policies”. Redistributing power or shifting paradigms cannot be limited to technocratic and intellectual interventions: social and civic action is required. But such action often provokes reactionary counter-measures which may be violent and oppressive. That is why it would be useful for a Commission to examine how the respected and privileged community of global health professionals can reach out to and stand by those social movements that are fighting for democracy, justice and survival on the frontline.

While this blog is written in my capacity as an academic at Queen Mary University London, Chair of the Board of Medact and a member of the Peoples Health Movement, the analysis, opinions and recommendations presented here can only be attributed to me as an individual.