'You can't blame liberalization for all our woes'

'You can't blame liberalization for all our woes'

It's convenient to externalise the enemy, says national convenor of the Jan Swasthya Abhiyan, B Ekbal, but it's the lack of political commitment and glaring deficiencies in the system that are really responsible for the mess the public health sector is in. In this interview, Dr Ekbal discusses the JSA campaign and the decline in Kerala's model healthcare system Fresh from the partial victory scored by the Left Front parties over the controversial Patents (Amendment) Bill, against which the Jan Swasthya Abhiyan (JSA) lobbied extensively with MPs and health policymakers, JSA national convenor B Ekbal, however, asserts that the "battle is far from over" and adds that close monitoring will be essential to safeguard the hard-won concessions. An informal alliance of 21 networks working on public health-related issues in different parts of the country, the JSA was formed as a follow-up to the first People's Health Assembly in Savar, Bangladesh, in December 2000 and the National People's Health Assembly held in Kolkata prior to that. The Savar conclave witnessed the coming together of thousands of civil society organisations and people's movements from various countries, to draw up an action plan to pressure governments around the globe to implement the 1970 Alma Ata pledge of 'Health for All by 2000'. Talking to InfoChange Agenda , Dr Ekbal details the campaigns taken up by the JSA, during the past four years, at the national, state and grassroots level to further the alliance's goals. He also talks of the decline in the healthcare system in his native Kerala, once lauded as a model for public healthcare systems in the country. How did a neurosurgeon like you get involved in public health and access to healthcare? How did you get involved with the Jan Swasthya Abhiyan? After finishing my medical studies in 1970 I got actively involved with the Kerala Sastra Sahitya Parishad (KSSP), which was taking up health-related issues apart from other social concerns relating to education, the environment, etc. I was also closely interacting with the Medico Friends Circle (MFC), which had then taken up a nationwide campaign against the selling of banned drugs in India . So, my interest in public health issues goes back some 25-30 years. As an activist of the People's Science Movement, I also got the opportunity to interact with several national and international organisations working on issues of right to healthcare. The Jan Swasthya Abhiyan was founded in India as part of the Global People's Health Movement, following the first People's Health Assembly at Savar in 2000. Before heading for the Savar assembly, national networks and NGOs had come together in Kolkata to organise the National Health Assembly, which declared the major goals of the Indian people's health movement in the form of an Indian People's Health Charter. What have the JSA's activities been? What do you see as its achievements? At the micro-level, in terms of specific programmes, and at the national level, in terms of policy, would you say that it is making a difference? I feel the JSA's campaigns are definitely beginning to have an impact, both at the national and state levels. At the policy-level, our foremost concern is to address the healthcare issue from a rights perspective. In this we have got very crucial support from the National Human Rights Commission (NHRC). The national-level public hearing ( jan sunwai ) on the right to healthcare, organised in Delhi in December 2004, clearly recognised our demand for the right to healthcare to be included in the chapter on fundamental rights of the Indian Constitution. The national public hearing, which was held following a series of regional public hearings in different parts of the country, also demanded the enactment of a Public Health Act by the central and state governments. Several structural anomalies in the public healthcare system, exposed in the personal testimonies of those who participated in the jan sunwais , are also being followed up in various states, notably Karnataka and Tamil Nadu. We have also prepared a format to hold jan sunwais right down to the panchayat, taluka, district and state level, in all the states. Close monitoring of the public healthcare system, with the active participation of the state human rights commissions, people's representatives, bureaucrats and public health activists, will make the system more responsive. For instance, in Karnataka, during the regional public hearing, we found that some three or four primary healthcare centres (PHCs) were located close to each other in one particular district, forcing people from other parts of the district to travel long distances to avail of their services. Some of the PHCs have since been relocated. In Kerala also, we hope to start the state-level jan sunwai from June-July. The purpose of these public hearings is not to find fault but to rectify structural anomalies in the public healthcare system, such as lack of adequate medicines and other infrastructural facilities like blood banks and investigative facilities at government hospitals, which force people to turn to private sector hospitals. In Kerala, the JSA took up the Patents (Amendment) Bill in a big way, initiating a debate, briefing MPs on the technical details, and collecting over 300,000 signatures. I can confidently say that the JSA played a small role in the Left parties' success in wresting major concessions from the government in the Patents (Amendment) Bill. Though the JSA's ultimate goal is to see that TRIPS is taken out of the WTO, for the time being we have to accept the reality of product patents becoming the norm, instead of the earlier process patent. However, given the present political situation, the left parties have been able to wrest substantial gains from the government, including reducing the number of drugs to be patented, compulsory licensing and the exclusion of a clause preventing the export of cheap Indian drugs to other developing countries. What are some of the JSA's future activities? What do you see as the big problems ahead? The follow-up of public hearings will remain an important focus area. The national working group of the JSA, which will meet in Kolkata in April, will examine the Rural Health Mission announced by the Government of India. Also in Kolkata on April 16-17, the JSA is organising a seminar on the Indian pharmaceutical industry. Apart from the patents rules, several other issues facing the industry, including the status of public sector companies and price control mechanisms, will be discussed. Some of the other campaigns taken up by JSA constituents include those relating to children and gender issues, geriatric problems and the changing demographic profile, mental health, and HIV/AIDS. Also, an appraisal of the General Agreement of Trade in Services, and its impact on health, education and other sectors and the public health impact of new technologies like biotechnology and reproductive technologies will be initiated shortly. Which are the participating organisations in the JS The JSA is an example of collaboration between political organisations and NGOs, and even religious organisations, some of which have in the past been distrustful of each other. How did this collaboration come about? Groups working on public health issues, ranging from the extreme left to those professing Gandhian ideology and faith-based organisations, have been in touch with each other for a number of years. They have discussed major issues at length with each other in an effort to arrive at some sort of clarity on them, if not consensus, on such organisational platforms like the Medico Friends Circle, All India Drug Action Network and National Campaign Committee on Drug Policy. Starting with 18 networks, the JSA has grown to an informal alliance of 21 networks. All these networks work in a decentralised manner, taking up issues jointly at the national level as well as individually at the local level.    The People's Health Charter, adopted after the Kolkata meet, is a consensus document. Thus, there is some degree of unanimity, a common bandwidth, among the groups constituting the JSA.  Also, there have been major changes in the world and the country in the past 10 years. In the face of imperialist globalisation and other threats facing the country, it is important for these groups to face these challenges unitedly. There are several factors binding these groups together. There is no time to quarrel. There are larger issues, stronger enemies that we have to fight together. There has been consensus among the participating networks on the issues to be taken up. So far, there has been no problem. Some of the 21 groups that constitute the JSA include the Medico Friends Circle, Bharat Gyan Vigyan Samiti, All India Democratic Women's Association, All India People's Science Movement, Catholic Hospital Associations of India, Christian Medical Association of India, Voluntary Health Association of India, Ramakrishna Mission, Federation of Medical Representatives Association of India, Forum for Creche and Child Care Services, National Federation of Indian Women, Joint Wormen's Programme, All India Drug Action Network and National Alliance of People's Movement. When it comes to health issues, there is no real categorisation of left or right groups. What do you see as the strengths of such collaborations? What are the problems? The biggest advantage of working in an informal manner is that each group is free to take up the issues that it considers important. There is complete decentralisation. Also, the issues to be taken up at the national policy level have been decided through consensus and there has been no difference of opinion so far on these. There are, however, some disadvantages also in working in such an informal manner. There is no funding from anywhere for the JSA. There is no office also. Thus, some of our efforts do take more time to get off the ground. Kerala was once seen as an ideal healthcare system, with an extensive network of government health services and high health indicators. Have there been any changes in healthcare access in Kerala since 1991? What has been the effect of neo-liberal policies at the national level? There are studies, including those by the KSSP, indicating that healthcare costs have shot up in Kerala, with the private sector playing a greater role than before. What has led to this situation? It is true that there has been a definite decline in the Kerala public healthcare system. However, I trace the decline not to 1991 but prior to that, to the early-1980s. The chief cause for this has been a lowering of political commitment to healthcare issues. There has been no proper planning at the policy level. Even where funds are available in the government sector, there is no proper utilisation. The government is spending more money on building super-specialty hospitals than concentrating on the primary and secondary health tiers. A study done by the KSSP as early as 1986 indicated that the public healthcare system in Kerala was on the decline. Disturbing trends had surfaced, mainly on account of the neglect of the primary and secondary healthcare sectors. New infectious diseases like Japanese encephalitis, leptospirosis and dengue fever have surfaced, and malaria has returned. Rising consumerism, resulting in changes in food habits, has also led to an increase in lifestyle-related diseases such as diabetes and hypertension. The changing demographic profile, with an increasingly ageing population, has given rise to another set of geriatric health issues. Studies show that the suicide rate in Kerala is three times the national average. This indicates the weak mental make-up of the people, unable to cope with stress and other social problems.  The KSSP study also highlighted that a majority of the population was turning to private sector hospitals for treatment. Even among the poorest, nearly 40% relied on the private sector, which, in Kerala's case, is totally unregulated. Lack of investigative facilities and drugs also forces those going to government hospitals for treatment to turn to the private sector for these services. Another study, taking the 1986-1996 sample period, showed that people's healthcare expenditure had gone up by five times. As for the impact of the neo-liberal policies of 1991, I think that they have had only a minimal impact on the total health scenario so far. The major issues are the result of internal factors. It is convenient to externalise the enemy and to blame globalisation or liberalisation. The fact of the matter is that there are glaring deficiencies in the system itself, which are not being addressed. To blame liberalisation for all our woes is a cliché now. It is actually lack of political commitment that has largely brought about a decline in the public healthcare system in Kerala. However, in the near future, because of changes in the Patent Act in India drug prices are likely to increase. This will affect the people of Kerala more than those in other states because more than 90% of people in Kerala access modern medical treatment. Also, the introduction of user fees at public hospitals as part of the liberalisation agenda will definitely lead to the internal privatisation of public health institutions. The difference that political will can make to the system is made evident by the major policy initiative introduced by the Left Front government in Kerala in 1996, under the People's Campaign for Decentralisation. Under this, 35% of the plan budget was allocated to local bodies for all their activities. Of this, 40% could be used for social services sectors like health and education. This led to a dramatic improvement in the facilities available at some PHCs and taluka hospitals. Surveys showed an especially excellent improvement in some of the more backward districts like Malappuram, Idukki and Wayanad, where the incidence of infectious diseases could be controlled. In a few places, private hospitals had to be closed down as people found government sector facilities to be on a par with them.      According to a rough estimate, one could say that nearly 40% of panchayats are performing well in service delivery, following the people's decentralisation campaign. However, with the coming of the UDF government four years ago, the tempo has again slowed down. Funds have not been released on time. New rules have been put in place to curtail the transfer of funds to local bodies. The Planning Board, which was playing an active role in the decentralisation campaign, has been distanced from the process. The UDF government has also allowed self-financing medical colleges to come up. Students who pay Rs 25,00,000-30,00,000 to get into private colleges are hardly bothered about ethical issues or the doctor-patient relationship. They see medicine only as a source of making money. However, all hope is not lost. The decentralisation process has been set in motion and it cannot be dismantled. A change of government in the state could revive the stalled process.