School textbooks in recent decades have frequently become battlegrounds for ideological contestation in India. Most textbook wars are to advance majoritarian perspectives on history and culture. However, a recent very different textbook skirmish broke out about the public and private sectors in healthcare. The story of this ideological clash is bemusing and instructive, illuminating competing perspectives on the nature of education, healthcare and markets in new India.
This clash surfaced when the Indian Medical Association (IMA) complained to the President and prime minister about the ‘objectionable description’ of private health providers in a Class VII NCERT social science textbook. They protested that private sector treatment was depicted as sometimes resorting to unethical practices, and much more expensive than in government hospitals. This would give the message that ‘private sector fleeces money’ (sic) and ‘brainwash’ students, ruining their faith in private health services.
The textbook is part of a remarkable series on ‘Social and Political Life’ developed consultatively by the NCERT with academics, teachers, researchers, and civil society organisations. The chapter interrogates the state’s responsibility in a democracy and the implications of insufficient provisioning by government of public goods, specifically healthcare. It relates the story of Hakim Sheikh, who fell off a train in West Bengal and suffered head injuries. Eight government hospitals refused to admit him for treatment, and he finally resorted to expensive private treatment. Later he went to court, which ruled that it was the duty of the State to safeguard the right to life, and directed the State to reimburse the cost of private treatment.
In a rejoinder to the PM to the IMA’s allegation that students will be ‘brainwashed’ against private healthcare, 200 medical professionals, educationists, academics, and other concerned individuals observed, ‘It has been long established that students, however young, bring to the classroom knowledge and experience that the classroom process needs to facilitate as part of the process of learning. The IMA’s objection… is not only disingenuous but completely misunderstands and disregards the educational requirements of textbooks’.
There is no doubt that the textbook is founded on the premise that it is the primary duty of the State to ensure healthcare of all its citizens independent of their capacity to pay. This is in conformity with the position of the Constitution, and Supreme Court rulings which maintain that the fundamental right to life includes the right to healthcare. However, this contradicts the view not just of the IMA but also of the Niti Aayog, which recommends that the private sector and insurance-based models be given an even greater role in the health system which would require people to pay for health services. It says that providing free treatment, diagnostics and medicines would be anachronistic at a time when the government was trying to rationalise and target the subsidy regime.
However, India’s public spending on healthcare, at just above 1% of GDP, is among the lowest in the world. By contrast, Brazil spends 4.7, China 3.1, South Africa 4.3 and the United States 8.1%. Public spending is under a third of total health spending in India, as compared with nearly half or more in these other countries. The WHO found in 2013 that 86% private health spending in India was ‘out-of-pocket’ payment. A 2011 Lancet study found that 39 million Indians fall into poverty yearly from medical expenses.
The inequities of India’s health system are well-summarised in the remarkable school textbook, which so offended the IMA. It points out that India is the largest producer of doctors in the world, but most settle in urban areas and opt for the private service or migrate abroad, but half a million people still die of tuberculosis each year, a figure unchanged since Independence. A 2013 WHO paper observes that in 1947, only 8% healthcare delivery was private. Today, 80-85% licensed physicians, 93% hospitals and 80% OPDs operate for-profit. Private physicians are remunerated on a fee-for-service basis. Non-profit private physicians, in non-governmental or faith-based organisations, provide only 1.32% of private consultations. Rural medical providers are generally unqualified. It further states that the predominance of private healthcare is largely a consequence of the government’s economic policies, the rapid influx of technology and the increasing number of Indians who have moderate incomes. It expresses concerns that private care is too expensive, poorly regulated and associated with inadequate training and a general lack of practice standards.
What riled the IMA most was the textbook’s observation that the private sector sometimes resorts to unethical treatment practices. The offending passage reads: ‘In order to earn more money, these private services encourage practices that are incorrect. At times, cheaper methods, though available, are not used. For example, it is common to find doctors prescribing unnecessary medicines, injections or saline bottles when tablets or simple medicines can suffice.’
But earlier this year, a whistle-blowing doctor in Maharashtra, Arun Gadre, reported much graver, widespread examples of irrational drug prescriptions, bribes for referrals, and unnecessary diagnostics and surgeries. He stated that India’s private healthcare sector ‘treats patients as revenue generators’. For instance, doctors get Rs 30,000-40,000 for referring patients for angioplasty. A pathologist he interviewed testified that he contacted 150 doctors but only three agreed to refer patients for investigations without kickbacks. Gynaecologists performed ultrasound without indications on pregnant women and then advised cervical stitches to prevent miscarriage. He also spoke of the shocking ‘sink test’, in which numerous unnecessary laboratory tests are prescribed, the results fabricated and blood samples poured down the sink.
Amidst all this, rather than try to block enquiry and compassion among school students, surely the IMA needs to introspect on the shameful state of private medical services in unequal market-led India. It needs to recall that medicine is a profession for healing rather than cynical profit making.