Leela is in her sixties and works seven nights a week.
She has been employed to look after Preeti, a woman in her eighties with dementia. Leela keeps her safe through the night. Her duties involve preparing her charge for bed, then hours of fitful half-sleep, when she springs from her mattress on the floor if Preeti wakes (she often does), the morning lavatory run, including the hand-washing of any soiled clothing and sheets, the daily bath. At nine in the morning, her shift ends.
Preeti sometimes breaks the usually cast-iron social barriers of class in India to grab Leela’s hand and squeeze it in gratitude. Leela’s devotion to her goes beyond that of a mere employee, but she longs for a regular day off.
If she feels unwell, she approaches one of Preeti’s children for a pill and is given a paracetamol or one of the numerous cold ‘remedies’ that are sold in India. But when she is truly worn out, she calls in sick. Then her son takes her to a doctor who treats poor patients. The doctor gives her an injection and relieves her of a bit of her hard-earned money.
For Leela the injection symbolizes that she has been taken seriously, even if it may only be, at best, a vitamin shot or, at worst, just saline solution. The doctor sees little point in asking her to take it easy, since he knows she can’t, or exploring other causes which may require treatment he knows she couldn’t afford.
Preeti’s family, meanwhile, can shop for specialists for their mother; doctors who will visit their home. Should the need arise, they could tighten belts and get her treated at enormous expense at the gleaming corporate hospital on the outskirts of the city, the kind that gets free land and subsidies from the government if they promise to reserve a few beds for the poor. It’s the kind of place that even draws Western foreigners who have either been on a waiting list too long or are just looking for treatment they can afford.
Yet Leela, with her placebo injections, is still better off than some of the rural poor in this vast and vastly unequal country. In the survival economy of many villages a person could die because they felt they couldn’t afford to get an X-ray for a diagnosis of tuberculosis, a disease for which a course of treatment can be as low as $20.
India has a public health system, but it is chronically underfunded: the government spends barely one per cent of GDP on health (whereas it is the world’s ninth largest purchaser of arms). As policy analyst Gita Sen put it: ‘Poor people go less and less to public facilities to which they would go earlier because they almost never have the free drugs they are supposed to provide. This is a great irony for a country that has gained respect in Africa for making drugs affordable through our export of generics to them.’1
So a banal and deathly truth pushes itself forward: in India, as in most of the world, the healthcare model that is available is one that is characterized by the stratification imposed by capitalist modes: pockets of technical excellence available to the rich, much more limited options for the poor. Recently, numerous Western commentators have noted that the Indian government is making a commitment to universal health coverage; Indians themselves will only believe it if it starts to happen.
What right to health?
Few people would disagree with the notion of a right to life. Its corollary, the right to health, raises objections in some quarters, mainly related to cost. But the end result of the neglect of either can be the same – the denial of life, sometimes known as murder.
The world’s citizens over-whelmingly want healthcare to be a public good; it takes global institutions a while to wake up to their demands
In the relatively affluent West, healthcare budgets come under strain because spending tends to be skewed towards increasingly sophisticated treatments (rather than the prevention of disease or the promotion of good health). The fraudulent practices of the major pharmaceutical companies also play a major role. This September the New England Journal of Medicine reported that 26 companies had been fined over $11 billion in the past three years for criminal wrongdoing, including supressing safety data and reckless promotion of drugs for unlicensed uses. This is just the tip of the iceberg for an industry that often places what is marketable above what is needed, producing highly priced copycat drugs of relatively little worth rather than genuine innovation.
In the Majority World the work of prevention and promotion is just as essential and cost-effective, and needs to include some pretty basic things: enough food to eat, clean drinking water and adequate sanitation, education that can improve both employment opportunities and health decisions. Treatment options need to be safe, appropriate, effective and publicly provided. Medical fees mean poor people face impossible ‘choices’: financial ruin, limiting food, buying some medicine oneself and hoping for the best, or not having any treatment whatsoever.
A different vision of healthcare was put forward at a historic conference in 1978 when the great and good of the medical policymaking community and representatives of the world’s governments gathered in the former Soviet Union with the aim of delivering health for all by the year 2000. Healthcare, they declared, would be ‘based on practical, scientifically sound and socially acceptable methods and technology made universally accessible through people’s full participation and at a cost that the community and country can afford’.
The lost decades
This glowing, globally endorsed, internationalist vision soon turned to dust in the 1980s when the World Bank and International Monetary Fund (IMF) enforced indebted countries to undergo structural adjustment programmes (SAPs), servicing foreign debt at the cost of public spending. One of the pillars of the SAPs was user fees for health (and education) referred to in euphemistic terms as community financing, cost sharing or cost recovery.
In much of Africa, they ripped up what little public health provision existed, penalizing the poorest and most vulnerable, and enabling preventable diseases to spread unchecked. Patients would wait far too late before seeking help. A fee of just 33 cents in Kenyan health centres led to a halving of users. This, coupled with an ongoing brain drain of skilled healthcare workers, has had a slash-and-burn effect.
The World Bank has hotly denied its role in the carnage, saying the poorest were always meant to be exempt from fees and people were to be charged on a sliding scale of ability to pay. Ridiculous arguments were made that small fees would discourage wasteful use of health services and make users value them more. Remember, this is about impoverished people who live extremely frugal lives and have only ever seen those wealthier than themselves be wasteful. Such reasoning shows how completely out of touch with reality the Bank’s policymakers were: the measures they suggested had no chance of success due to lack of an administrative framework, corruption and the messages not getting through to the poorest people.
The legacy lingers on in countries like Tanzania, where official fee exemptions are rarely put into practice – 73 per cent of women delivering babies in a government facility still pay, despite maternal services being free. The country has tried to implement finely calibrated health insurance schemes – the estimated take- up has been just 15 per cent. The vast majority of Tanzanians thus will continue to be reluctant to seek medical care due to its cost.2
Righting the wrongs of three lost decades must take as its starting point the dropping of debt, which the World Bank, IMF and the club of wealthy nations can do based on their existing assets. After years of strenuous civil society campaigning, this is beginning to happen, though the debt mountain is still far from being levelled.
What kind of health for all?
Today, the policy talk is returning to publicly funded universal health coverage (almost as if it were some bright new idea) – in September this year the medical journal The Lancet launched a series of papers on the subject at the UN general assembly. The world’s citizens overwhelmingly want healthcare to be a public good; it takes global institutions a while to wake up to their demands. Ironically, one of The Lancet writers championing the renewed call for ‘healthcare for all’, David de Ferranti, was previously a major voice within the World Bank rubbishing public provision and calling for the imposition of user fees.3
An embracing vision of healthcare must be public and political. It must tackle social inequality, not entrench it
Among the papers is one by bestselling economist Jeffrey Sachs, who notes: ‘Poor health has negative spillovers, from individuals to the community, and from poor countries to rich countries. Society at large therefore has a vested interest in ensuring that poor individuals have access to health coverage.’ He goes on to enumerate how a minimal healthcare package would cost roughly $50-60 per person per year and how this figure is beyond reach for the lowest-income countries where, according to his calculations, low GDP means a fraction of that sum ($9) is potentially available.4 That international solidarity is urgently required on this front is a given. But can it move beyond vaccination programmes and the wishes of philanthrocapitalists? What of the ongoing healthcare crime of a population numbering nearly a billion that goes hungry on a regular basis? An embracing vision of healthcare for such a world must also be a vision for greater equality.
It must go beyond the sops of providing the bare minimum to something that approaches adequacy. It must look beyond preventing or intervening in diseases to actually building health. The likelihood of this happening via a free market in medicine and user fees is zilch, unless one has an evenly high-earning population. The vision must be public and political.
It must also tackle social inequality, not entrench it as tiered healthcare systems do. That social inequality matters is obvious in countries where abject poverty exists; here only the rich can maintain health standards that are common in affluent nations. But over the last two decades study after study has shown that social inequality also matters deeply in wealthy nations where poverty is, in the main, relative. It is the inequality itself that diminishes health, and the wealthy world has never been more unequal.
In his 2005 book The Status Syndrome, eminent epidemiologist Michael Marmot reflects that poverty is more than just monetary; it affects the degree to which one can participate in society and it affects how much control one can have over one’s life. Unequal societies lack the social cohesion that could offset such negatives. The underlying, chronic stress of low status and low control in societies where community support is hard to find is a trigger to a range of health problems, from immune deficiencies to blood sugar and blood pressure irregularities. It relates directly to the Western world’s epidemic of obesity and depressive illness.
Changing such health inequality does not mean making everyone fabulously wealthy; it means making everyone more equal. Countries with high inequality, like Britain and the US, perform worse over a range of health conditions than those that are more equal, such as Japan and Sweden. The availability of sophisticated medical interventions is of limited use here. Indian economist Amartya Sen has pointed out that life expectancy in Britain improved the fastest not during times of highest economic growth, but during the world wars, when social cohesion was at its highest. (Conversely, we have the more recent example of Russia’s ‘missing men’, when male life expectancy plummeted after the breakup of the Soviet Union. This is not to say life in the Soviet Union was idyllic, but that the splintering of society that followed took its toll.)
With social inequality only deepening with the financial crisis, so will health and healthcare inequality. The British National Health Service, created out of the bonding of the country’s wartime experience and showcased as a social treasure at this year’s London Olympics, is facing creeping privatization and dismemberment. Greece and Portugal are hiking up user fees as diseases of poverty make a return.
Meanwhile, demonstrating that healthcare provision is a political challenge as much as it is one of resources, middle-income countries like Thailand, Mexico and Brazil have cranked up their efforts for good public coverage. Remarkable in its achievement is a country that has faced much adversity but is committed to social equality – read our feature on Cuba on page 24.
Making explicit the connection between social disadvantage and health is Australia’s civil society-led ‘Close the gap’ campaign to improve indigenous people’s health. The government has acknowledged that aboriginal wellbeing can only be improved by a multitude of measures designed to reduce disadvantage, and funds have been earmarked for such work. In Britain, meanwhile, the radical recommendations of the 1997 Acheson Inquiry into inequalities in health have, at the most, received lip service. Why? Because the recommendations go beyond applying a sticking plaster and place much emphasis on protecting and strengthening the vulnerable members of an unequal society with outlandish suggestions like job creation and the security of social housing.
Medical science has made tremendous advances in the last century. The scope of small interventions making big differences in people’s lives in the Majority World is vast, but not the end of the story. Health and healthcare inequalities will only be dislodged once we view them as embedded in the systems of a hugely stratified world. To change that will require political vision and will. The challenge remains, as ever, to create it.
Resources on health equity
Gita Sen, ‘Getting India’s health care system out of the ICU’, The Hindu, 2 September 2012. ↩
Anna Marriott, ‘Does health insurance work in Tanzania?’, Global Health Check, 6 October 2011, globalhealthcheck.org ↩
Sarah Boseley, ‘From user fees to universal healthcare – a 30-year journey’, The Guardian website, 1 October 2012, nin.tl/T8XGVP ↩
Jeffrey D Sachs, ‘Achieving universal health coverage in low-income settings’, The Lancet, Vol 380 No 9845, 8 September 2012. ↩