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India's health system challenges

20 March 2018
Women workers at a sit-down demo
On 17 January 2018, in an enormous show of strength and determination close to 6 million community-based workers in health, education, nutrition and care services, 90% of them women, went on strike across India. But less than a month later, when the union budget was presented, their legitimate demands for decent work and quality public services were ignored.

Worse, the healthcare budget is shifting to a system based on private insurance packages. The Indian government has not only failed the promise of universal access to quality healthcare, but contributes to furthering the privatisation of the country's health system.

17 January All India Strike

A joint platform of 10 national trade unions centres made the call for the 17 January strike. It was the first call of its kind for a particular sector. Despite government's threats of retrenchment and cuts of up to a month’s remuneration, close to 60% of the workforce joined the call.

More than 10 million workers are employed under 'temporary' government programmes, or schemes, to provide crucial nutrition, health, education and care services to their communities. For instance, under the National Health Mission (NHM), close to 1 million community-based health workers, called Accredited Social Health Activists or ASHAs, provide maternal care, neonatal care, infant care, vaccination, family planning and other essential services to the most vulnerable populations. They provide an essential link between the local health facility and the community. Similarly, 2.7 million Anganwadi workers under the Integrated Child Development Services (ICDS) Scheme provide for child nutrition and care (crèche) and 2.8 million workers under the Mid-Day Meal Scheme cook and serve nutritious meals to school children. Close to 4 million workers are deployed under other similar schemes.

Yet, these community-based workers are not recognised as workers, and receive neither minimum wages nor social security. Instead, they are given incentives or honorarium, which are as low as INR 1,000 (Euros 12.5) a month for some categories of workers. This is despite the fact that the 45th Session of the Indian Labour Conference, held in May 2013, recommended that scheme workers be recognised as workers, and the provision of minimum wage and social security, including pensions.

These crucial government programmes are also threatened by budget cuts and structural changes. These include involving organisations linked to private companies, such as food companies, in the provision of the services; making access difficult for the target populations; and replacing universal services with targeted cash transfers. The government has given no sign of interest to address the issues that were raised in the strike call.

Decline in Health Budget 2018-19

One of the key demands of the strike was adequate allocations for government programmes providing basic services to the masses so that workers can earn at least a minimum wage and services offered with adequate infrastructure and quality of provision.

However, the Budget 2018-19 presented by the Central Government on 1 February did not make the appropriate allocations. Despite the growing crisis in access to health care in the country, the allocation to healthcare has decreased in real terms. For 2018-2019, the government has allocated INR 546.67 billion, which represents only a 2.5% increase (lower than the inflation rate) over the revised estimates of INR 531.98 billion the previous year.  The allocation for the principal health programme, the NHM under which the ASHAs work, received less allocation than what was spent the previous year (INR 306.34 billion against INR 312.92 billion last year). The demands of ASHAs and other scheme workers alike have not been taken into account in this budget.

Continuing Privatisation

While the NHM has seen its budgetary allocation decrease, the government announced a new flagship programme, the National Health Protection Scheme (NHPS), also known as 'Modicare'. Under this programme, 100 million families would be covered for hospitalisation expenses up to INR 500,000 (Euros 6,250) per year for a family. Like earlier public funded insurance schemes in India, only hospitalisation is covered for a specific list of procedures, and treatment can be provided either in public or in private facilities. In practice, this boosts the private sector. For instance, in the state of Andhra Pradesh where the oldest such scheme is implemented, a large majority (77% in the period from 2007 to 2013) of public resources get directed to treatment in the private sector.

What is more, most infectious diseases, chronic diseases, and other health issues that require prolonged treatment without hospitalisation are excluded from coverage, despite their prevalence in the population (in Andhra Pradesh, 25% of the state budget was used to cover 2% of the burden of disease). Thus, public resources are wilfully directed away from already neglected primary and secondary care facilities towards tertiary care facilities where the private sector dominates.

Firstly, necessary allocations not been made to respond to the demands of the workers, and secondly, the government is directing public resources to strengthen an already dominant private health sector by assuring a steady clientele through the “largest government funded health care programme.”

This strategy of backdoor privatisation has been called out by the progressive public health community in India. The trade union platform of scheme workers is planning further agitations and mobilisations to create a broader platform against the threat to the provision of basic services. Arguably the next steps will require state-based mobilisation strategies. On 25 February, the First National Convention of United Nurses Association (UNA), a PSI affiliate that has been fighting low wages and informal employment conditions in the private and public hospitals, was held. Increased informalisation of employment in public hospitals are another outcome of the neglect of public facilities. On the other hand, the dominant role of the private sector contributes to the lack of implementation of existing laws, including labour laws, in private facilities.

Yet, as long as these different movements work on their own, their impact will remain limited. Broad coalitions and joint strategies are essential to derail the plans of a government that is committed to the agenda of dismantling public services across the board.

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This article is an extract from the “Right to Health” newsletter issue 04 (April/May 2018). Subscribe to the newsletter. Send us your stories.

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