ISSN (Print) - 0012-9976 | ISSN (Online) - 2349-8846

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The Complex Truth

A government which believes that medical education and healthcare are best provided by the private sector is deliberately starving government hospitals of funds. Until a clear plan to ensure health for all is in place and the poor demand medical care as a fundamental right, public health services will remain skewed and unjust.

30TH ANNIVERSARY OF ALMA-ATAEconomic & Political Weekly EPW november 22, 200839and integration of diagnostic/therapeutic interventions across different levels of care – something hard to come by even in relatively sophisticated settings today.Certification for Healthcare Profession-als and Institutions: This process can be thought of at the level of healthcare pro-fessionals who would require certification in order to practise their profession, as well as for institutions (public, as well as private, or any combination of the two) that would serve as care-giving centres. In both cases the process of certification would include a process of mapping skills, knowledge and practice that are put to use, as well as the societal obligation ful-filled, perhaps through a mapping of the categories of patients treated on a cashless basis or with single payer payment (whether by the government, private party, or insurance company). Medical insurance programmes, as and when they become a significant reality, would also require certi-fication, and subsidised insurance pro-grammes would thus make healthcare equally available to all sick people. Other Prerequisites for Health: Univer-sally applicable schedules of access and entitlements to public distribution of food,healthcare, health facilities, nutri-tion and other prerequisites for health. The Supreme Court directives issued from time to time in thePUCL Right to Food case may serve as a model for other areas where no such directives exist. As Paul Farmer puts it, it is necessary to recognise the state order as a guarantee of rights: “It can be said with certainty that the liber-ties of citizens are better protected by their own institutions than by the well meaning interventions of outsiders. State failure can-not be rectified by human rights activism on the part ofNGOs” (M Ignatieff, 2001, quoted in Paul Farmer, op cit, 2003).George Thomas (george.s.thomas@gmail.com) is chief orthopaedic surgeon at St Isabel’s Hospital, Chennai and editor, Indian Journal of Medical Ethics.The Complex TruthGeorge Thomas A government which believes that medical education and healthcare are best provided by the private sector is deliberately starving government hospitals of funds. Until a clear plan to ensure health for all is in place and the poor demand medical care as a fundamental right, public health services will remain skewed and unjust.An incident that occurred when I was a medical intern at the gov- ernment hospital in Chennai comesbacktome as I begin this article. The wards used to be so crowded that patients had to be accommodated in the verandahs. One late evening, aided by the light of a dim bulb swaying wildly due to the stormy rain outside, my col-leagues and I were working on one such patient who was very ill. Our efforts to aspirate the pus from his lungs though partly successful were too late and he died. That was in 1981, three years after the stirring Alma-Ata declaration of “Health for All by 2000”. I do not know how many doctors were inspired by the declaration but I suspect the number was very small. The government hospitals then swarming with the sick and the desperate did not allow much room for optimism.State of Public Health SystemThirty years after the declaration, where does our public health system stand? Recently in the middle of the night, I received a telephone call about an acquaintance who had been rushed to the Government General Hospital, Madras Medical College after he met with an acci-dent. The scene I witnessed in the trauma ward was horrifying. Nearly 50 injured patients and their anxious relatives wereoccupying every inch of available space. The sheer size of the problems faced by the public health system is overwhelming.From 1983 to 1987 I worked in Kerala. The success story of Kerala’s public healthsystem is well-known. It has a very good rate of vaccination, a low infant mortality rate, and among the highest rates of institutional deliveries in India. But the base of this system is fragile going by the epidemics of Chikungunya and Dengue which swept the state in the last two years. There are a large number of private institutions, some highly sophisticated and a distinctive feature is the charitable ones run by various reli-gious organisations with the Christians running the maximum number. Such institutions are an important source of secondary level medical care in Kerala. The services are not free in these institu-tions, but the charges are modest and they are popular. The government sector is patronised only by the very poor. These institutions offer a basic level of care. If you have appendicitis or a perforated ulcer, you can be quite sure that you will be given appropriate care. If you have a chronic disease like diabetes or hyper-tension, getting the regular supply of medication required for these diseases is near impossible. If you need a kidney transplant, it is quite unlikely that you would get it in a government hospital. The regular change of government between the Left parties and the so-called centrist parties has however not meant
30TH ANNIVERSARY OF ALMA-ATAEconomic & Political Weekly EPW november 22, 200841In the provision of medical care we are witnessing the rapid abdication of the State from the commitment to pro-vide universal care. Especially since the inception of the first corporate hospital in Chennai in 1984, and more so since 1993 when the World Bank came out with specific recommendations in its report “Investing in Health”, the gov-ernment has quietly starved the medical caresector of sufficient money to provide universal medical care. The technique is simple: it proclaims in every public forum that every intervention is available in government hospitals, but does not provide the infrastructure to make the proclamation a reality. The doctors, a majority of whom do not believethat medical care is a funda-mental right, go along with the charade. The poor patient with a serious illness waits and waits in the government hospital, finally gets the idea that nothing dramatic is going to be done, and goes home. Very few complain. The idea that medical care is a fundamental right has not permeated society. People still consider it a favour bestowed by a benevolent government.This perhaps, is the key: Health and medical care for all will only become a reality when people demand it as their right.Role of the World Health OrganisationIndira ChakravarthiIndira Chakravarthi (indira.chakravarthi@yahoo.co.in) is a public health researcher based in Delhi.The Alma-Ata Declaration of 1978 on Primary Health Care together with the slogan of Health for All by 2000 AD is considered one of the most significant public health initiatives of the 20th century. The 30th anniversary of the declaration provides an opportune time to revisit its history and arrive at some fresh perspectives. This article examines the role of World Health Organisation in developing countries as a directing and coordinating authority on international health, and in providing impartial, evidence-based technical information. The World Health Organisation (WHO), the specialised health agency of the United Nations (UN), is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and stand-ards, articulating evidence-based policy options, providing technical information, and monitoring and assessing health trends (http:// www.who.int/about/en/). Of late there has been plenty of critical writing about the WHO, such as about its transformation/marginalisation in inter-national health (Brown et al 2006; Ollila and Koivusalo 2002; Navarro 2001), its internal problems, the need for it to refo-cus (Katz 2007; Levine 2006), and how it generates its evidence-based guidelines (Cheng 2007). The 30th anniversary of the Alma-Ata Declaration of September 1978 by the World Health Assembly (the gover-ning body of WHO) provides an opportune time to revisit its history and come up with some fresh perspectives. Against this background this article examines how the WHO has been fulfilling its role as a direc-ting and coordinating authority on inter-national health, and of providing impartial, evidence-based technical information. 1 The Idea of Primary HealthcareThe Alma-Ata Declaration of 1978 on Primary Health Care, together with the slogan of Health for All by 2000AD (HFA) proposed at the 1976 World Health Assembly, is considered to be the major public health initiative of the 20th cen-tury. It was made at the International Conference on Primary Health Care, jointly sponsored by two UN organisa-tions, the WHO and the United Nations Children’s Fund (UNICEF), and held at Alma-Ata, Kazakhstan, in theerstwhile Union of Soviet Socialist Republics (USSR). Alma-Ata has since come to be identified with certain basic tenets of public health, such as those of primary health care (PHC), universal access to healthcare, and of health for all. There are several explanations of the emergence of the concept of primary health care in the 1960s and 1970s, and its subsequent adoption by the WHO. The em-phasis on PHC in the Alma-Ata Declaration was an outcome of the failures of the tra-ditional vertical programmes concentrat-ing on specific diseases, as well of the criti-cism of the assumption that “western medical systems” would meet the needs of the common people in developing coun-tries. The 1960s and 1970s was a period of social ferment, of several movements, in-cluding the radical science movement in the west. Radical political critiques arose from several quarters, such as from the anti-war movement, from the organised left, and from the women’s health move-ment. There were calls and movements for alternative technologies, for “appropri-ate” technology, “intermediate” technology, as also opposition to ideologies propound-ing a “technological imperative”. This was also the time of McKeown’s much-cited thesis relating the improved health of populations to better living standards and Illich’s discourse on the negative effects of modern medicine. There was questioning of the hospital-centred bio-medical model

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