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Counter-hegemonic Movement in India?

State and Health Markets in the Time of Pandemic

This paper attempts to explain three broad trends that underpinned the relationship between the state, market, and healthcare: first, the state is moving away from its health provider role to a regulator role, which involves shifting the resources, authority, and responsibility to diverse public and private actors. Second, in the name of the pandemic, the state has opened up fresh frontiers of privatisation and corporatisation of healthcare, extending to non-metropolitan cities and small towns. Third, the above two processes would lead to further exclusion of lower castes, classes, and genders from access to healthcare, spiralling health inequalities.

Across the world, governments, including the Indian state, presented the COVID-19 situation as an unexpected crisis to be dealt with as an emergency. And yet, as Rob Wallace (2016) argues, these pandemics are neither unp­recedented nor unexpected given the deeper connection bet­ween the capitalist agribusiness and aetiology of epidemics, ranging from SARS to Ebola to COVID-19 (emphasis mine). ­COVID-19, in fact, brought to the fore the fault lines across the world—countries without strong public health systems and with unequal access to resources, social inequality, democr­atic polity, state institutions, etc. While influenza, tuberculosis, malaria, HIV/AIDS continue to kill millions of people every year, ­COVID-19 has exacerbated health inequalities and insecure futures in India.

The government imposed lockdowns, containment, segregation, quarantine, etc, during the first wave of COVID-19 to control the spread of the virus. However, millions of migrants and informal workers, with no secure homeland of their own either in urban or rural India, went through widespread social suffering1 and died, not due to the virus but the failure of the state in providing basic entitlements. Engels (1891) called this social murder. He had argued that the then English ruling class and the state had created such horrendous working and living conditions for the workers, without the “necessities of life,” that they suffered not only ill health but met early deaths too. The suffering during the second wave was termed as the worst ­humanitarian and public health crisis in post-independence ­India (Bhatt et al 2021).

A year and a half into the pandemic, the Indian government revised its understanding of COVID-19, contradicting its earlier claims of victory over it. One, the government now “recognised” COVID-19 was not a “one-time disaster” but rather an ongoing pandemic, which would continue to occur in waves with different intensity, symptoms, and mutations, with no certainty regarding the end. Second, it now recognised the need to spend on medical infrastructure to contain COVID-19 deaths. Both these responses were stated in its 189-page affidavit to the Supreme Court. This paper examines the shifts in the state’s perception of the pandemic by analysing its competing priorities and the way it has been juggling with “welfare agenda” and privatisation of health services. The analysis of the state–market nexus in the health sector and the role of civil society organisations in generating the counter-narrative is followed by the way the state has moved away from provisioning to the neo-liberal regulatory role and its ramifications ­during the pandemic period and the possibilities of reimagi­ning “post-pandemic” India in reducing health inequalities are discussed.

State–Market Nexus in Healthcare

India’s health system was already broken and fragmented prior to the pandemic as over four-fifths of all the healthcare expenditure was private. The current pandemic has highlighted structural weaknesses in India’s health system ranging from humanpower shortages, low public health expenditure (little over 1% of the gross domestic product), highest out-of-pocket (OOP) expenditure,2 and regi­onal, rural–urban disparities in health infrastructure contributing to high morbidity and mortality rates (Deshpande 2021; Singh 2020). India’s population grew by approximately 13.25% between 2011 and 2020, while the total public health expenditure of the central and state governments combined increased by only 0.39% during the same decade (Bommaraju et al 2021).  

From 1947 to the 1970s, Indian health policy in some ways adopted a primary healthcare approach guided by the principle of the John Bhore Committee recommendations. From the late 1970s, the Indian state emphasised tertiary care over primary healthcare, paving the way for the privatisation of health services. The road map for healthcare and policies, from then on, emer­ged from these tensions between hospital-based medicine and primary healthcare (Jeffery 2019). This is reflected in the way the state was a signatory to the comprehensive primary healthcare approach as part of the Alma-Ata Declaration in 1978 but moved towards selective, target-oriented, vertical “national health programmes” focusing on one disease at a time, by the early 1980s. The liberalisation policies from the 1990s marked a remarkable shift towards greater commercialisation and opening the health sector to more private investment. In the post 2000s, government intervention in healthcare, especially the delivery of services, is restricted to the financing of care, contracting services, and negotiating reimbursement with private providers, rather than providing health services.

The health industry and markets, primarily, comprise the hospitals, health insurance, pharmaceuticals, medical devi­ces, diagnostics, clinical trials, medical education, and medical tourism, of which the hospital sector alone accounts for about 70% of the total market. Significant changes in the health sector have taken place since the late 1990s when hospitals were set up as private and public limited companies. The first private equity (PE) investment in Indian healthcare was in 1999 by the United Kingdom-based global asset management company Schroder Ventures, which invested in Indraprastha Medical Corporation Ltd. This was followed by several foreign-based PE investors—IHH Berhad, Malaysia; TPG Group, Carlyle Group, Advent International, and Columbia Asia and DaVita from the United States; Government of Singapore Investment Corporation, Singapore; Fresenius (Germany), Sakra Hospitals (Japan), Abraaj (Dubai), etc. With several hospital projects funded by the International Finance Corporation (of the World Bank group), the corporatisation of healthcare3 got accelerated. Besi­des, the state facilitating private capital into health sector, the Central Government Health Scheme’s (CGHS) inclusion of corporate hospitals contributed almost 30% of the patients supply to corporate hospitals, fuelling the growth (Baru 2018).

By the 2000s, the Indian state allowed 100% foreign direct inv­estment (FDI) route in the hospital sector, pharmaceuticals (greenfield projects) and the manufacture of medical devices, and third-party administrators by the Insurance Regulatory and Development Authority of India (IRDAI). From the mid-2000s, the health insurance market has grown rapidly under the union government’s Rashtriya Swasthya Bima Yojana (RSBY), Pradhan Mantri Jan Arogya Yojana (PMJAY), and several similar state schemes. In fact, the National Health Authority (NHA) was created under the NITI Aayog in 2019 with the explicit purpose of managing PMJAY and catalyse market-oriented reforms across the health sector (Sundararaman et al 2021). Healthcare based on government-funded health insurance schemes occupied centre stage in policymaking and as a panacea for all the health-­related issues. In a nutshell, the concept “medical industrial complex” by Relman (1980) captures how the escalation of corporate medical power in every domain of the healthcare industry has taken place in India.

Does it mean that state policy has been linear and straitjacketed? I argue that the Indian state has been aggressively pursuing hegemonic, dominant, market-oriented policies on the one hand, and at the same time articulating community health discourses due to the pressure from below. State health policy can be characterised as “double movement” using Pol­anyi’s framework. In Polanyi’s view, when the state “attempts to create a market-oriented society from [the] above compels a movement from [the] below to moderate its severely dislocating effects” (Corbridge et al 2011). That is, the state straddles between market expansion and countermovement to restrict market expansion. For Polanyi, “the creation of a market economy entails a ‘dual shift’ in state policy, a combination of agg­ressive intervention to extend the play of market forces and expanded social protection, to relieve the hardship of those displaced by the market” (Levy 2008).

The civil society groups have been quite proactive in the health sector and a brief account of this countermovement in contesting the hegemonic health discourse is mentioned here. Comprehensive rural health project Jamkhed in rural Maharashtra, established in 1970, championed a comprehensive community health model with village health workers belonging to the lower caste and local women. Medico Friend Circle (MFC), established in 1976, was a support network for groups of doctors influenced by the ideas of social justice, equitable access to healthcare for all communities, castes, and genders challenged the state’s attempt to turn public health into a purely technocratic realm of expertise and utilitarian calculations (Sunil 2007). Even during the era of intense privatisation in health sector, alternative ideas and people’s health movements emerged; to mention a few, the Mandwa project (Antia 1985) experimented for six years in rural Maharashtra, provided an alternative strategy for healthcare, and highlighted resistance in terms of the rural power structure and medical professionals. Similarly, the Centre for Enquiry into Health and Allied Themes (CEHAT)4 and Jan Swasthya Abhiyan (JSA), est­ablished in 1991 and 2001, respectively, have raised the voices of dissent and advocated the right to health, decentralisation of health services, women’s health rights, gender equity, access to medicines, etc.

During 2004–14, given the coalition politics and people’s health movements, the Indian state launched the National Rural Health Mission (NRHM) in 2005 (along with the Mahatma Gandhi National Rural Employment Guarantee Act in 2006). The NRHM was intended to actualise comprehensive primary healthcare and provide accessible, affordable, quality healthcare to rural populations, especially vulnerable groups. Subsequently, a high-level expert group (HLEG) was constituted in 2011, which recommended universal health coverage (UHC) to achieve health for all. Similarly, the Rajasthan government experimented successfully with a healthcare model of providing free diagnostics and medicines during 2010–14. During this phase, the proportion of people seeking healthcare from public health institutions increased significantly (Pandey 2017). Despite the state pursuing aggressive neo-liberal policies, it launched the NRHM, constituted HLEG for UHC, and experimented with free medicines in the post 2000s indicating the counter-narrative and the movement, from below.

In fact, several progressive legislation and regulatory mechanisms were brought partly because of the pressure from civil society organisations, political expediency, and the imperative for the state to appear “pro-welfare” while not really operationalising it. For instance, the Clinical Establishments (Registration and Regulation) Act, 2010, which defines how much to be charged for each of the surgeries, is an important intervention by the state but corporate hospitals did not follow any of these regulations either before or during the pandemic. Studies point out that public and private interests alike have been complicit in keeping the provisions of this law unimplemented (Nandraj 2015) and that corporate hospitals and diagnostic chains operate on their own terms (Nundy et al 2018). This is true of large unregulated markets in the medical devices sector as well (Datta and Selvaraj 2019; Baru 2018).

The question of how the Indian state can be characterised has been a long-standing concern of the political economists. Rudolph and Rudolph (1987) dubbed India as a “weak–strong state,” one where “demand politics” and “command politics” remained in unsteady equilibrium. The weak–strong state has another essential ambiguity, as Jean Drèze points out, while the state can appear inflated and ubiquitous, it often exhibits scant presence in the lives of marginalised social groups, people living in remote rural areas, or those operating in the vast informal economy (Jenkins 2020). The state has been analysed as a market activist in relation to capital accumulation (Patnaik 2011), as an aggressive market player similar to a corporate entity (Rajan 2006, 2017) and state policy directed only to govern private enterprises (Prasad 2018).

As Antonio Gramsci pointed out, the market and the state were ­always mutually implicated. Gramsci comments on the state and state power saying that the economy in its inclusive sense comprises an “accumulation regime + mode of regulation” and that acc­umulation occurs through “self-valorisation of capital in and through regulation.” Gramsci emphasised that the state was always present in the regularisation of the capital relation. The state has an active role in the organisation of economic relations and class domination, securing the long-run interests of the bourgeoisie, facilitating concessions to subordinate classes, and securing the active consent of the governed and/or effectuating their disorganisation (Hoare and Smith 1996).

As big businesses have gradually strengthened their alliance with the state (Jafferlot et al 2019), I argue that a hegemonic health discourse5 allowed healthcare to be appropriated by the interests of capital, undermining the well-being of the citizens. What are the major trends that have emerged from the growing state–market nexus in healthcare? Based on the available secondary studies, I have discerned three aspects: one, in the 1980s and 1990s, upper and intermediate castes who invested in hospitals, medical colleges, pharmaceuticals, and diagnostics are increasingly taken over by the multinational companies (Baru 2018). This is evident with top hospitals in every metro city in India effectively taken over by foreign capital. It resulted in the cost of treatment getting hiked from 5% every year in the decades of the 1980s and 1990s to 20%–25% now in the 2020s (Chakravarti et al 2021). Second, middle segment—smaller private hospitals below 40 beds, espe­cially one-speciality clinics/hospitals, nursing homes, and small players in the health sector—are losing out and it has been estimated that about 20% closed down during 2019–21. Several charity hospitals in Mumbai have tied up with for-profit hospitals or hospital management companies for ope­rations and management of hospital services.6 In April 2019, Jaslok Hospital, one of the oldest trust hospitals in Mumbai, entered into profit-sharing agreement with IHH Malaysia (Chakravarthi et al 2021).

Third, it enabled footloose corporate hospital chains to function with high-value production and flexible labour markets and recruit paramedical and nursing staff on contract, with lower wages and poor working conditions. The professionalisation of nursing in India was intertwined with caste hierarchy and the stigma associated with menial, manual lab­our str­uctured by class, caste, and sexuality, which is evident in the nursing labour market (Ray 2016). Bisht and Menon (2021) pointed out that a vast array of casual, contract, temporary, and part-time healthcare workers fill the lowermost ranks of the health services. About a million accredited social health activists (ASHAs) in the government sector are not treated as staff, occupy a liminal position in the state, ­belong to Dalits and Other Backward Classes, and are paid poor wages with limited welfare protections (Marwah 2021; Biswal 2018). Thus, conjugated opp­ression7 explains the status of front-line health workers and this is how capital gets serviced and subsidised by ­underpaid care work done both in the public and private hospitals.

Healthcare during the Pandemic

While the public health sector with 27% inpatient facilities was overcrowded and crumbled during COVID-19, the private and corporate sector with 73% inpatient facilities is estimated to have handled less than 10% of the total COVID-19 cases (Sundararaman et al 2021). Realising the limited health infrastructure, a few state governments (Karnataka, Maharashtra) ordered private hospitals to reserve 75% of their beds for COVID-19 patients, rate capping of the treatment and hospital expenses to be paid for, under a public scheme. However, a survey conducted in September 2021 from 2,579 families who have undergone treatment for COVID-19 in various hospitals across Maharashtra indicated that 75% experienced overcharging compared to the official rates. The average medical expen­diture for COVID-19 patients treated in government hospitals was found to be `17,000, while in the case of private hospitals, it was more than five times, costing them `90,000 on average (Corona Ekal Mahila Punarivasan Samiti and Jan Arogya Abhiyan 2021).

The state announced new schemes, pushing the middle and lower classes to depend on private healthcare for their day-to-day needs. For instance, new insurance schemes such as ­Corona Rakshak and Corona Kavach were offered with the directions of the IRDAI in June 2020 (IRDAI 2021). Despite the insurance coverage, it is reported that around 43.5% of the medical cost was paid by individuals from their own pockets (Duggal and Hoodai 2021). A study on the efficacy of the PMJAY in Andhra Pradesh, Karnataka, Kerala, and Tamil Nadu (TN) found that 85% of them have paid for their hospitalisation from their personal savings and borrowings (Jeevan Raksha 2021). Out of the total 2,579 patients surveyed, only 3.8% of the patients (98 cases) received entitlements from the state-sponsored Mahatma Phule Jan Arogya Yojana, which helped in paying their hospital bills (Corona Ekal Mahila Punarivasan Samiti and Jan Arogya Abhiyan 2021). Thus, for COVID-19-affected people, OOP expen­diture was the highest, while health insurance companies’ profits grew substantially during the pandemic, when the larger eco­nomy was declining and in the dumps.

The Indian state relied on its attempts to regulate other actors and outsource critical capacities, especially vaccines. This is quite evident in the way the Indian Council of Medical ­Research (ICMR), a key scientific body of the government, collaborated with a private vaccine manufacturer Bharat Biotech for the production of Covaxin and not with public sector units (PSUs). While seven public sector vaccine manufacturers have the infrastructure and capability to make over 500 million doses of COVID-19 vaccines per year, the Indian state did not make any effort to increase the production capacities of PSUs (Varshney 2021). However, research studies implicate the state and its vaccine policies not just during the pandemic but since 2008, when the Bill and Melinda Gates Foundation was allowed to engineer a shift in research and manufacture of essential technologies, such as vaccines from the public sector to private biotech labs and factories (Srivasan and Rao 2021).

The two private vaccine companies Bharat Biotech and ­Serum Institute of India were able to make COVID-19 vaccines only because of considerable government support and resources (Koshy 2021). The government provided a grant of `4,500 crore during the second wave, to increase their manufacturing capacity. However, the Indian government not only permitted the two companies to set their own differential prices but also bought vaccines at a price determined by the suppliers. This goes to show two things: first, the government’s pricing policy has provided a huge booster to make a quantum leap in profits for pharma companies producing vaccines. Second, the state subsidises research and development with public money only to go on and create an oligopolistic market for vaccines dominated by a small number of pharmaceutical companies on which the state then depends.

Several scholars explained the above trends in terms of a “neo-liberal regulatory state,” which emerged as part of the wider shift from government to governance, thus diminishing the ability of the state to address basic healthcare (Jones and Hameiri 2021; Caduff 2021; Braithwaite 2021). As Raco (2016) points out, fundamentally, the neo-liberal regulatory state involves shifting the implementation and compliance burden away from the state agencies towards the entities being regulated. Where governments once directly supplied public goods and services, now “client-operator contractualism” prevails, with public bodies becoming “negotiators, rather than providers.”

Poynter argues that the main beneficiaries of the rise of the regulatory state have been the large-scale businesses for whom it has opened up new avenues for capital accumulation (Jones and Hameiri 2021). This is quite evident in the way the health sector has emerged as one of the largest businesses in India, with a market size of $194 billion in 2020 and is projected to reach $372 billion by 2022 (India Brand Equity Foundation Report 2020) and received large FDI flows of $50 billion in 2019–20, which was merely $2.5 billion in 2000–01. In March 2021, the total number of Indian billionaires rose from 102 to 140 despite the pandemic and that two of the 10 richest Indians got their wealth from the healthcare sector (Karmali 2021). Cyrus Poonawalla of Serum Institute became the sixth richest person in India and his wealth increased by 74% with the supply of COVID-19 vaccines (IIFL Wealth Hurun India Rich List 2021). Eight of the top 10 richest individuals from Telangana and Andhra Pradesh are pharmaceutical industrialists and their cumulative wealth increased by 54% in 2020–21 (IIFL Wealth Hurn India Rich List 2021)). As Susan Sell (2019) points out, not everyone is looking forward to the end of the pandemic in the same way; it really depends on where one stands in the global distribution of health, wealth, and power and when every bit of public life is being subjected to privatisation.

The pandemic has exposed further fault lines indicating how the state not only promoted the interests of private capital but also increased its authority over civil society, especially the labouring classes, and widened the gap in terms of access to healthcare for the lower castes, women, and vulnerable groups. I have noted three major trends from the pandemic experience here: first, the COVID-19 exception was used by the state to ­bypass the statutorily constituted the National Disaster Response Fund under the Disaster Management Act, 2005 to bring Prime Minister’s Citizen Assistance and Relief in Emergency Situations (PM CARES) Fund, a public charitable trust which is neither answerable nor accountable to the public (Acharyulu 2021). Similarly, it passed three new labour codes where government minimises its regulatory role and reduces its responsibility for oversight (Sood 2021) and three farm laws accelerating the role of big capital in agriculture, commodification of land and labour for the urban capital (Pattenden and Bansal 2021) which were subsequently rolled off in 2021. As Agamben (2005) pointed out, there is a danger of exceptionalism becoming a rule rather than an exception.

Second, during the first wave of COVID-19, the government dec­lared that there is “no data” on migrants, while in the second wave, it claimed “no deaths” reported due to lack of oxygen despite intense suffering and millions of deaths. The government denied any knowledge about the number of front-line health workers who lost their lives, the number of deaths caused by manual scavenging, or the information on the condition of labour during the pandemic (Chisti 2021). Thus, the state abrogated its responsibility and accountability to the public. Foucault’s notion of governmentality helps us understand how and why the state continues to play such a central and constitutive role (Jessen and Eggers 2020).

Third, the upper and middle classes during the COVID-19 realised the individual vulnerability to factors outside one’s perceived control and that one’s health is tied closely to others as much, and the need for strong measures by the state and its institutions. Suddenly, access to a private hospital, health ins­urance, or best of the specialist doctors did not count as they also needed to go through vulnerability and fear like the lower classes. The state was expected to step in but it was not there. The promise of post-liberalisation India was that it would insulate the middle classes from the plight of the poor who cannot access healthcare on a daily basis (Caduff 2021). The lower castes and classes have always known this—that their health is not within their control; that the choice is between drinking no water at all and drinking contaminated water. But their lives have not mattered enough to generate the kind of discussion on state interventions that COVID-19 has raised. The situation is exacerbated by structural inequities of caste, class, gender, geography, and community in India that translate into health inequalities and are amplified by the state of the health system (Patel et al 2021).

Quest for an Alternative: Countermovement?

Can “post-COVID-19” rip open the possibilities of the other world? If so, what alternate pathways does it open up? A glimpse of historical events indicates that crises have shaped the history of several nations. For instance, the global flu epidemic of 1918 helped create national health services in many European countries. The twin crisis of the Great Depression and World War II set the stage for the modern welfare state. At the end of World War II, as a battered Britain scrambled to regain its economy and heal the trauma of its citizens, William Beveridge instituted a public health system that led to the establishment of the National Health System (NHS), where high-quality medical services are provided to all citizens by the state. Of course, one is not romanticising the British NHS as one needs to take the ideological context when it was brought in the late 1940s. With Lansley reforms, huge structural changes have taken place even within the NHS in the last 10 years. Critics point out that the British NHS is also increasingly getting oriented around private providers, private insurers, and market structures for allocating resources (Legge 2018; Singh 2021).

As the pandemic has exacerbated the inequalities and the inaccessibility to healthcare, whether and how personal and collective insecurities of the subalterns associated with contemporary capitalism will give way to a countermovement/discourse? Arundhati Roy (2021) points out:

Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And be ready to fight for it.

COVID-19 provided concrete experiences and the need to strengthen government healthcare. Successful integration of local government into the healthcare system—Kudumbashree, a decentralised government healthcare service in Kerala—have translated into a more effective overreach, timely testing, early case detection, and more rational treatment for COVID-19 patients, which together reduced fatality rates. Similarly, TN’s efficient healthcare model lies in the efficiency gains resulting from separate and well-organised approaches to public health and medical care. Several studies indicated that effective public health services reduce the need for (expensive) curative services resulting in better value for public expenditure on health (Choudhury et al 2021; Dasgupta et al 2010).

Recent studies also provide evidence that strengthening the public health system does help achieve equity and social justice. Based on their analysis of the National Sample Survey Office (NSSO) 71st round and for 2017–18 (NSSO 75th round), it is pointed out that there is a significant increase in utilisation, especially by the poorer sections of ­society, of public facilities for both outpatient and inpatient services. As a result, there is a consequent fall in the overall financial burden8 on patients who would have otherwise used the services of private healthcare providers. If government health expenditure and access to government provision of health services increases, there could be a significant shift of patients from private providers to public ­facilities and a dramatic fall in OOP expenditure and catastrophic health expenditures (Muraleedharan et al 2020). Can Kerala, TN, and Rajas­than’s free diagnostics and medicine models be emulated on a national scale? While the healthcare model of these three states is also distorted with increased preference for hospital-based tertiary care rather than primary healthcare in the last two decades, which is evident during the pandemic (Chathukulam and Tharamangalam 2021), there are several components that can stand out for scaling up and reimagining national health services.

Pushing aside these experiences and evidence gained during the pandemic, the Indian state is more inclined towards stre­ngthening its capacities through corporate outsourcing and dependency on private companies, and third-party agencies. This can be seen in terms of two broad trends: one, the NITI Aayog; the government think tank sees COVID-19 as a prime business opportunity to be exploited in the hospital segment—the exp­ansion of private players to tier two and tier three locations, beyond metropolitan cities, offers an attractive investment opp­ortunity. It suggested running district hospitals on the public–­private partnership (PPP) model, and that all states allot part of state-run hospital’s space to private players on a 30-year lease for setting up facilities with 50 or 100 beds. The NITI Aayog justifies involving private players for the sake of reducing the burden of non-communicable diseases (Sarwal et al 2021). As part of the Atmanirbhar Bharat Package, the government approved financial support to PPPs under viability gap funding, where hospitals can be set up in tier-two and tier-three cities, supposedly, for the wider insurance coverage of the poor and medical colleges to address the shortage of qualified doctors.

Proposals for handing over public hospitals to private operators and establishing new hospitals and medical colleges only on commercial lines will have deeper ramifications, especially the public health services, which were hitherto free of cost, would begin to be charged (Shukla 2021). Apart from hospitals, an array of allied health services like diagnostic centres, which range from the local level to the chain of corporate diagnostic centres, operate through franchise networks across ­India, pharmacy, ambulance services, and small organisations which provide specialised paramedic professionals on-demand, have mushroomed. Van der Zwan (2014) calls this process “fin­ancialisation of the everyday,” which includes “a shift towards financial markets for the provision of people’s basic needs.”

Second, the state is increasingly moving towards insurance-led healthcare, supposed to increase access and reduce catastrophic health expenditure. This is evident with central and state governments increasing health allocations towards ins­urance schemes during the pandemic, leading to reduced spen­ding on primary and secondary care and increased hospitalisation in the long run. For instance, Choudhury et al (2021) point out that in Andhra Pradesh, about a quarter of the health budget is directed towards insurance schemes leading to a slowdown of expenditure on primary and secondary healthcare services. There has been an increase in OOP expenditure on inpatient care, which is partly driven by the latent demand for hospitalisation.

Towards a Conclusion

This brings to the fore a central question: How should healthcare be reorganised in India and what experiences do we learn from the pandemic? Two contradictory discourses are at play in the current moment: one, the state accelerating the interests of capital by strengthening the health markets in myriad ways using the pandemic as an opportunity; second, counter-hegemonic health discourses getting articulated, but voices of the margins are not so effective. In strategising this, Gramsci pointed out that a head-on assault on the state and the hegemonic elites that hold it may not work. He distinguished bet­ween the war of manoeuvre, which is a full-blown attack on the institutions of hegemony, trying to seize the state on the one hand, and the war of position, which is a long-range contestation for ideological hegemony and is a gradual process taking place on many fronts (Hoare and Smith 1996). A war of manoeuvre may succeed in overthrowing the current hegemony, but if its impact is to last, and a new hegemony is to be forged, it requires the organisation of widespread consent, only achi­evable through a prolonged war of position within civil society. Indeed, the challenge lies in building consent among different civil society organisations whose visions are diverse.

The experience of the pandemic has made two things clear: first, the role of the state and its intervention are critical for any improvement in the health status and well-being of subaltern classes. It was evident that the public sector could mobilise vast resources in times of crisis. Therefore, the state should ­focus on provisioning rather than restrict its role merely in fin­ancing care, contracting services, and negotiating reimbursement with private providers. Second, with the corporatisation of healthcare and insurance-led healthcare models, increased financialisation of healthcare has spiralled OOP expenditure, for the lower and middle classes, beyond limits. Hence, civil society organisations should not confine their role to policy-related issues, rather they should build broad-based democratic movement making healthcare a political agenda. The question here is whether and how a coalition of caste, class, and gender from the subaltern classes gets constituted to take the war of position to engage the ideological as well as the political struggle to advance the counter-hegemonic movement in India.


1 Takes in the human consequences of war, famine, depression, disease, torture—the whole assemblage of human problems that result from what political, economic, and institutional power does to people and, reciprocally, from how these forms of power themselves influence responses to social problems (Kleinman et al 1997).

2 The WHO estimates that 62% of the total health expenditure in India is OOP which is among the highest in the world.

3 Refers to the process of establishing hospitals as corporations or companies; private companies investing in healthcare for increasing profits and dividends to shareholders; entry of publicly listed companies in setting up of hospitals or listing of hospitals on stock exchanges.

4 Is a research centre which facilitates diverse activist groups.

5 Gramsci’s concept of hegemony pertains to the condition in which the dominant classes utilise the state to both coerce and at the same time achieve consent to their dominance within civil society. In the health sector, it implied how ruling classes maintained their authority and power by promoting curative over preventive and most medical interventions routed through inpatient care (hospitalisation) in the multispecialty tertiary care institutions rather than comprehensive primary healthcare leading to commodification of body and health.

6 Some prominent examples are: Nanavati Hospital has linked up with Radiant Lifecare, a hospital management company with foreign private equity investments; Raheja Hospital has tied up with Fortis Healthcare; Masina Hospital with Apollo Health Enterprises Ltd; SRCC Children’s Hospital with Narayana Healthcare; Ambani Hospital runs Malti Vasant Heart Trusts Hospital; Parsi General Hospital taken by Medanta the Medicity Global Health Pvt Ltd.

Lerche Jens and Alpa Shah (2021) point out that social oppression and exploitation along the lines of caste, tribe, ethnicity, gender, and class are inextricably linked as different sides of the same coin.

8 Increased cost of medical care is the second most common cause of rural indebtedness in India.


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Updated On : 5th Jun, 2022
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