Public health privatisation in Bengal

August 29, 2008

By Indira Chakravarthy, Guest Contributor.

As a complement to Dipankar Basu’s piece on the “achievements” of the CPM government in West Bengal on the economic and social fronts (, I would like to share a few facts/concerns about the health status of common people in W Bengal. Using publicly available data, Dipankar had demonstrated that West Bengal’s growth story was rather unspectacular when compared to other Indian states. Now, I would like to raise a related but different question: has even this below-average “economic growth” translated into improvements in the social sector for the common people?

The CPM government of West Bengal could have shown the way in public health. However, in spite of having had a so-called Communist government ruling the state for nearly three decades, the situation regarding not only health status, but also health infrastructure is no different from what it is in the rest of the country. Let us bear in mind that health is a state subject, and so the buck cannot be passed on for the dismal `state’ of affairs.

It needs to be pointed out that `better than the national average’ scores on several indicators of health status hide immense within-state variation. While the Infant Mortality Rate (IMR) and the Maternal Mortality Rate (MMR) may be better than the national average, however there are large intra-state variations across districts and socio-economic groups. To give an example – poorer districts such as Purulia report IMR two-three times those of districts near Kolkata. Also, the `achievements’ of the state stand no comparison with our smaller neighbours like Sri Lanka. Sri Lanka has an IMR of 13 and MMR of 0.92 (per 1000 LBS), and literacy rate of 90.4, and is in any case ahead of India in the HDI ranking, with far better public health provisioning. Not to mention that many non-communist welfare states across the world have ensured availability of basic education, water, health facilities for their population.

As is the situation with the union and the state expenditures, in West Bengal too the level of public health expenditure is very low, and has been declining, at just 0.8 % of state GDP. As in most other parts of the country, provision of drugs in public institutions is inadequate; there is lack of doctors, specialists and support staff at the Community Health Centre (CHC) level as well as other levels of health services; maintenance and utilization of building and equipment is poor, and so on. As in the rest of the country, such inadequate public provision has led to ad hoc growth of a large, unregulated private sector in the state.

As in many other states, the West Bengal government too resorted to World Bank loan (Rs 701.46 crores) in 1996 for state health systems development project (SHSDP), to improve secondary level health infrastructure. Just like in other states, the funds under this HSDP were not utilized properly; procurement and supply of medical equipment without assessing their requirements has led to idle and dumped medical equipment worth at least Rs 55 lakhs in several hospitals in the state, and has thus led to wasteful expenditure of loan money that carried an interest burden.

We also find that the `Communist’ government has not instilled, or brought about any different culture and values in the functioning of the state health department. The extent of depravity of the system can be gauged from the following shocking incident that took place in Kolkata some time ago. A woman visiting her mother in the mental hospital at Kolkata found all the women in the ward, including her mother, were without any clothes on. The brazen explanation from the staff – “their clothes had been sent for washing and there was no spare set; in any case what difference did it make whether or not these `mad people’ were clothed” – though it shocked people at large, led to hardly any long-lasting changes in the regular functioning of the health care personnel in the State.

While all this may not really come as a surprise or news to some of us, what is really disurbing is the manner in which the ruling Communist government proposes to improve the situation. Apart from availing of World Bank loans, like all the other states in India, in West Bengal too World Bank and other donor-led `health sector reforms’ (HSR) are the preferred tools for improvement. Among externally aided projects there were also an EC funded reform programme – Sector Investment Programme (SIP) in the state. It needs to be mentioned here that several (public health) intellectuals sympathetic/belonging to the CPM had opposed WB-policies and intrusion and all these reforms in the health sector in the 1990s (on paper at least and from various fora). All over the world the drastic impact on the poor of the HSRs, initiated by the WB as part of Structural Adjustment Programmes (SAPs), have been documented and decried as a way of bringing in private interests into the publicly funded health sector, and commoditizing health provisioning.

While the earlier `health sector reforms’ have not led to any significant `improvements’ (whether they could have at all led to any improvements is a question one is not going into here), the state government, in 2005, has drawn up another Health Sector Development Initiative (HSDI), this time involving the World Bank and DFID (Department of International Development, the bilateral assistance wing of the UK government) – basically another multi-donor health sector support programme.

So, West Bengal can be now credited with `leading the way’ on the health sector reforms that have come in for criticism from many quarters, not always just the left. Two of these are worth mentioning: (1) renewed emphasis on user charges in public hospitals in the state that were introduced around 2001, and (2) using `public-private partnerships’ for delivering health services.

As far as development of primary level public infrastructure for health is concerned, the West Bengal state government is categorical that the emphasis would be on consolidating and upgrading existing infrastructure rather than proliferating `ill-equipped infrastructure’. For instance, it will not add new Primary Health Centres (PHCs), which are the first referral points for rural areas where doctors and some rudimentary medical services are made available. This logic conveniently bypasses/ignores questions as to why, in the first place, this infrastructure was not set up in all these years, and why are they still ill-equipped and dysfunctional?

Three things need to be pointed out regarding the role of user charges in public facilities. First, experience from other states in India indicates that user charges cannot in any way bring in resources for health services; seond, in many places (including urban hospitals in Kolkata) they (funds collected through user charges) have not been utilized at all for patient welfare but have been lying in bank accounts of health department officers. Lastly, user fees have led to poor patients being effectively prevented from accessing much needed medical care in states like AP, Punjab, and Maharashtra. While the AP government was compelled to withdraw the user charges it had introduced, the `pro-people’ West Bengal government proposes not only to continue with user charges but also to streamline and revise this system further as part of its HSDI.

In fact – the HSDI document goes so far as to say that – it is not feasible to sustain the drugs budget, although free supply of essential drugs and services is an avowed policy of the state government. It therefore needs to `review the policy of free drugs supply’. As experience shows that free drugs seldom reach the people it should, and the system breeds corruption, it proposes that `essential drugs be supplied free to only BPL ration card holders; all others must pay for supply of drugs’. Even on the issue of free supply to BPL population, it states that `Ultimately, PRIs will have to share with the state government the responsibility of free supply of essential drugs to BPL families through community drugs bank and community funding. It would never be financially feasible for the state government to bear the entire fiscal burden of providing free drugs to population below the poverty line at the required level. The community funding for that matter can play a critical role in supplementing public expenditure on drugs………’.

As far as I know, West Bengal is the only state so far to have a clear policy on developing public-private partnership in the health sector. It has gone in for large-scale privatization of laboratory and diagnostic services, for supply of `fair price’ drugs and accessories in government hospitals, all the way up to the rural health centres (PHC) level. And now, in order to `enhance the quality of medical education and strengthening tertiary health care, the government has decided to involve reputed specialists in private sector working in India and abroad as consultants. From the automobile-led industrialization program to the `improvement’ of the health sector in the State, the West Bengal government’s faith in the private sector seems to be growing at a phenomenal pace.

1 Comment »

One Response to “Public health privatisation in Bengal”

  1. Mike Cooper Says:
    January 8th, 2011 at 12:36

    I work for an urban Indian NGO that treats for free 60k patients anually,acting by default as an outpatient department for govt hospitals, and is a model for a cheap health delivery service at the annual average of 570IR per patient (this includes two schools, and two handicraft projects) the model is replicable at minimum cost anywhere given a minimum supply of doctors, nurses and pharmaceuticals. How far do you think a State Government would be interested in a partnership arrangement to roll out the model on a wider scale?

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