OOP health expenses of Indians growing alarmingly

Even before the regional advisor of WHO, Dr. Kathleen A Holloway, sounded alarm on the ballooning out-of-pocket (OOP) health expenses of the average Indians and the direct relation of that fact with the progressive/catastrophic pauperization of the Indian population, the planning commission has apparently acknowledged the scenario (TOI, 2 NOV 2011). The commission has admitted that about 39 million Indians are pushed to poverty (below or close to the poverty line is a matter of debate as there is no consensus in this country yet about this ‘imaginary’ line). A LANCET article estimated that as many as 30% of rural population and 20% of their urban counterparts could not access medical care, during the year 2004, due to financial constraints.

Analysing NSS data on morbidity and health-related expenditure from 1980s till about 2005 it has been shown (Selvaraj and Karan, EPW, 3 October, 2009) how the public expenditure has progressively dwindled significantly over the years. It was estimated by the authors that more than 80% of Indians end up with private cancer treatment facilities and of them more than 90% meet the expenditure for such treatment OUT OF THEIR OWN POCKET. The TOI article mentioned above cites a statistics that about 47% and 31% of hospital admissions in rural and urban India, respectively, were financed by loans and sale of assets. These figures are roughly consistent with the WHO estimate of about 70% Indians having to meet their health expenditure from their own funds (by beg-borrow-sale route, stealing and other similar means may not entirely remain in the realm of movies in future). The trend in progressive reduction in government spending on purchasing drugs and other support to the public health care system is borne by cold statistics (TOI article as above).

By a detailed survey (conducted during 2006-2007) of the economic cost burden on ‘poor’ people (average monthly per capita household income of Rs 1835/-) suffering from a critical illness like cancer and having accessed significantly ‘cheaper’ treatment in a government funded medical facility adjunct to AIIMS, New Delhi, Mohanti and others (EPW, 22 October, 2011) have found that the overall OOP expenditure for a typical 5-7 week radiation therapy was between 330-450 % of their monthly family income. This was apart from the expenses on diagnosis and other complementary treatments like surgery or chemotherapy. It is important to note that about 60% of these expenses were on transport and food (possibly including those required by the supporting family members and relatives). But still 40% of the expenses which are purely medical are not borne by the government but by patients and the families. With the ideological lurching   towards reducing the government support to all kinds of public services these expenses can only grow with potential penury and destitution looming large.

Drug prices escalation potential in India, senior citizens beware

Drug prices are of significant interest to the senior citizens everywhere including India. Being on the margin of the society especially in urban India, the old denizens cling desperately to the medicines prescribed by their doctors for continuing their tenuous toehold on life and thereby fighting off their shrinking sense of autonomy. That the expanding medical bill would be a fait accompli in their twlight years was clear to many since India became signatory to the TRIPS agreement and accepted product patent regime in the mid 1990s. Under this regime, Indian companies are no longer legally permitted to manufacture a drug whose main active component molecule or a combination thereof are being sold as a patented drug under a brand name. Not only the same molecule but even minor structural or compositional variants that may have remotely similar medicinal properties – the so called generic drugs – can not be made by indigenously developed manufacturing technology with a significant price advantage. The ‘reverse engineering’ credo employed by the protected Indian pharmaceutical companies pre-1990s which had allowed these Indian companies to produce a large number of generic drugs at affordable prices and make them available in the country as well as export profitably in the foreign markets (particularly in the third world countries), had to be discarded. Simultaneously, the price control exercised by the government was also relaxed to promote competition. From the 347 drugs in the list of essential medicines as in 1995, it had come down to about 37 as of now. As a result of these policy changes the prices of most medicines (for diseases spanning routine infections, ones related to lifestyle changes, as well as those for critical illnesses like cancer and HIV) in the retail market, where you and I buy medicines, have shot up appreciably.

As they say all ‘good’ (for the foreign multinational companies) things come to an end, the patents have a seventeen-year life of monopoly protection. Many innocent thinkers (think tanks in the government, academia and industry) during the early years of this century dreamt of resurgence of manufacture of the generic versions of many drugs coming out of the shadow of patents by the indigenous companies vis-à-vis many common and critical diseases that would help reining in the escalation of costs of health services borne both by the government and the individuals/insurance companies. Indians wishfully propose, MNCs dispose with firmness and remarkable deliberateness. There was this famous case of Novartis a few years back, wherein the company tried (though unsuccessfully) to extend the patent protection for one of its branded drugs beyond the initial period by trying to secure a fresh patent on a replacement drug molecule obtained by a mere tinkering of the originally patented molecule. What is more recently being discerned as a notable trend is the spate of successful bids for take over of major pharmaceutical manufacturing companies by MNCs (The Hindu, 3 September 2011, knowledge@wharton Today, 24 August, 2011). This happened under the government’s liberalization policy over the years of allowing 100% FDI in the pharma sector. As it has been argued in the articles cited above, the indigenous manufacturing infrastructure having come under the MNC leash the priorities may be reconfigured to producing blockbuster patented drugs for the rich developed countries rather than manufacturing cheaper generic drugs for the multitudes in India and the poor third world countries.

It is in this context that the public discussion (TOI, 30 October 2011) of a new ‘possible’ policy of the concerned government to introduce price control on a large number of essential medicine, bringing out a new national list of essential medicines (NLEM) and revising the Drug Prices Control Order (DPCO), 1995 make interesting reading. DPCO, 1995 having pruned the original list from 347 items to 74 (further watered down to the current number 37). It is being proposed to revise list in the light of developments and availability of new drugs and increase this number to 348. There is apparently a proposal to redirect the FDI investments to ‘greenfield’ (new product manufacture in new facilities) from the tendency make the so-called ‘brownfield’ investments (i.e. acquiring existing companies).

This is only a draft proposal and first the cabinet and then the empowered group of ministers (EgoM) have to debate and approve it (in the teeth of resistance from the pharmaceutical industry bodies). It is well to remember that such government initiatives to lay down new policy had not been successful twice (challenged in court in 2002 and again stuck in the EgoM in 2006) without success.

Postcript to the left front debacle in West Bengal

 

Two residual questions :

(a)    LF still polled 41% of the popular votes in an election that everybody agreed has been conducted in a fair and acceptable manner. The overall vote percentage all over the state has significantly increased. As usually reticent and even cynical voters might have exercised their votes this time, young newly eligible voters, without either the ideological baggage or a political opportunism, hatred and vendetta, carried their weightage too in a critical balance flipping game, did the LF at all derive any benefit out of this surge ? If not, this 41%, not a small number by itself, represents a solid unwavering support base for the left parties. What do they expect from the parties they had supported even under these hostile conditions probably at great personal risks (validated by the daily events of bloody vendetta by the ruling party supporters) ? The left parties should humbly reach out to this natural resource if they have to survive politically or otherwise.

(b)   To say that the vote against LF played a bigger role than the vote for TMC/Congress combine is no-brainer. However, there must have been some key expectations of both the traditional anti-left constituencies in the state and the sizable ‘adjustable’ segment of voters (who played the arbiter of the election results) from a new government formed by an alliance of parties and colourful individuals who were so far known for their demagoguery, hate speech and pandering to perceived persecution and injustice rather than articulating a coherent policy for the economic renewal of all sectors of the state. What are the changes these sections expect the government to initiate ? Accelerating liberalisation and industrial development (and not touching the interests of the peasantry ) ? Rejig the land relations in favour of the dominant farmers with political clout at the cost of share croppers and labourers, especially those painted with a colour remotely resembling red ? Replacing your favourite cultural and educational elites with a set of mine ?

Such questions must await detailed unbiased analysis of the facts and trends to be unfolded in future.

Withering left front in West Bengal : maladies closing in

Endgame

In the mean time the Berlin wall had fallen. The sense of loss could not have been felt more keenly anywhere in the world. A decrepit regime had fallen after a lot of bravado and pretenses and belying expectations of generations. Was there an object lesson here, asked the more perceptive intelligentsia some still empathising with the left front (LF) government ? But the voice of reason emphasising the need for introspection and course correction did not find favour with the left establishment which more and more was being overrun by opportunists and gradually by people with corrupt and even criminal backgrounds, at various levels of the parties, having a stake in perpetuating themselves at the helm for any but altruistic reasons. The moral ascendancy of the left was seriously undermined in the eyes of a whole lot of left sympathisers. The natural immunity against political incumbency was all but lost.  

Finally, the centrally sponsored liberalization and the eventual globalisation agenda having won the day since 1991 West Bengal found itself in a perilous competition with the center and most states in the country for which the state was ill prepared. Being presented with an alternative path for economic growth and well being embraced by the country, with spectacular results at least in some states, regions and cities detailed daily in the print and the television media, the sense of being left out in this new growth scenario was unavoidable for most Bengalis, more so for the articulate middle class intelligentsia. Desertion of the ship began in right earnest. Looking for better opportunities (education, job, material gain) anywhere in the country or even abroad became the norm. With growing interaction with other places, people who ventured out brought new perspectives and these in turn provided further centrifugal pull against the inertia of the ungroomed. Most sections of Bengalis felt an urgency about acquiring material prosperity and a quality of life they felt they were entitled to, being enjoyed  by people elsewhere in the country and which they were long deprived of. How best they could compensate themselves and their children for the lost years was what occupied them more than the morality of the liberalisation and the naked exploitation that this would eventually entail and the lurking imperialist design behind the globalisation programme. No wonder Karat and co’s strident anti-American rant did not cut any ice with the voters during 2009 loksabha elections. This was a classic demonstration of the disconnect of the party from the people, though as a trend this was discernible earlier.        

It was only a matter of time that the left front had to fall like the Berlin wall twenty years ago.   

Roots of malady of the left rule in West Bengal (contd.)

Stagnation in agrculture, lack of industrial development and the government policy lurching to the opposite extreme of potential expropriation of peasants of their land, disconnect with the Muslim vote base were all important causal factors in preparing for the ensuing electoral upheaval. But there was probably another little appreciated reason for the debacle.

Demise of Ideology

The Bengali intellectuals and the articulate elite have almost always taken to leftist ‘ideology’ as fish in water. Even if this ideological affinity has often been based on very superficial understanding, this used to be considered a given till possibly mid 1980s. A democratically elected left-oriented government was almost a popular expression of the ardent idealism of a large section of the urban intellectuals, artists, writers, theater and movie artists, singers and of course the general consumers of the cultural products. Many of them spent their youth and much of the adulthood in the fond hope of waking up in a city, a state which is ruled by people of supposedly socialist (if not communist) persuasion - a group of earnest people, who grew up within this milieu sharing the idea of uplifting the condition of the peasants, workers, urban poor significantly within their lifetime. There was a strong (pathetically naïve in the hindsight) moral underpinning to the Bengali intellectual’s sentimental and somewhat uncritical attachment to the ‘left’ ideology and all its baggage. Left’s was a righteous path. Also it had to happen in Bengal (“what Bengal thinks…” etc), with all its post-independence record of popular, secular and anti-establishment political agitations for all the right causes.    

The beginning was suitably spectacular : land-reforms (however limited) with at least a modicum of redistribution of land, release of political prisoners including the extremists who were bitter antagonists to the ruling parties not long ago, freedom of agitating for their economic demands for the industrial workers and so on.

But the plot was undergoing subversive changes even during the first decade of the LF rule. The strain of not living up to the claims of completing the unfinished task of bourgeois democratic revolution was telling. The task of catering to the practical needs (food, shelter, health, education, employment) of the broad populace within the confines of a state as a part of a federal structure (with an obviously indifferent if not partisan central government, itself mired in growing financial insolvency) was not getting any easier. Freedom to agitate, strike work was degenerating into labour indiscipline and diminishing work ethic and thereby leading to headline-grabbing flight of capital from the state. Government seemed nonplussed, had stock parrot like responses (like blaming the central government for all ills), offering, as far as possible, only blind eyes and ears to loss of work ethic among the vast army of government employees, police inaction and/or brutality, growing crimes (including significant rise in political murders), human rights violations. Left parties, CPM in particular, were more seriously engaged in perpetuating themselves, often by devious means not excluding outright bullying, even indulging in electoral malpractices in some areas, making disingenuous propaganda against the enemy without (often the central government, inimical foreign agents, media houses), rather than looking inward at the deficiencies at the party and the government levels and looking for an innovative way out of the growing mess. A broad section of the ordinary middle class people, many of them left sympathisers, educated and the urban elite, artists and intelligentsia came to be rubbed in a wrong way by the bulldozing party apparatchicks in the field of education and culture, the latter exercising an effective, almost ‘totalitarian’, control of many of the associations or organizations in these fields and dispensing selective partisan favours).

Pre-eminence of the party and the manufacture of the consent

Post 1977, the CPM, on its part, was largely content with entrenching itself in the new vote catchment areas (short shrift to the ideology at the alter of expediency gave ‘politics’ its dirtiest meaning), expanding membership in an indiscriminate manner. Using this growing political influence as the make or break in many aspects of their daily life the majority in the rural Bengal were gradually ‘won’ over forming a captive vote bank for many years to come.

To partly circumvent the stagnation in the economic growth and opportunities, both in rural and urban areas on governmental as well as non-governmental initiatives there was some spread of small scale informal economic activities (“informalisation of the economy”) in many parts of the state. Fruits of these initiatives were distributed, controlled at the lower working levels by the party and the distribution was based on the carrot/stick principle (patronage for those who would support the party, threat for those who wouldn’t). It is conceivable that for years this was probably one of the main mechanisms operative behind the subtle manipulation of the consent in favour of the government.

Roots of malady of the left rule in West Bengal

Agriculture : success/failure

From all accounts, the left front (LF) generated substantial goodwill in the early years (land reforms etc), though subsequently, government initiative in agriculture was not much more than a holding operation. The aspirations and the growing economic needs of the rural masses who were, ironically, unfettered by the early land reform related steps were held in check by the lack of follow up actions by the government in terms of massive agricultural development. Apart from fund crunch, lack of financial help from successive unfriendly/indifferent central governments, wasn’t there a positive lack of imagination at the government as well as at the party levels as to what the newly assertive peasantry, share croppers, landless labourers would need in order to sustain themselves and grow, given the reality of small and fragmented land holdings, high input costs, lack of markets for the produce.

Agricultural decline and LF’s lurch towards industrial revival via classic capitalist path

Despite limitations, West Bengal’s agricultural growth was possibly among the better ones in the country over the years, acknowledged by people like Swaminathan Ankleswaria Iyer (Time of India 22 May, 2011), not a great friend of LF or the Communist Party of India, Marxist (CPM). There were much fewer debt-related and starvation deaths (though the number of cases of under-nutrition was not necessarily miniscule) in West Bengal (WB) in comparison with Maharastra, Orissa or Andhra. But this growth story was clearly coming towards an end with the population growth and the dependence of the growing rural population on the land produce alone was becoming unsustainable. By 2006, some wise men in Bengal CPM must have realized this and wanted a way out : embracing massive industrial development, even at the cost of a prime agricultural asset, land, which, anyway, was appearing to become unremunerative. After a resounding electoral victory, feeling a little self righteous, this part of the leadership of the ruling party/parties including, most notably, the chief minister, decided to bite the bullet and chose a path that came to be associated with and portrayed by LF detractors as a new drive for the ‘primitive accumulation of capital’.

A government sworn to protect the interests of the working class and the peasantry was assailed by a growing popular perception of worst collusion with the industrialists/businessmen. The chief minister and his industry minister did not seem to appreciate the need to communicate the path forward to the rural masses who would be the most affected. The LF appeared confused and somewhat divided though outwardly the differences were papered over and went along with a chief minister who led it through a successful electoral process in 2006. After the start of the tailspin since the 2009 loksabha elections one has heard plenty of ‘sorry, made a mistake’ kind of perfunctory confessionals from many related quarters, but during 2006-2008 when the new ‘industrial policy’ was being experimented with not many contrary voices were heard. 

 

Muslim vote

Another important factor in the last election was the Muslim vote, which represents a significant share in the electoral pie. Traditionally, Muslims have been staunch supporters of LF and these relationships of mutual trust and friendship grew over years of secular support that left parties have provided for the Muslims. The secular credential of the left parties was testified by the fact that West Bengal had not had any communal clashes worth mentioning in all these decades of LF rule even while many parts of the country convulsed in communal tension during and after 1992 Ayodha kand. However, in terms of the economic progress as a group, vis-à-vis other groups or communities, Muslims in West Bengal have fared worse than they have in most parts of the country, if the Sachar Committee’s findings are to be believed. Despite feeble protestations and some contrary figures, these observations had struck a cord with the popular Muslim perception.

Many commentators have routinely mentioned about the LF government’s open alignment with the clergy and the conservatives among the Muslims in the case of the externment of Taslima Nasreen from Bengal (which became an emotive issue with many Kolkatans and other liberal intelligentsia). Add to it the shabby treatment (bullying) of Rizwanur, an upcoming Muslim youth trying to break the glass ceiling, by the state police (in collusion with a businessman/industrialist with some clout with the administration) leading to his tragic death/suicide. These events no doubt were construed by Muslim voters to indicate growing indifference of the LF government towards the sensibilities (intellectual and emotional) of one of its important constituencies.

Finally, perhaps the potential threat of expropriation of land in Singur and the proposed land acquisition elsewhere for fast-track industrial development was taken very seriously by the Muslim peasants in some parts of West Bengal (especially in Nandigram making it the flashpoint), active inciting by the TMC, the Maoists and the fundamentalist groups notwithstanding. There was an inevitable perception of the state acting with unseemly haste as a facilitator for the thinly disguised land grab on behalf of the big industry.  This was considered as an additional evidence for the growing disconnect between the ground level needs and aspirations of the Muslim peasants and the insensitive LF government who were plotting to take away their primary assets by outdated edicts and without adequate compensation.

The spectacular demise of the left rule in West Bengal (India)

Like many others concerned about West Bengal (WB), one could not, in the context of the resounding loss of the left front (LF) in the May 2011 assembly elections, avoid pondering about the key factors that undermined the long standing left rule in WB.

Trinamul Congress (TMC)/Congress leaders, sympathisers as well as a host of commentators in the media have had a clear prognosis about the endgame since 2009 parliamentary elections. Nobody other than die-hard LF supporters was left in doubt about the rot and debility in the government administration and the despondency enveloping the party organization at various levels.

What were the roots of this malady and the trajectory of its growth ? Was it a post 2006 election development or rather a work-in-progress over the three decades of the LF rule ? Many commentators (e.g., Sumanta Banerjee, EPW June 4 2011) have pointed in that direction. But then how did they manage to stay in power this long despite growing anti-incumbancy ? Beyond TMC’s hell raising claims about electoral malpractice by CPM/LF, vote splitting due to non-alignment of non-left forces there must be some substantial reason for the remarkable electoral success of the left all these years and the spectacular failure this time. 

Urban votes were probably always more evenly partitioned between LF and non-LF categories. When and how did the rural vote banks of LF collapse ? If the rural masses (and even a decent section of urban voters) were ‘solidly’ behind LF even at the time of 2006 elections (their vote share was a little over 50%), what happened during the next 2-3 years to cause a tectonic shift in this support base (2008 Panchayat elections were the early evidence of this shift). Is it possible that the misadventure, mismanagement and miscommunication at Nandigram and Singur were like straws on the camel’s back pulling down this illusory and waning support base like a pack of cards ?

Have been thinking about the roots of the malady and the spectacular demise. Watch this space for more on this subject ...