 Hello and welcome to NewsClick. Today we have with us Dr. Amit Sengupta from Janasastra Abhiyan discussing the draft 12th five-year plan on health. Amit, recently it has come out that the draft the 12th five-year plan on health seems to be a sharp departure from earlier health policies of the government. How do you characterize this major shift in the plan document? I think the major issue that one needs to be very concerned about in this document is that for the first time in a public document, we are talking about what is called managed care. Managed care that is going to be financed by the public sector, by government finances and is going to be provided for largely by the private sector. This is the international definition of managed care. This is what for example you have in the United States. Now while over the years we have seen the growth of the private sector in India, we have seen a decline in public finances, a decline in health infrastructure, but nowhere before have we articulated it clearly that now the government is going to hand over health care, clinical care over to the private sector, not just to the private sector, to the corporatized private sector. So that is the major departure, it is an ideological departure. It is not just a technical issue that we are talking about, it is an ideological departure because it is in sync with what the government is doing in various other sectors. This is the first time that they are doing it in health and putting it down in black and white. But health is significantly different in one respect because effectively the person who seeks the health care does not really know what he or she should get. Effectively, he or she is completely in the hands of the system in which she goes and therefore they decide how much expenditure is really going to be incurred. Yeah, that is precisely why if you look at the market economy countries across the world. Even where they have market principles working in various other sectors, the health sector is something that has always been kept out. So across Europe for example, Japan, public financing and some form of public provisioning of health care is the norm. It is not the aberration, it is the norm. United States is actually the only real exception in market economy countries where you have such a large private provisioning and financing of health care. And by all accounts, the health system in the United States is the worst performing among all developed economies in the world. It has for example, parameters which are worse off than Cuba which spend something like one hundredth of what the Americans spend on health care per capita. So that is really the kind of mess you get into which the United States has got itself into. If you really sort of use the managed care model because precisely that there is a logic of health system. There is a public logic of health systems and there is a logic that the private sector uses in health care. The public logic of health systems is that you need to keep people healthy whereas the private logic is that the more people fall sick, the more money you make. So it is impossible to combine the public and the private logic and believe that you will have a health system which has both private and public players. What you are saying the logic of the market is against the logic of a healthy nation. Absolutely. The market really does not apply to health. No, it applies to more disease. Yes, it applies to actually producing situations where you promote disease. I mean, you can actually see that happening. I mean not just in the United States or elsewhere but in India that today if you go to the private sector, there is a battery of investigations that you would be subjected to. I mean, it may seem an exaggeration but it is not so that you can go with a simple pain in the abdomen which is radiating to your left arm which is known to happen in lots of hyperacidity kind of cases and you can come out of the hospital with a triple bypass. So there are umpteen examples of how today the private sector would like to have people be in hospital for longer times, spend more on medicines, spend more on investigation because that is how they are going to make money which is entirely against the whole logic of public health systems. Last two decades particularly, we have not seen any expansion in terms of hospitals. We have not in fact whatever existed seems to be allowed to go into decline. In this context, do you think it is a way of creating the ground for this kind of a shift? Well, I would differ slightly with that with the National Rural Health Mission which was one of the things that the UPA-1 had launched and in fact the left had a major role in pushing for some of these schemes including NREGA, NRHM was one of another of these. Now it is not as if that the NRHM has sort of vastly improved the situation as where public health infrastructure is concerned. But what it has done is that it has brought back the public ethos in health systems in many parts of the country and there has been moderate expansion. It is true in infrastructure and in fact many would argue that the present plan document is the neoliberal lobby striking back and in fact from what we understand from reports even the health ministry is extremely unhappy with this because people in the NRHM, in the health ministry who have started seeing some difference being made see this as also an attack on the public system that the NRHM constitutes and attempt to reverse this so that the path to entirely privatized the health sector is made easier and this is not just in India. We have had this experience in many developing countries, Mexico is a classic example of this the managed care model in Mexico that started in 2004 very clear parallels that you starve the public sector of funds then you say that the public sector cannot deliver at the same time you agree that yes catastrophic expenses are causing people to die and then you see that the public sector does not exist so we need the private sector to provide care. So this is really the roll out of a very clear game plan. But you can see in the urban areas for example now the public sector is actually shrinking in terms of hospital hospitals per capita if you look at it because expansions of Delhi has taken place quite dramatically but new public hospitals have not really come up and the gap is being filled by private hospitals. So there has been at least in the urban areas a clear shift from public to private delivery in most states in the country. So do you think that this is also a way of supporting this for corporatized hospitals that are coming up? Yes you see also I think we need to factor in one more thing that this is a floundering economy at the moment growth rates forecast is being sort of pegged down every day. Now for a planning commission led by new liberalizers today there I do not think they are really interested in healthcare they are looking at this money this public money that can be pumped into a private sector to prime pump of floundering economy. Now in new liberal sense probably it makes some sense but it has it is absolutely against the logic of the public health system. Would you also say it is against the logic of the health system? Yes because I would argue that health systems have to be public they have to be publicly financed and publicly provisioned anything else can be an interim arrangement it is it is possible to for example argue that in situations where you do not have an infrastructure in the public system you may need to utilize some forms of private entities but that for me is an interim arrangement it is a technicality it is not the long term vision of how you are going to build up the public system. So if you really talk about a health system it has to be a public system. India is one of the most privatized health systems in the world this is what you have written about. Now do you think that this is in effect in order to show up that kind of private health system which is already come in in various ways and as you said it is only to help the Rambaxis the Maxis and all this private health corporate entities that have come up to really become much bigger. Well I would say that would be part of the game plan it is also interesting that there was a year and a half lead up to this planning commissions document there were various committees and commissions and task forces that was set up by the government and all along there was this promise at the back that there will be significant increase in public health finances. Now what the planning commission document says now is that it will increase to 1.58% from the present 1% of GDP. Now that is even smaller promise than what the 11.5 year plan had said which was 2.5% it is less than what UPI 1 in 2004 had said which was 2.5 to 3%. So the planning commission neither has it delivered in terms of what how much of finances you are going to put into health care against the promise that was held out and even that meager increase that it is now promising and we will have to really see if that meager increase actually takes place is now going to be siphoned away from the public sector into the private sector and what is this private sector that we are talking about we talked about Max etc. Now what we are starting to see and it is in a way unique across the world except in the United States nowhere in Europe you have this you do not have this kind of private sector in Japan integrated chains of private sector which integrate insurance companies pharmaceutical companies and hospital chains this is the kind of monopolized integrated chains that are now coming up in India and they are pushing out all the small players I mean in fact in Delhi the general physician has disappeared it has been replaced by franchises of these hospital chains who are not interested in primary care these franchises where they exist are foraging for patients that they can bring to their hospital systems so that they can charge money out of them. You cannot even get small things today treated privately you have to go into this kind of precisely so that I mean Delhi is really sort of the worst off in that sense I mean other cities still have a modicum of what used to exist earlier in terms of GPs etc. but that is the trajectory that you are starting to see so essentially what this planned document is doing is not matching its earlier commitment to increasing financing but whatever financing it is going to be provide is going to provide is tied is going to be tied increasingly to the private sector providing medical care and the public system is going to be limited increasingly to providing vaccination health education antenatal care things that the private sector anyway is not interested in. So what you are saying is that a small increase in outlays but a much larger amount of money actually going in to serve a much smaller number of patients because the cost of care is going to increase manifold so in effective terms it means the health care reaching the people act is going to decrease the consequence of such precisely I mean if the same money whatever amount they are going to put in instead of putting it in the pockets of your Apollo's and Max's had been used to expand the infrastructure in the public system that's a national asset that's a public asset that you would have had for all times to come instead of that you're siphoning up that money and putting it in the pockets of the private sector. Thank you Amit I think this is something that we are seeing across the board not only in the health sector but health sector is particularly vulnerable because people don't have control over their own health. Thank you very much. Thank you.