Published online: September 7, 2017
This is in reference to the book review “India’s health system: No lessons learned” by Sunil K Pandya, published online in IJME on August 30, 2017 (1). Before responding to the review, a clarification may be in order. The book Do We Care? India’s Health System is not an autobiography. It neither lists out my achievements nor explains my failures. It only records my understanding of the evolution of India’s health system over the years and provides an insider’s perceptions on how policies are made in the corridors of power.
Retirement gave me time to read and reflect. More importantly, I was able to distance myself and contextualise issues more objectively; a privilege that the daily battle normally precludes. This experience, Dr Pandya finds fault with. He caustically alleges that deficiencies “became apparent” …”only in 2012″; makes a remark about not mentioning the name of a district or an officer’s name; comments that it was “the failure of the general body of bureaucrats to rise en masse in support of their colleague who had done no wrong”; and speaks of his negative experience with a health secretary in such a way as to demonstrate his bias against bureaucrats.
Despite reading the review multiple times, I am confused as to what Dr Pandya seeks to convey and what his understanding is of the evolution of health systems in general and the book in particular. Half of the eight-page review is strewn with quotations from the book, words or sentences taken out of context and commented upon with the reviewer’s own experience or understanding. For example, in reference to a general comment on how the public health measures the British introduced were perceived by the people as an imposition by a colonial power, Dr Pandya has written a long paragraph on how positive the British rule was in opening medical colleges – a point not even mentioned in the book.
Dr Pandya found the book to be full of facts “most of them conducive to dismay” and stated that “the volume would have gained much from the addition of details of what Ms Rao did to change the situation for the better during the years when she influenced events pertaining to healthcare”. It seems from this summarising paragraph that Dr Pandya may not have read Part II of the book that provides several insights into my contributions and more importantly those of several dedicated people who, despite a challenging environment, were able to achieve successes in reducing HIV incidence, eradicating polio, reducing maternal and child mortality, and improving the functioning of rural health systems.
A careful reading of Dr Pandya’s comments brings out two issues that could merit some discussion. One, who or what is responsible for the current situation? I had offered three reasons: weak leadership – political, administrative and technical; low resources, and poor management. Understanding the complexity of policy making is critical as policies are not outcomes of rational thinking or autonomous action of a few individuals, no matter how “powerful” they may be, de jure. Power is constrained by the political economy that imposes limitations. A case in point is how an otherwise politically powerful leader like Ghulam Nabi Azad failed to institute the public health cadre to work in peripheral facilities. In such a situation, who is to be held accountable and responsible?
Dr Pandya raises another issue of how the much needed transformative change can come about. He feels that it is the ministers and the bureaucrats who have all the power and therefore, the responsibility for effecting change; not the doctors or the judiciary or the people. I disagree. The book is replete with examples of not just the constraints of power but the shrinking space and loss of autonomy for decision making. Consider the fact that since 2000, despite the might of the Supreme Court setting aside the MCI and placing it under its direct supervision, despite the government in 2010 (I was secretary then) taking the unprecedented step of setting aside the Medical Council of India by an ordinance, and despite the scathing report by the Parliamentary Standing Committee of 2013, yet, the MCI stands unchanged and the status quo continues.. Who then is to be held accountable? According to Dr Pandya, it is the minister of health and the secretary. And what will make these two people alone bring about change? What if they do not? The truth is that systems are designed exactly for the purpose the political system intends and desires.
Further, in democracies, policies are made in accordance with the relational strengths of the actors involved. The judiciary, the media, civil society and the doctors and other care providers all have a role and responsibility. They are as responsible and accountable for the situation since there is nothing like neutrality, and silence too is a decision. Based on and frustrated with my own experience of policy making, I feel that India’s health policy can be brought out of the morass only when people and doctors push for change.
And such changes do not come with writing articles in journals as Dr Pandya would like to believe. In Thailand, a group of dedicated doctors steered the health system over thirty years, including collecting half a million signatures to force the government to introduce strong anti-tobacco policies. In the UK, a million people were led by NHS doctors and nurses to halt the privatisation of the NHS. In the US, it was the American Association of Physicians that got Abraham Flexner to review the quality of medical colleges resulting in half of them being closed down. In the UK, the Bristol heart surgery scandals resulted in a complete revamp of the British Medical Council and the revamping of the NHS. In most countries, therefore, at some point, leaders have forced governments to recognise their primary obligation of providing their people with a good healthcare system. In India, such examples have been rare. Even the small step proposed by Dr Rath, saying ‘No to Corruption’, has not invited any response and the IMA and the elected representatives of the doctors in the MCI continue to stonewall reform. In such an environment nothing will change, since neither the “powerful minister nor secretary” that Dr Pandya has so much faith in, actually has any power.
We, as a people, have failed to make health central to our development dialogue. That has to change. We need to build clarity in our vision, in our policy design, and provide appropriate funding and incentive structures over a span of a decade and more. This can only come about when doctors and other care givers say enough is enough. There is no point blaming bureaucrats for, after all, as PV Narasimha Rao, the then PM called them, they are but trained horses but need good riders to ride them.