The brief references to Kerala’s health and education sectors by Congress president Rahul Gandhi in his public address on Sunday have triggered a severe backlash from the ruling CPM. Led by the health minister KK Shailaja, the party apparatus has launched a counter-attack against Rahul Gandhi alleging that he has humiliated Keralites by making wrong charges against the health and social sectors that the state prides itself in.
KK Shailaja even drew a parallel between Rahul Gandhi’s references to Prime Minister Narendra Modi’s remarks some time back in which he reportedly said that the infant mortality among the tribal people in the state was comparable to that of Somalia. The message of Shailaja and the party cadres, which also include hundreds of cyber-proxies who troll and bully political rivals on social media besides writing long Facebook-essays on critical issues, was very simple: Rahul slighted Malayalees with his health and education remarks exactly like Modi did with his Somalia comparison.
But, did Rahul say anything wrong?
A close look at Rahul Gandhi’s speech shows that he didn’t. All he did was asking questions such as where the hospitals and schools were that everyone could access.
The minister in her retort was not specific about Rahul’s remarks, but repeated the exemplary basic health indicators of the original “Kerala Model of Development” that had long since become a human development legend across the world. She also reeled out numbers of hospitals, assistance given to people and names of some of the schemes that her government was undertaking and even claimed how people were coming from all over the world to seek medical treatment in the state. And certainly she was right in claiming the state had first rate health infrastructure. However, not even once, did she address the two most critical questions: who owns most of them and who pays for people’s health. When Rahul Gandhi rhetorically asks where the hospitals are, the message clearly is if people have universal access to healthcare.
Shailaja’s wounded pride and rebuttal, echoed by party cadres and proxies, may sound true in terms of numbers, but what it hides under the carpet is a dangerous anomaly that can rollback Kerala’s hard-earned development gains. She is right about the state’s health infrastructure, but most of it is owned by the private and corporate investors. Who pays for the health bills when people fall sick and who pays for maintaining the state’s pride of place in health – that’s the real story that Shailaja or none of the development specialists from the CPM-stable wouldn’t talk about. It’s truly a scary story.
A few critical facts would dispel the popular narrative that Shailaja repeated and would point to some merit in Rahul’s political questions: the out-of-pocket expenditure for health is the highest in Kerala (means, the financial burden of healthcare on people in the state is the highest in India), Kerala has one of the most privatised health sectors in India which according to various studies range from 65 to 90 per cent (means majority of the people go to private hospitals, and not government hospitals, for their healthcare needs), and since the 1990s, the state had recorded one of the steepest declines in public health investment (means the state is still resting on past glory). A 2014 state government report (Twelfth Five Year Plan Expert Committee Report) citing the National Health Accounts said that the share of the private sector in the state’s healthcare was as high as 90 per cent. It also said that 12 per cent of rural and 8 per cent of urban households had been pushed into poverty because of high healthcare bills.
In other words, what’s keeping most of the people of Kerala seemingly healthy are the private hospitals which come at a huge personal cost. There are multiple studies that show a very high share of household income — particularly among the poor — going to medical expenditure, which also leads to catastrophic expenses (in simple terms, catastrophic medical expenses are those that can impoverish people).
In comparison, till the mid-1980s, the government had a bigger role in people’s health and that indeed had contributed to the Kerala model of good health at low cost. It’s in the mid-1980s that the government expenditure on health began to shrink and that’s precisely when the private sector started booming. The trend was never reversed. By the 1990s, the private sector had almost completely taken over and during the same period, the household health expenditure rose four times, more so among the poor people. The private sector today has the highest number of hospitals, facilities, specialists and even human resources in the state. Most of what the government spending on health goes into salaries and recurring costs and the burden of healthcare is mostly borne by people themselves which as various studies show affects the poor disproportionately. This is what Shailaja should talk about and even worry about.
Even at this personal cost, is Kerala as healthy as Shailaja or the party-apparatus claims? Unfortunately not. While indicators such as Infant Mortality Rate, Maternal Mortality Rate, Fertility Rate, Life Expectancy and so on continue to remain high keeping the Kerala Model still shining, the state has become the virtual capital of non-communicable illnesses such as diabetes, cardiovascular diseases and heart attacks, and has also become the hotbed of many communicable diseases that it either had banished years ago or had not heard of. The state also has the highest level of morbidly in the country. These features certainly add to the healthcare burden of the people and obviously keep the household expenditure on health the highest.
Kerala indeed had an outstanding public health story that had been much ahead of the rest of India even before Independence. The rulers of the princely states of Travancore and Cochin had laid great emphasis on modern medicine and had put in place systems that gave most of the state (except the British-ruled Malabar) a head-start. As researchers time and again have pointed out, it’s not a post-1956 phenomenon that can be attributed to a single party or government, but a legacy hardwired into the state’s socio-political consciousness. But since the mid-1980s and 1990s, it’s just past glory and the present boasts like that of the health minister are of “successes” that are self-financed by people themselves.
What’s worse is that the future of public health in Kerala looks even bleaker because the state government is aggressively pushing health insurance instead of a tax-funded universal healthcare model where people get cashless medical treatment without any strings attached. In addition to all the other inherent flaws, the insurance model is not even consistent with people’s health expenditure pattern. Unsurprisingly, a 2017 study has established that the Rashtriya Swasthya Bima Yojana (RSBY) of the government of India hasn’t reduced the out-of-pocket expenses of people even after so many years. As researchers Gayathri Balagopal and M Vijaybaskar argued in an EPW article citing the evidence from health insurance schemes of Tamil Nadu, it would lead to the increased use of the private sector and a possible erosion of human resources. Except in extremely controlled settings governed by high levels of rule of law and strict safeguards against exclusion and fraud, insurance driven models lead to a collusion of private/corporate hospitals and insurance companies that results in unnecessary interventions and inflated costs.
It’s indeed strange that a government led by the CPM, which otherwise argues for universal access to services, is pushing ahead with insurance and had allowed intense privatisation of the health sector over the years. It’s not because there are no scalable models of universal healthcare. Thailand, with a tax-to-GDP ratio similar to that of India, had over the years set up a UHC (Universal Health Care) model which even pays for chronic treatments such as dialysis.
With such deliberate push for insurance and privatisation, the data of hospital buildings and upgradation of facilities by the health minister are mere numbers or outputs. What’s required are outcomes, which in this case is universal access to healthcare wherein the healthcare burden of people, including indirect costs, are state-funded. Boasting about a health sector that’s almost entirely occupied by the private sector betrays a complete lack of understanding of the role of the State in people’s welfare.
Rahul Gandhi was right, where are YOUR hospitals?