Universal health care in India: Panacea for whom?

This paper examines the current notion of universal health care (UHC) in key legal and policy documents and argues that the recommendations for UHC in these entail further abdication of the State's responsibility in health care with the emphasis shifting from public provisioning of services to merely ensuring universal access to services. Acts of commission (recommendations for public private partnership [PPPs], definition and provision of an essential health package to vulnerable populations to ensure universal access to care) and omission (silence maintained on tertiary care) will eventually strengthen the private and corporate sector at the cost of the public health care services and access to care for the marginalized. Thus, the current UHC strategy uses equity as a tool for promoting the private sector in medical care rather than health for all.

Medical tourism in India: perceptions of physicians in tertiary care hospitals.

Senior physicians of modern medicine in India play a key role in shaping policies and public opinion and institutional management. This paper explores their perceptions of medical tourism (MT) within India which is a complex process involving international demands and policy shifts from service to commercialisation of health care for trade, gross domestic profit, and foreign exchange. Through interviews of 91 physicians in tertiary care hospitals in three cities of India, this paper explores four areas of concern: their understanding of MT, their views of the hospitals they work in, perceptions of the value and place of MT in their hospital and their views on the implications of MT for medical care in the country. An overwhelming majority (90%) of physicians in the private tertiary sector and 74.3 percent in the public tertiary sector see huge scope for MT in the private tertiary sector in India. The private tertiary sector physicians were concerned about their patients alone and felt that health of the poor was the responsibility of the state. The public tertiary sector physicians' however, were sensitive to the problems of the common man and felt responsible. Even though the glamour of hi-tech associated with MT dazzled them, only 35.8 percent wanted MT in their hospitals and a total of 56 percent of them said MT cannot be a public sector priority. 10 percent in the private sector expressed reservations towards MT while the rest demanded state subsidies for MT. The disconnect between their concern for the common man and professionals views on MT was due to the lack of appreciation of the continuum between commercialisation, the denial of resources to public hospitals and shift of subsidies to the private sector. The paper highlights the differences and similarities in the perceptions and context of the two sets of physicians, presents evidence, that questions the support for MT and finally analyzes some key implications of MT on Indian health services, ethical issues emerging out of that and the need for understanding the linkages between public and private sectors for a more effective intervention for an equitable medical care policy.

The ART of marketing babies.

New legislation can be oppressive for a significant population depending upon the politics of its drafters. The current upsurge of the surrogacy trade in India, and the label of a "win-win" situation that it has acquired, points towards an unfettered commercialisation of assisted reproductive technology and the practice of surrogacy that is blinding its middle class users as well as providers, policy makers and law makers, and charging an imagination that is already caught up in spiralling consumerism. This paper analyses the Draft Assisted Reproductive Technology (Regulation) Bill and Rules, 2008, in the Indian socioeconomic context. It identifies the interests of the affected women, and examines the contradictions of the proposed Bill with their interests, as well as with current health and population policies, confining itself to the handling of surrogacy and not the entire content of the Bill. The bases of the analytical perspective used are: the context of poverty and the health needs of the Indian population; the need to locate surrogacy services within the overall public health service context and its epidemiological basis; the need to restrain direct human experimentation for the advancement of any technology; the use of safer methods; and, finally, the rights of surrogate mothers and their babies, in India, as opposed to the compulsion or dynamics of the medical market and reproductive tourism.

Toward an ecosocial epidemiological approach to goiter and other iodine deficiency disorders: a case study of India's technocratic program for universal iodization of salt.

The program of universal salt iodization (USI) was intensified in the 1990s. Unfortunately, a recent World Health Organization review finds that there was a global increase of 31.7 percent in total goiter rate from 1993 to 2003. However, the WHO review places only 1 country as severely, 13 as moderately, and 40 as mildly deficient in populations' iodine nutrition, and places 43 countries at optimal, 24 at high, and 5 at excessive levels of iodine nutrition. Thus, it is imperative to weigh the benefits and risks of intensifying USI further. The WHO review places India in the category of "adequate" iodine nutrition, but in 2005 the Government of India promulgated a universal ban on sale of non-iodized salt, calling iodine deficiency disorders (IDDs) a major public health problem. This article attempts to understand these contradictions and weigh the benefits and costs of USI. Based on a review of studies since the 1920s, the authors reconstruct the evolution of IDD control in India. Conceptual and methodological limitations challenge the evidence base and rationale of stricter implementation of USI now. Finding evidence for its negative impact, the authors recommend a reexamination of the USI strategy and propose a safer, people-centered, ecosocial epidemiological approach rather than a universal legal ban.

Goiter and other iodine deficiency disorders: A systematic review of epidemiological studies to deconstruct the complex web.

A systematic review of the available literature on goiter and other iodine deficiency disorders (IDDs) was carried out with the aim of analyzing available evidence and providing inputs to the policy makers and program formulators regarding the entire issue. The findings point to major issues such as the following: methodological issues in epidemiology of goiter and other iodine deficiency disorders (IDDs); lacunae in causal linkages; inadequate attention to multicausality; flawed assessment of the impact of intervention, i.e., iodized salt; and harmful effects of iodine not given due cognizance. Most of the research to date has been unidirectional and does not provide comprehensive data on all aspects of IDDs. To further compound the issue, many independent researchers, on finding something different from the existing dominant paradigm (iodized salt as panacea for goiter) have tended to ignore these in their final conclusions and recommendations. Thus, evidence from this systematic review demonstrates enough basis to start a debate on the entire issue, recognizing opposing research findings while continuing with the present strategy. This imposes specific problems and necessitates area-specific solutions instead of a universal solution, which apart from being less effective may be harmful in the long run.

The National Rural Health Mission (NRHM): a critical overview.

This paper explores the forces that led to the conceptualisation of the National Rural Health Mission (NRHM) including the role of the Common Minimum Programme and the Structural Adjustment Programme. The paper analyses the key components of the NRHM in terms of the theoretical frameworks of decentralisation, integration of programmes, primary health care, community health workers and standards.