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Indian Journal of Community Medicine

View Point: Public Health Foundation of India - Will the Public be Placed at the Centre?

Author(s): Abhay Shukla

Vol. 31, No. 2 (2006-04 - 2006-06)

This short note seeks to outline some issues for discussion, concerning the Public Health Foundation of India being currently launched. Overall, given the unsatisfactory state of Public health research and training in India today, any initiative towards its strengthening should be considered welcome. We do need to understand all aspects of the initiative, and wait for it to further unfold before coming to any definitive conclusions about it. However, there are certain areas of concern which need to be addressed and if possible remedied, if the Foundation and its associated institutes are to live up to expectations of their genuinely strengthening Public health in India.

Privatisation of Public health?

As stated in the PHFI Agenda document, the majority (85%) of funding for this initiative is to come from private sources: out of the $100 - 110 million projected to be required, 30% from Private health foundations (e.g. Bill Gates Foundation); 30% from corporations, 25% from individuals and 15% from the government. As we understand it, supporting Public health is a core function of the welfare state, and Public health research and training in India have till now been largely the responsibility of Public institutes and mostly publicly funded Medical colleges, which of course have had their own limitations. Now if private (essentially corporations, corporate foundations and individuals) funding is to be the main basis of the entire Foundation, how will this influence the prioritisation, decision making, choices of technical inputs, staffing at apex positions and other aspects of the Foundation? Why are donors with a direct potential of conflict of interest such as Ranbaxy Healthcare represented on the Governing board? What would happen if say, a Vaccine manufacturing multinational or Health Insurance company were to make a large donation and join the Governing board - would this not have the potential to influence the research and policy decisions being made by the Foundation? How would industry representatives view major public health issues like hazardous and polluting industries where the industry itself is largely responsible? What would be the decision making status of the GOI representatives on the board, and what would happen if they were outvoted by the (numerically larger) private representatives on an issue involving national public health interest?

The Institutes are supposed to become 'self sustaining from year 3 onwards' and the revenue model mentions that 45% of revenue would come from tuitions. The resulting tuition fees are likely to be quite high - each school would need to earn an estimated approx. Rs. 8 crores annually from tuition based on the figures in the Agenda document - according to a rough estimate based on the numerical student load expected, this could come to a fee of up to Rs. 20,000 per month per trainee. Which kind of students would most likely be able to avail of such training courses? Would these institutions be able to look at the public health problems of the rural and urban poor of the country, or would they become 'Centres of excellence' facing towards a global market?

These and other questions need to be addressed in considerable detail, to make it clear how such heavy reliance on Private funding and high tuition fees based education will not lead to 'Privatisation of public health' in terms of both structures and work content of the Foundation, notwithstanding the genuine intentions of certain of the public health - minded founders. One way of putting this question could be to ask how it will be ensured that 'those who pay the piper do not influence the tune' - which should be guided solely by public interest. Given the importance of this initiative, and the renewed emphasis on Public health, why is it not possible for the Union government to invest a larger amount (say about Rs. 225 crores over a couple of years, which would be 50% of the projected total of 450 crores), and allocate some funds for ongoing costs, which would endow a strong and unequivocal Public character to the Public Health Foundation?

Influence of US Public health institutions - what are the benefits?

Certain US based public health schools (Harvard School of public health, John Hopkins School) and the US Association of Schools of Public Health are involved in the foundation; they appear to have a significant role in developing this initiative. Of course, positive academic contributions from various sources should be welcome, and we should be in favour of exchange of knowledge with various other institutions; however to the extent that such collaboration is necessary, we need to see whether the sources involved are most appropriate for the Indian setting.

Here two issues of concern may be pointed out: firstly, the US Health care system model based on large scale private insurance and HMOs, which despite being practically the most expensive health care system in the world leaves 45 million US citizens uninsured, is definitely not the kind of Health care model we need to develop in India. While seeking expertise on Health system development in India, rather than keeping the US type Health system as a model, we may be better off looking at experiences of countries like Sri Lanka, Costa Rica, Cuba, Brazil and among developed countries, perhaps Canada, UK and some of the Scandinavian countries. Even concerning communicable disease control and larger public health measures, a predominantly bio - medical model as adopted by many mainstream Public health institutions in the US is unlikely to be relevant for Indian conditions. Secondly, collaboration in the Public health field between institutions in developed countries and their Indian counterparts has prominently included trials of vaccines and new bio - medical measures. The Indo - US Vaccine Action Plan conceived in the late 1980s, where a number of new vaccines that were not approved for use in developed countries were to undergo trials in India, had come under significant criticism and was subsequently shelved. With the major involvement of private foundations, the trend of 'outsourcing' medical trials, and the participation of pharmaceutical companies not ruled out, it will need to be clarified how the Foundation would treat the issue of such trials and studies in India. Relationship with existing Public health institutions and PSM departments.

The PHFI is of course not entering the Public health scenario in India in a vacuum; there are a large number of Preventive and Social Medicine departments in various medical colleges, along with established national Public health institutions. Due to a variety of factors, including limited mandate and often low priority given by policy makers, the contribution of these bodies concerning Public health training and policy formulation in India has on the whole not been upto the requirements of the situation. Given this larger context, it is positive that the PHFI institutes would seek to build upon and strengthen selected existing institutions. However, a wider national engagement with the existing public health profession and interaction with existing departments and institutions, with a view to both learning from their contributions (which should not be ignored) and strengthening their expertise, should also be centrally on the agenda of the Foundation. Need for an integrated Social Medicine approach, not a narrow Bio - medical approach.

It is too early to comment on the approach to Public Health, which would be adopted by the Foundation. However, the documents available so far do not give any indications of departure from the mainstream, bio - medical / behavioural modification focused approach to Public health. It need not be reiterated here that the spectrum of Public health issues in India today - such as communicable disease resurgence due to social - ecological imbalances, large - scale undernutrition due to poverty and food insecurity, occupational and environmental hazards to health, addictions and mental health problems, conflict and its health impacts - are unlikely to respond to a narrow bio - medical or behavioural modification approach. A distinct break from current thinking would be the pre - requisite for effective integrated public health action, which would require addressing the full spectrum of determinants in the complex Indian context. Whether such a positive departure is made by the Foundation remains to be seen.

Need for Community Health Orientation

A number of prominent Health activists from various NGOs active in Community health and public health had been invited for the PHFI launch function; this is in itself a positive feature. However, it remains to be seen whether the PHFI adopts a definitive Community - empowerment approach to public health, which would entail not only engagement with some NGOs but also people's organisations and movements, health movement platforms such as Jan Swasthya Abhiyan, and an appreciation of processes such as the Decentralised health planning experience in Kerala. If genuine activation of communities is accepted as a prerequisite for strengthening community health, then such movements would need to be consulted and interacted with while deciding on priorities and plans for the Foundation. When strategies for strengthening Public health are being devised, concrete experiments and alternatives developed in collaboration with community groups would need to be studied and supported; the role of the Foundation at its best would be to support such wider social health initiatives, rather than its expertise appearing as a 'prescription from above' for improving Public health in the country. Whether regarding its financial means, its trainee clientele, its collaborative framework or its orientation to community health efforts, it would be fitting for the Public Health Foundation to keep a 'Public' perspective at the centre of all its endeavours.

... palliatives will no longer do. If we wish to take remedial action, we must be radical. Palliatives in such cases are more costly than radical action...
- Rudolf Virchow

Report on the Typhus Epidemic In Upper Silesia, 1848.

SATHI - CEHAT,
Email: [email protected]vsnl.com
Received : 13.05.2006

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