Do We Care?: India’s Health System
by K. Sujatha Rao
Oxford University Press, 479 pp., 2017.
For an administration of such scale, retired Indian bureaucrats reveal remarkably little about their experiences of how policies are made and implemented. Memoirs tend to come from prime ministerial circles, offering a seductive blend of office gossip and the gilded intrigue of foreign policy machinations – pre-filtered through dinner parties before arriving on the shelf at BahriSons. Domestic health policy, by contrast, is not sexy.
On page 389 of “Do We Care?”, former Indian health secretary K. Sujatha Rao notes that building consensus around policies for effective and equitable health systems is a “tedious but vital” process. There were moments when I felt similarly about wading through this 433-page tome. As a field, health policy in India is in need of a comprehensive yet pithy overview that transcends sweeping rhetoric fuelled by cherry-picked stories of corruption and sensational malpractice, but also avoids alienating non-expert readers through the minutiae of health economics.
“Do We Care?” is not that book. Nor should it necessarily be – the responsibility for elevating health as a policy priority cannot solely be laid at the door of former bureaucrats. And the wealth of detail here is a goldmine for students of public policy that they won’t find elsewhere. On balance, Rao’s palpable frustration with India’s failures to establish reliable public healthcare, and the firsthand experience she draws on to suggest potential remedies, rescue the book from the risk of tedium. It is, let’s say, dense but important.
Rao spent much of her civil service career working on health issues, culminating in her tenure as director of the National AIDS Control Organisation (NACO) and Union Secretary in the Ministry of Health and Family Welfare during the Congress led-UPA 1, before her retirement in 2010. India’s long-standing political apathy towards health notwithstanding, Rao worked in interesting times. NACO and the National Rural Health Mission, both of which she was intimately involved with, receive exhaustive attention in their own chapters, each of which is almost 100 pages long.
Rao has since become a regular in the Indian English language media; her op-eds strike an effective balance between evidence-informed critique and value-based rhetoric. “Do We Care?” clearly demonstrates an ambition to go deeper. The book is very much a project. Fuelled by determination and, I suspect, a sense of obligation to speak a certain truth to power once its author was unshackled from the implicit and explicit strictures of the civil service. It is an impressive attempt to interrogate India’s enormously complex healthcare system (or lack of). Part memoir, part manifesto, part textbook; in one sense the book is a cri de coeur, in another the apologia of a former bureaucrat looking to both prove her understanding and seek understanding in return about the constraints she operated within.
The book offers compelling diagnoses of the various ailments afflicting India’s health system:
‘Not achieving improved health is not a question of a lazy government or insensitive doctors but a reflection of the relational power balances between the political and economic forces at play, competing priorities, implementational capacities of public institutions, the extent and strength of the prevailing structural inequalities and the effectiveness of public policies in addressing them, and so on.’
Rao is similarly convincing when she urges a political economy approach to understand the power imbalances and market asymmetries that plague India’s health system and skew it away from the interests of the poor. She is vehement of the need for improved health governance, as well as the more common demand for an increase in GDP devoted to health from the current 1.02% to 2.5%. Historical apathy, and the contemporary corruption of key institutions – most notably the Medical Council of India (MCI) – are discussed in a tone of bewildered fury that any student of Indian health systems will recognise.
By dint of its length and the sheer density of administrative detail, “Do We Care?” is inevitably preaching to the converted. Its passages of scholarly argument elevate the book above polemic and lend it an undeniable intellectual credibility. Whether anyone reading this book needs a detailed explanation of the core tenets of health systems theory, whether those who do would come to this book looking for it, and whether the inclusion of such academic detail detracts from the book’s overall power, however, remains open to question.
I imagine those picking up this book are looking for additional detail about the workings of NACO, or arguments around the conceptualization of the National Rural Health Mission, from the specific perspective of the central roles Rao held. The book serves that purpose wonderfully. Similarly, there is enormous value in reading a long-serving bureaucrat’s confirmation of the political apathy (“the lack of will to govern” as Rao puts it) towards health that scholars have long puzzled over.
Rao often returns to the need for health policy to be better informed by evidence, and there is an enjoyably wry invocation of Keynes’s pronouncement that ‘there is nothing a government hates more than to be well-informed; for it makes the process of arriving at decisions much more complicated and difficult’. How to effectively institutionalize the use of research and operational data in policy making is a complex challenge, however. The memoir format offers the luxury of being able to suggest the kind of sweeping reforms needed to ensure health policy works in the interests of India’s most vulnerable citizens, and not predominantly those of corporate hospitals, while sidestepping details of implementation. Rao, at least, obliquely acknowledges this – to ignore it would be to undermine the principle of the book. She describes reforms as painful processes:
‘…they hurt some, benefit others. But they need to be undertaken – revamping regulatory authorities, rebuilding anew the broken health system, and fixing it in a manner that makes all stakeholders accountable to serving the last person standing in the line. This calls for thinking.’
It is in this final statement that the power of the book lies. It is a thoughtful and committed reflection on a career in one of the most vital and least valued sections of the Indian civil service. And in this critical global political moment, calls for those in power to stop and think should be encouraged and amplified. Calls to stop and care, even more so.
Dr Anna Ruddock is a writer and social scientist currently working on a book about MBBS education at the All India Institute of Medical Sciences in Delhi. She also works as a global policy advisor at the Wellcome Trust in London.