We, the undersigned, medical professionals, educationist, academics, teachers, civil society organisations and other concerned individuals are writing to express our deep concern over the recent demand by the Indian Medical Association (IMA) for “immediate remedial action” on content included in the National Council of Educational Research and Training (NCERT) Social Science textbook on Social and Political Life (SPL) for Grade 7. The IMA’s demand to rewrite or delete the chapter is clearly unreasonable and unacceptable, as are the threats that the IMA has issued against the NCERT and the authors.
Chapter Two on the “Role of the Government in Health” in the above-mentioned textbook, sections of which the IMA is raising objections to, is part of a series of textbooks that were developed through a consultative process initiated by the NCERT, involving academics, teachers, researchers, government school teachers and civil society organisations with substantive experience and expertise in the thematic areas covered in the textbooks during 2005-08. These textbooks also underwent an independent process of systematic review prior to publication.
The SPL textbooks, as the name suggests, focus on themes related to social, economic and political life in contemporary India building on the well-recognized pedagogic principle that children learn best through concrete examples. The SPL textbooks aim to develop the abilities of children to critically engage and analyze these realities in keeping with the tenets of the Constitution of India. The chapter that is under contention, focuses on the critical role that equality exercises in Indian democracy and each of the five units of the book highlight a particular issue related to elucidating this theme. Health is one of the issues discussed and is included in Unit 2 on ‘State Government’, which contains two chapters on the “Role of the Government in Health” and “How the State Government Works”.
As the titles make clear, these chapters aim to present and discuss the government’s role and responsibilities around providing quality health care for all in a democracy.
Specifically, the chapters attempt to get students to begin thinking critically about inequities in health care, including concerns of availability, accessibility and quality. In presenting these concerns, the chapter includes a discussion of the private and public facilities, which comprise the health sector in India. The objective of the chapter is not a comparison of the public and private health care sectors, rather the chapter seeks to reiterate the state’s responsibility in a democracy and emphasize the implications of the withdrawal / insufficient provisioning by the government for public goods, namely health care. Reference to this central idea can be found in the “The Story of Hakim Sheikh”, where many government hospitals refused to admit him for treatment. This real case study is used as a running thread through the chapter and illustrates that denial of health care violates the constitutional provision for the right to life. This landmark judgment by the Court would encourage the student to think of the wider public interest and not accept the implications of these situations as natural.
The IMA’s allegations and demands are unfortunate and based on a selective reading of the chapter. The IMA has raised objections to a couple of lines regarding the costs of treatment in the story board – however, following the story board are questions that invite students to look at it in an open ended manner, relate to the social context and bring their own experience in an illness to the classroom. The storyboard is an important educational tool that facilitates students’ understanding of the diversity and inequalities evident in access to health care (not a simple public versus private distinction as has been understood by IMA); and the government’s role in health care provisioning, governance and accountability.
Further, abundant evidence exists that indicates the severe costs of health care in the private sector. It is a known fact that private health care is largely unaffordable for the vast majority of Indians. Indeed, out of pocket expenditure on health in India is one of the highest in the world, and health care costs contribute to indebtedness for a significant portion of our population. According to the World Health Organization (WHO) India National Health Accounts (NHA) data for 2013, out of pocket (OOP) expenditure as percentage of Private Health Expenditure in India, was 86 percent. On average, a much higher amount (four times) is spent for treatment per hospitalized case by people in the private (INR 25850) than in the public (INR 6120). The average cost of hospitalization for childbirth in rural areas is Rs. 1587 and Rs. 14778 and in the urban areas Rs. 2117 and Rs. 20328 in public and private hospitals respectively (NSSO). Health Surveys have also pointed to, for example, that the number of caesarean deliveries in private hospitals was almost three to 10 times more as compared to government hospitals (AHS2012-13). A World Health Organization study, which reviewed 1,10,000 births from nine countries in Asia including India in 2010, revealed more than 60 per cent of the hospitals studied, where these C-sections took place, did it for financial gains and not because it was required.
The IMA’s objection is to sentences which discuss the private sector and state:
“In order to earn more money, these private services encourage practices that are incorrect. At times, cheaper methods, though available, are not used. For example, it is common to find doctors prescribing unnecessary medicines, injections or saline bottles when tablets or simple medicines can suffice.”
Evidence of such practices is widely available including in a recently released book-based on interviews with 78 doctors across India also includes narratives of “widespread irrational drug prescribing, kickbacks for referrals, and unnecessary investigations and surgical procedures”.
Further, IMA’s allegation that students will be “brainwashed” against the private health sector, is unfortunate and unfounded. It has been long established that students, however young, bring to the classroom knowledge and experience that the classroom process needs to facilitate as part of the process of learning. The IMA’s objection to one frame from a storyboard is not only disingenuous but completely misunderstands and disregards the educational requirements of textbooks.
Undoubtedly, there are doctors who conduct ethical private practice, as there are government hospitals that are run effectively. The chapter as currently written provides enough questions in the text to enable students to engage in a discussion based on their health care experiences thereby allowing them to agree or contend with the information that the chapter makes available and to understand that there are implications for society that faces such inequality in access including costs for a basic need, especially given the current environment that is encouraging of privatisation- indeed corporatization of health.
As the above data show, a large section of society in our country is denied basic health care. The IMA’s demand will result in students receiving a distorted and incorrect representation of issues that the Indian health care sector continues to grapple with. It would also work to stymie the development of critical thinking skills in students through engaging difficult concepts like ‘equality’ and ‘democracy’ through their own experiences. Sound and proven educational principles should not be allowed to be jettisoned by particular interest groups, irrespective of their political and ideological position.
We, therefore, reiterate the unacceptability of the demands by IMA and oppose any attempts to undermine the intent of these textbooks. We urge the government to reject the demand by IMA to rewrite or delete Chapter 2 on ‘Role of the Government in Health’ in the Social and Political Life Class 7 textbook.
Signed by the Textbook writing team for the SPL textbook for Grade 7:
Dr. Sarada Balagopalan (Chief Advisor), Arvind Sardana (Advisor), Dipta Bhog, N Sarojini, Malini Ghose, Prof Krishna Menon, Prof Mary John, Prof Anjali Monteiro and Sukanya Bose (Members)
and endorsed by 213 others