Why India's Founders Championed a State-Dominated Healthcare System

The current government's complaint that it is unable to take good care of the health of the people seems to be another way of saying "we are not committed enough to this objective".

In 1943, after decades of criticism from Indian intellectuals and leaders, colonial British officials decided to finally embrace the question of the health of around 300 million native Indians. A committee was formed to undertake a grand survey and suggest recommendations. This committee became known after its chairman as the Joseph Bhore Committee. From 1943 to 1946, while India’s political leaders agitated and deliberated furiously to secure freedom for Indians from British domination, Bhore committee members debated and deliberated patiently to secure freedom for Indians from debility and ill health.

Though commissioned by the colonial government, the Bhore report was readily accepted by free India’s leaders after independence. The majority of the members were well-respected Indians, including the star doctors Bidhan Chandra Roy and A. Lakshmanaswami Mudaliar, and most of their recommendations concurred with the stands of the Indian National Congress. Perhaps the single most important point of concurrence was the “idea that the state should assume full responsibility for all measures, curative and preventive, which are necessary for safeguarding the health of the nation.”

Why did Bhore et al, together with Jawaharlal Nehru and his government, want the government to assume full responsibility for the health of the nation? Why were they skeptical of the idea of devolving that responsibility to private actors?

The historian Sunil Amrith explains in his book Decolonising International Health (2006) that for decades, the British government tended to devote paltry sums of money and resources towards the health of native people, instead depending on voluntary actors (NGOs in today’s parlance) like missionary organisations or on donations from wealthy Indian merchants.

Such a superficial approach to healthcare was anathema to the leaders of the Indian independence movement, who believed that abysmal health outcomes in the country were a result of the low priority accorded to health by the British. The only way to improve India’s health, they believed, was for Indians to oust foreign administrators and their methods of governance, and for the new Indian government to work steadfastly towards the welfare of all. Many other national governments like those in Australia, Canada, even Britain, were taking up increasingly wider health-related responsibilities. Why should India not?

The Bhore committee also shared this ambition:

“We feel that a nation’s health is perhaps the most potent single factor in determining the character and extent of its development and progress. Expenditure of money and effort on improving the nation’s health is a gilt‐edged investment which will yield not deferred dividends to be collected years later, but immediate and steady returns in substantially increased productive capacity.”

Their report approvingly quoted the UK Ministry of Health’s ideas of a National Health Service, adding:

“… this is an ideal which we in this country may well place before ourselves, not as some distant shadowy objective to be  approached through leisurely advances if and when conditions are favourable, but as a definite goal the attainment of which is vital for the nation’s progress.”

The Bhore committee’s rationale can be dissected as follows. Firstly, no nation can develop without ensuring that its population stays healthy. Such an optimum level of population health can be achieved only through robust healthcare services. These services should be centred in rural and small-town India, as that is where most Indians live and where services are the least. Now while such services can be provided by both government and private agencies, the poverty of the majority of Indians is a huge deterrent when it comes to paying at private facilities.

Charitable organisations cannot be a sustainable solution, as charity frequently is sporadic. Thus in conclusion, “We consider that medical service should be free to all without distinction and that the contribution from those who can afford to pay should be through the channel of general and local taxation.”

That is, the government should create an overarching healthcare infrastructure financed through general taxation (absent user fees at individual facilities), and make these facilities free for all: “We propose a comprehensive health service offering preventive and curative medical care to all, irrespective of their ability to pay.”

With the ‘rollback’ of the Indian state from healthcare provision since the 1980s, the state today has become a pale shadow of its ambitious 1950s and 1960s versions. The most consistent argument of politicians and bureaucrats, including the NITI Aayog, is that the government cannot do it all on its own. It is in the context of this argument that the high ideals of our founders assume significance. The irony is telling. Today, when India is very wealthy and ostensibly self-confident, even brash, the state has been reduced to whimpering that it cannot handle healthcare services for its own people – while the colossally poor India of 1947 rose magnificently to the occasion without complaining.

We should also not forget that immediately after independence, India was subjected to the overwhelming stresses of Partition, communal and caste conflict, wars, food scarcity, a growing population and a highly skilled physician workforce intent on leaving the country for greener pastures. Despite these and other challenges, our founders managed to make substantial, if not stellar, strides in healthcare, including making and nurturing perhaps the world’s most generous health insurance scheme, the Central Government Health Scheme.

Of course, idealism and compassion are not the only arguments in favour of governments assuming the primary responsibility for people’s health (the word ‘primary’ is crucial, since private payers always have important, but secondary, roles to play). There are numerous economic arguments. Healthcare professionals and activists, like the Jan Swasthya Abhiyan, have explained well the many ways in which privatisation can wreak havoc with people’s health. But in the specific sociopolitical environment today, it is important to focus on ideas. The present government in India has proven, through many recent policy stands, that if it believes in an idea, it will go to any lengths and overcome any number of obstacles to implement it. Whether we take the example of this government or of our earlier governments (as mentioned above), it is clear that when politicians are deeply committed to an idea, they will always find ways to fructify them.

Considering this commitment context, the current government’s complaint that it is unable to take good care of the health of the people seems to be another way of saying “we are not committed enough to this objective”. As those who will gain the most if the state works sincerely towards healthcare provision, and lose the most if private players and their profit motives are allowed to reign supreme, it is now up to the Indian public to force the government to reset their priorities.

Kiran Kumbhar is currently studying the history of science at Harvard University, focusing on the history of medicine in modern India. He is also a physician and a health policy graduate.