Articles posted by Radical Socialist on various issues.

Suggested paths to 21st century socialism in Venezuela

Eric Toussaint[2]


Reduce dependency on hydrocarbons and on the United States

One of the challenges that several previous governements have had to face, just as Chávez’ government must, is to diversify the productive apparatus in order to shake off the country’s extreme dependency on hydrocarbons (this is also true for the majority of the big oil-exporting countries). It was precisely to this end that, in the 1960s, a company such as SIDOR, the iron steel corporation, was created. Later, during the 1980s and 1990s, the neo-liberal governments privatized several public companies like SIDOR and decided to rely on foreign investments to diversify the economy. This was a failure.


In recent years, the Hugo Chávez government has in its own way been endeavouring to diversify the production infrastructure:

1. development and reinforcement of a steel and iron pole by carrying out a policy of import substitution (for instance, Venezuela is going to produce the pipes it needs for its pipelines whereas, up to now, they have been imported; with the help of the Chinese, Venezuela is going to produce railway equipment and re-develop its rail network);

2. support for local food production so as to come as close as possible to a situation of food sovereignty, while currently almost 90% of food products consumed in the country are imported (legacy of a decade-long use of oil revenues to import whatever Venezuela needed) ;

3. development of a  petrochemical industry;

4. improvement of the production and supply of electricity, produced in the great majority from hydraulic energy (and fortunately not from oil). In this regard, contrary to the official position, Venezuela must avoid getting into electricity production from nuclear power;

5. nationalization of the cement industry so as to develop the government’s housing construction policy.


Venezuela is also seeking to reduce the share of exports to the United States,[3] its main buyer of hydrocarbons, by trying to increase its supplies to China (according to some goverment sources, there is hope that China will be buying as much as the United States by 2014, which seems  a difficult objective to achieve).


Land policy

A land reform has been carried out,[4] cooperatives and small farms have been granted substantial subsidies, but the initial situation was very delicate. The share of agriculture in the country’s GDP is very low[5] and, with some important exceptions (for instance the regions of big market-garden production in the Andes[6]), Venezuela is one of the countries where the system of farmers’ smallholdings has been notably weakened due to the importing model that has prevailed for decades.


How can a local farming population be reconstituted so as to ensure food sovereignty for a population that will reach 30 million inhabitants in the coming years? The problem is admittedly a difficult one to solve. To this end, the State needs to implement a vast package of incentive measures such as: a substantial improvement in the quality of public services in rural areas so as to reduce rural exodus; support for family farming and other traditional forms of agricultural production without favouring cooperatives exclusively;[7] the development of a public retail network for farmers’ production, guaranteeing stable outlets and prices high enough to encourage producers and save them from the clutches of the private networks that impose their prices on producers and secure excessive profit margins for themselves.

Michael Lebowitz made a number of proposals regarding farming policy in Venezuela that should be implemented to improve the situation: “taking into account the existing contraband due to an overvalued bolivar and the diversion of goods through the black market, the solution does not lie in subsidizing by supplying free inputs such as means of production, nor in direct monetary subsidies to agricultural production (except in cases where new production facilities are built). Why? Because, given the circumstances, there is no kind of control ensuring that products go where they are needed – especially when control or monitoring mechanisms, which involve high transaction costs, are lacking.

Therefore to ensure that subsidies lead to a real increase in food supply on the national market, and at decent prices, the best form of subsidizing is through a State agency that buys products at a set price. This State agency can offer the producers a price that encourages production and can later make sure that the items are sold to the population via the Mercal network at prices lower than those paid to the producers.”[8]

The Venezuelan government’s debt policy

The public debt burden in percentage of GDP has been reduced over the last few years but one has to emphasize that the Chávez government is not initiating a comprehensive audit of the public debt, whereas it promised to do so on several occasions.[9]

Besides, one can only wonder about the appropriateness of taking on new loans when the price of the barrel of oil was high and when liquid assets were abundant. And yet, in 2006 PDVSA went into debt for 12 billion dollars by issuing bonds on the international financial markets. How can this decision, which was not discussed in the National Assembly, be justified? With the decline in the price of the oil barrel since July 2008 (even if the current price – between 70 to 80 dollars a barrel during spring 2010 – keeps Venezuela on the safe side for the time being), don’t the repayments by the PDVSA put a strain on its budget and excessively reduce its liquid assets? Why go into debt and transfer interests to the international (or national) private financial players if one has enough cash assets not to be forced to borrow money? These questions are unfortunately not being answered.


One should note that Chávez emphasizes the country’s endogenous development, which he defines as “self-centred, based on domestic resources and an integral part of the strong comeback of the national dimension.” Reducing PDVSA's external debt should be an interesting way of developing this definition.

Other steps to be programmed


One of the solutions that need to be implemented so that the State (instead of the present private banking sector) can retrieve a substantial share of the money it distributes (or spends) consists of transferring to the public sector (nationalizing) the greater part or the whole of the capitalist banking sector of Venezuela.[10] The State will then be able to re-invest part of the money it distributes (derived from its oil income) into the economy in the form of social spending or productive investments, in order to generate a virtuous circle of accumulation and the development of a public sector of the economy, as well as other kinds of ownership to be supported and strengthened (small private ownership, cooperative ownership, traditional forms of property among indigenous communities, etc.).


A second measure could consist of State control on foreign trade, so as to prevent a great part of the revenues it generates from being diverted towards capitalist accumulation and/or towards other countries through outflow of capital. A series of incentives of different kinds (taxes, subsidies, priorities in State orders…) is also needed to support the non-capitalist sector of the economy (obviously including small private ownership).[11]


Citizens’ and workers’ control to avoid 20th-like socialism

But what is absolutely essential is to set up mechanisms aimed at avoiding two major pitfalls: 1) the monopolization of decision-making processes by the State bureaucracy and

2) the emergence of a new bourgeoisie from within Chavism, which is already dubbed  “bolibourgeoisie” (= the Bolivarian bourgeoisie, the section of the Chavist leaders who take advantage of their position to begin accumulating capital). [12]


Among other mechanisms, let us mention: establishing limits to the range of wages (for instance a scale from one to six) by reducing the highest wages and significantly raising minimum wages as well as other wages up to the average wages;  forcing agents and civil servants to make an annual declaration of global incomes (salaries and other earnings and incomes) and personal wealth (since the accumulation of capital by bureaucrats is more often done through backhanders which do not appear in income statements whereas they do in statements of personal wealth); forcing citizens to declare their various bank accounts in the country and abroad (lifting bank secrecy); substantially increasing proportionality in income tax.


Improving the training of managers in public companies is also vital, because nationalizations require the creation of a recruitment pool of managers with high technical competence and a high level of political, social and ethical training. To step up the pace of nationalizations, a pool of managers has to be created, while simultaneously developing, as mentioned above, a policy of worker and citizen control. Unless this is done, there is the risk of creating public companies that are inefficient, and even corrupt.


The essential and certainly the most efficient remedy is to implement a policy of workers’ and citizens’ control over the accounts and running of companies and public institutions. It would enforce transparent management (so as to prevent embezzlement, squandering, use of the resources of companies or institutions for projects which are not socially or environmentally justified) through a comprehensive audit policy in which workers and users of services must actively take part.

There is also a need for appropriate transition from workers’ control to company self-management (while maintaining an external control). The whole battle for workers’ control, for citizen control (which I also call control by users), for self-management, is part of the building up of grassroots popular bodies, such as the communal councils. The right forms still remain to be found so that this construction of grassroots entities is not restricted to a fragmented view. This raises the question of setting up a national federation of control organizations through which popular power can become a reality.



Translated by Stéphanie Jacquemont and Judith Harris, in collaboration with Francesca Denley and Christine Pagnoulle


[1] The first part of this series ‘Bolivarian Venezuela at the crossroads’ was posted on the CADTM website on 14 April 2010 under the title ‘Venezuela. Nationalization, workers’ control: achievements and limitations’ http://www.cadtm.org/spip.php?page=imprimer&id_artice=5587, the  second part was posted on 18 June 2010 http://www.cadtm.org/Debate-and-contradiction-in-the (see also: http://www.europe-solidaire.org/spip.php?article17417 ) under the  title ' Debate and contradiction in the PSUV (United Socialist Party of Venezuela)’; the third part was published on 24 June 2010 under the title “The Venezuelan economy: in transition towards socialism?”

[2] Eric Toussaint, Doctor in Political Science (University of Liege and University of Paris VIII), is president of CADTM Belgium (Committee for the Abolition of Third World Debt, www.cadtm.org ). He is the author of A diagnosis of emerging global crisis and alternatives, VAK, Mumbai, India, 2009, 139p; Bank of the South. An Alternative to the IMF-World Bank, VAK, Mumbai, India, 2007; The World Bank, A Critical Primer, Pluto Press, Between The Lines, David Philip, London-Toronto-Cape Town 2008; Your Money or Your Life, The Tyranny of Global Finance, Haymarket, Chicago, 2005.

[3] According to the Instituto nacional de estadísticas, in 1999, the United States accounted for 47.36% of Venezuelan exports, and imports from the US amounted to 40.61% ot the total imports of the country. In 2007, these percentages respectively decreased to 52.4% for exports and 25.8% for imports.

[4] At the end of 2008, 2,675,732 hectares had been recovered from latifundias (large estates) and farmers had been given title deeds and contracts for a total of 1,862,247 hectares.

[5] The agricultural sector accounts for barely 4.39% of GDP whereas in Colombia it accounts for 12.1%. The Latin American average is 6.22% of GDP.

[6] See Alexandra Angeliaume and Jean Christian Talet, « Mutation maraîchère et accompagnement institutionnel dans les Andes vénézuéliennes (1950-2007) » chapter 4 of the second part in Olivier Compagnon, Julien Rebotier and Sandrine Revet (eds), Le Venezuela au-delà du mythe. Chavez, la démocratie, le changement social, Editions de l’Atelier/Editions Ouvrières, Paris, 2009, 238 pages

[7] The impact of the creation of the many farming cooperatives (and other cooperatives) has been rather mitigated in Venezuela (as has been the case for other countries that prioritized cooperatives over individual family farming).

[8] Michael Lebowitz, “De los subsidios agrícolas a la soberanía alimentaria”, 2 February 2008, 7 pages.

[9] Hugo Chávez announced the launching of a debt audit when he met a hundred or so delegates of social movements from all over the world in Januray 2006 after the 6th edition of the World Social Forum, a polycentric forum held in Caracas, Bamako and Karachi. I attended this meeting, which was entirely broadcast live on public television. Chávez also made a commitment to audit the debt in late 2008, during an ALBA meeting.

[10] A first measure in this direction was taken in 2009 when Banco de Venezuela was nationalized.

[11] In this respect, see Victor Álvarez’s proposals in the final part of his document mentioned earlier.

[12] Roberto López, a professor at the University of Zulia, criticizes a process “where private company sectors, which are not necessarily those trying to overthrow the government, but private sectors allied to the Bolivarian bureaucracy, have become multimillionaires during this period. An analysis should be made of these private groups and of their relationship with the economic assets of many leaders and prominent figures of the process.  There seems to be a new Bolivarian bourgeoisie associated with business circles. For instance, a fact I heard about almost directly concerned subcontracting companies that had just been nationalized, expropriated, in the region of the Eastern Coast of the Lake and in almost all of them there were leaders who had participated in the coup (the military coup d’Etat of April 2002), in the oil lockout, and all were associated with PSUV leaders, revolution leaders, members of Parliament, Bolivarian governors, etc. ” See http://www.aporrea.org/actualidad/n136767.html

Bolivarian Venezuela at the crossroads The Venezuelan economy: in transition towards socialism?

(Part 3)[1]


Eric Toussaint[2]

The capitalist sector is growing faster than the public sector and is still predominant in Venezuela’s economy despite the nationalizations.

The share of the private sector (greatly dominated by the capitalist sector[3]) in Venezuela’s gross domestic product has grown from 64.7% in 1998 (before Hugo Chávez was elected president) to 70.9% in the third quarter of 2008.[4] Although the government has nationalized a significant number of large companies in the electricity, telecommunications, steel, food, cement and banking sectors, the capitalist sector has recorded more rapid growth than the public sector, which explains that its relative share in GDP has increased whereas the share of the public sector has decreased (from 34.8% in 1998 to 29.1% in 2008).[5]


This can be explained by the way the country’s oil income is used. The overwhelming majority of the Venezuelan State’s revenue comes from oil exports. The government massively uses the resources coming from oil to improve the living conditions of the poor majority of the population (as well as of the medium income brackets) in the fields of health (where results are impressive), education (also impressive), supply of low-priced basic products through the distribution and marketing channels Mercal[6] and Pdval[7] (staple food and other basic products for households), housing construction, the building of infrastructure and public transport (subway, train), wage increases in the civil service, increases in a large number of grants and social allowances, not to mention expenses in the field of culture and sports. It grants substantial subsidies for cooperatives, communal councils, etc. The result is clearly positive: the percentage of Venezuelans below the poverty line was reduced by half between 2003 and 2008, from 62.1% to 31.5% of the population. As for the percentage of people in extreme poverty, it was reduced by two-thirds, from 29% in 2003 down to 9.1% in 2008;[8] illiteracy dropped sharply, the level in training improved, access to free healthcare increased greatly, mass consumption rose.


But to a large extent the capitalist sector is also benefiting from government spending because it is still dominant, by a long way, in the banking sector, in trade and in the food industry. The extra money that goes to the people and comes from public spending ends up in the capitalists’ pockets because it is in the capitalist banks that individuals (and also cooperatives, municipal councils, municipalities and many other public entities) deposit their money. It is the capitalist banks that issue consumer credit facilities in the form of credit cards, and support a growing share of the consumption (and charge high interest rates for this). It is the capitalist companies of the food industry that produce or market most of the food products consumed by the masses.  It is the capitalist import companies that bring from abroad the many imported products consumed by Venezuelans. The private retail chains still dominate trade even if Mercal and Pdval are significant players in supplying basic products. When the State nationalizes private companies that belong to the national capital, it is the local capitalists that receive buyout compensations from the State.

In brief, the capitalist sector continues siphoning off most of the money spent by the State to help the poor or middle-income sectors of the population.

According to a study[9] by Mark Weisbrot and Luis Sandoval that is in fact very favourable to the Chávez government, the private financial sector grew by 37.9% in 2004, by 34.6% in 2005 and by 39.2% in 2006, while the growth of the public sector (all sectors taken together)  was only 12.5% in 2004, 4.1% in 2005 and 2.9% in 2006.

As stated by Victor Álvarez : “During the previous mandate of President Chávez (2000-2006), most financial, fiscal, exchange rate incentives, most public spending, most technical assistance, etc., went to the existing production apparatus, fundamentally consisting of commercial companies, which reproduce a capitalist mode of production that is, paradoxically, the very one we want to overtake and transcend.”

We are thus far from the assertions made by the mainstream media, which see in the Chávez administration a rampant imposition of state control over the Venezuelan economy.


Gifts made to the banks

An additional issue, stems from the policy of overvaluation of the Venezuelan currency against the dollar. This question requires some explanation. Since 2003, companies that want to import goods and services have had to buy dollars from a state administration called CADIVI. This is a useful measure taken to fight capital outflow. The problem is that the exchange rate between the bolivar and the dollar overvalued the value of the former. It therefore exacerbated a perverse pattern: for a capitalist who has a large amount of bolivars, it is more profitable to change them for dollars which are sold cheaply by the State and import products from the United States or elsewhere than to produce them in the country. Thus the policy of an overvalued bolivar deterred productive investment and encouraged trade based on the frenetic import of goods[10] and sale of the same through the big private retail networks. These massive imports are in fact subsidized by the State since the State sells the private sector the cheap dollars it has accumulated through its oil exports.  Another point also needs to be examined: how this policy of an overvalued bolivar and a high level of imports influenced the inflation rate, which has been particularly high in Venezuela in recent years. This high inflation rate reduces the impact of the pay rises granted by the government.


One vicious example of this policy of an overvalued bolivar and of gifts made by the government to the private banks: the Venezuelan State bought debt bonds issued by Argentina in 2004-2005. The problem is that it sold part of these Argentine debt bonds, drawn up in dollars, to the private banks. These banks bought them with bolivars at the official overvalued exchange rate. What did some (in fact many) of them do with these bonds? They sold these Argentine debt bonds in the United States or elsewhere to obtain dollars. This allowed them to bypass the control imposed by the Venezuelan State over capital movements. Officially, they did not export capital; they only got Argentine debt bonds out of the country.

Since then, the State has kept on making gifts to private banks thanks to similar manoeuvres.  PDVSA and other public entities issue public debt bonds drawn up in dollars that are bought in bolivars by Venezuelan banks at the official exchange rate. Then these banks sell part of the bonds on the international market for dollars[11]. In brief, the State policy has two negative consequences: first, it permits capital flight in a circuitous but perfectly legal way; second, it encourages parasitic banking behaviour (buying of debt bonds) to the detriment of productive investment.


The conclusion that can be drawn is that although the State is trying to carry out a policy of endogenous development (i.e. designed  to meet the internal demand through greater domestic production), the way the oil money is redistributed, combined with the overvaluation of the bolivar, tends to strengthen the capitalist sector and its importing pattern.


In a speech given during the meeting of intellectuals organized by the CIM, the writer and lawyer Luis Britto aptly summed up the situation: “We live in a dual society, and in a fable I wrote I explained that if one tries to set up a mixed system with hens and foxes in one single henhouse, then the following week, there will only be foxes left, and then they will eat the farmer.”[12]



Dealing with the thorny question of exchange rates: the January 2010 devaluation

In January 2010, the government carried out a devaluation. What does this devaluation consist of? Two official rates were set: the first one represents a 21 percent devaluation of the bolivar against the dollar (instead of 2.15 bolivars, 2.6 bolivars are needed to obtain one dollar); the second rate represents a 100 percent devaluation (one has to pay 4.3 bolivars for one dollar instead of 2.15 bolivars). The first rate (2.6 bolivars per dollar) is in force for expenses considered to be vital or at least to be a priority: imports of food, medicines, technologies, equipment for industrial or agricultural production, imports made by the public sector, the payment of scholarships to Venezuelan students studying abroad, of pensions to retired people living abroad. The second rate (4.3 bolivars per dollar) is applied to imports of automobiles, beverages, tobacco, cell phones, computers, home appliances, textiles, chemical and metallurgical products, rubber, etc.


In the short term, this devaluation will increase the State’s tax revenues. The dollars that the State gets from oil exports will be sold for a larger amount of bolivars. This is certainly one of the main goals pursued by the government which has seen its tax revenues dwindle due to the impact of the international crisis on the country’s economy. But this does not mean that the Venezuelan State is going to win on all fronts. The repayment of the public debt, 67.8 percent of which is drawn up in dollars, will cost the government more. The Venezuelan bankers and other capitalists who bought debt securities drawn up in dollars will get richer once again.


Obviously there are other consequences: for the workers and all low income earners who receive this income in national currency, the devaluation means lower purchasing power: the cost of the products they consume will be higher because many products are imported or produced in the country with a large imported component. Importers, retailers, producers will pass on the additional costs to the retail price. This loss of purchasing power can only be limited or compensated if wages increase in proportion to the cost of living, which is not the case. On 1 May 2010 Hugo Chávez decreed a 15 percent increase in minimum wages and pensions but inflation reached 25 percent in 2009 and will probably be even higher in 2010.


This devaluation aims at other objectives in the longer term, but it would be risky to say whether they can be reached or not. Among these objectives, the most important one is certainly the promotion of import substitution. Since importing now costs 21 or 100 percent more (depending on the products imported), imports should decline and local producers should be in a better position for selling their production on the national market. Even better: the devaluation should convince them that it is profitable to produce products that were formerly imported. This could create a virtuous circle thanks to which the country could strengthen its industrial and agricultural base by replacing imported products with local ones.



Translated by Stéphanie Jacquemont and Judith Harris, in collaboration with Francesca Denley and Christine Pagnoulle

Next part: Suggested paths to 21st century socialism in Venezuela (Part 4)

[1] The first part of this series ‘Bolivarian Venezuela at the crossroads’ was posted on the CADTM website on 14 April 2010 under the title ‘Venezuela. Nationalization, workers’ control: achievements and limitations’ http://www.cadtm.org/spip.php?page=imprimer&id_artice=5587, the  second part was posted on 18 June 2010 http://www.cadtm.org/Debate-and-contradiction-in-the (see also: http://www.europe-solidaire.org/spip.php?article17417 ) under the  title ' Debate and contradiction in the PSUV (United Socialist Party of Venezuela)’

[2] Eric Toussaint, Doctor in Political Science (University of Liege and University of Paris VIII), is president of CADTM Belgium (Committee for the Abolition of Third World Debt, www.cadtm.org ). He is the author of A diagnosis of emerging global crisis and alternatives, VAK, Mumbai, India, 2009, 139p; The World Bank, A Critical Primer, Pluto Press, Between The Lines, David Philip, London-Toronto-Cape Town 2008; Bank of the South. An Alternative to the IMF-World Bank, VAK, Mumbai, India, 2007; Your Money or Your Life, The Tyranny of Global Finance, Haymarket, Chicago, 2005.

[3] For instance, the share of social economy within the private sector is very low: it reached 1.6% of gross domestic product at the end of 2008, up from 0.5% in 1998. Out of a total of 11,692,071 working people at the end of 2008, only 201,773 work in the social economy cooperatives, i.e. barely 1.7%.

[4] See Victor Álvarez “The transformation of the Venezuelan productive model : review of ten years of government”, Revista La Comuna n°0, p. 37 to 55. Victor Álvarez was Minister of Basic Industries in the Chávez government from January 2006 to August 2007.

[5] This statement has to be qualified: until 2002, although a public company, the operation of PDVSA (Petróleos de Venezuela Sociedad Anónima) had progressively favoured the private sector. A large part of its revenue was declared and taxed in the United States. The measures taken by the Chávez government from 2002 onwards enabled the State to take over the company’s management, which resulted in a strong increase in revenue to be later used to finance social policies.

[6] The Misión Mercal S.A. (MERCado de ALimentos) is one of the social programmes promoted by the Venezuelan government. Officially launched on 24 April, 2003, the Misión Mercal is designed to serve the food sector and comes under the control of the Ministry of Food. The programme involves building shops and supermarkets and supplying them with staples and basic products at low prices that are affordable by the needy.  Food products are subsidized and arrive on the shelves without middle-men, so that the prices offered usually represent a discount of 30% to 45%, compared to the prices charged in other distribution channels.   http://es.wikipedia.org/wiki/Misi%C3%B3n_Mercal

[7] Productora y Distribuidora Venezolana de Alimentos (Pdval) was created in January 2008 http://www.abn.info.ve/go_news5.php?articulo=117377

[8] Quoted by Victor Álvarez.

[9] See Mark Weisbrot and Luis Sandoval, The Venezuelan Economy in the Chávez Years, Center for Economic and Policy Research, Washington, 2007, www.cepr.net

[10] A personal anecdote: in late November-early December 2006 in Caracas, I was utterly astounded to see in the middle-class neighbourhoods that thousands of Christmas trees imported from Canada were being sold. In the shops, they were also selling quantities of devices to spray artificial snow on the trees. It should be added that in Caracas the temperature around Christmas is over 20°C. The massive import of Christmas trees from the Great North is very profitable thanks to the overvalued bolivar. It is true that Chávez criticized this pattern of systematic imports, all the more so as, he said, it was linked to cultural traditions (Santa Claus for instance) that were also imported and unquestioningly adopted to the detriment of local cultures.

[11] The foreign financial papers The Economist and the Financial Times regularly stress that Venezuelan private banks are very pleased with this opportunity given by the State to bypass capital movements control.

[12] See http://www.cadtm.org/IMG/article_PDF/article_a4492.pdf and Martha Harnecker “Selección de las opiniones más destacadas de los intelectuales reunidos en el CIM” (Selection of the most prominent opinions of the intellectuals in the CIM meeting) http://www.rebelion.org/noticia.php?id=88131 which takes up extracts from several speeches given during the meeting of intellectuals organized by the CIM in early June 2009.

Bolivarian Venezuela at the crossroads Debate and contradiction in the PSUV (United Socialist Party of Venezuela) (Part 2)

Eric Toussaint[1]

During the 2007 constitutional referendum, one might have thought that the party created by Hugo Chávez in 2006 was stillborn since fewer people voted 'Yes' than the number of people officially enrolled in the party.[2] But this impression was partially belied in the following months: grassroot meetings multiplied, which resulted in the nomination of candidates for the municipal elections and for governors of the 23 states that make up Venezuela. However, the process is contradictory. While participation from the party’s rank and file was active and effective and while grassroot members did appoint candidates for the elections, the fact stills remains that when it came to the party’s executive board, ordinary members could not vote for all the leaders and Chávez himself put his government’s ministers in the party's key posts (for example, the 8 vice-presidents of the PSUV). This creates a regrettable confusion between the State, the government, and the party.

In this respect some voices have been raised within the PSUV to challenge the fact that the party’s management and coordination are left to the ministers who are already overloaded with their governmental mission. Moreover their position as ministers gives these leaders the power to disproportionately influence the decisions taken by the party. It is also easier for them to influence some party members when the latter are called to the polls. A critical view, shared by a substantial number of activists, was expressed by Martha Harnecker as follows: “One of the things that surprise us and, I imagine, must shock people abroad, particularly in Europe, is that the State is the instrument with which the party is built. It is in clear contradiction with our vision of the party.[3]

Gonzalo Gómez, a PSUV activist and co-founder of Aporrea, also shows concern regarding the relationship to be built between the party and popular power (which he also calls “the constituent player”): “The party can seek to propose and give direction, accompanying social movements in the building up of popular power, but it cannot subjugate popular power: in other words subjugate this constituent player by the constituted power.”[4]




Communal councils: when “constituent power” challenges constituted power


The law entitled Ley de los consejos municipales (LCC)[5] was voted without any genuine debate on 7 April 2006. Its article 3 states: “The organization, functioning, and action of communal councils must meet the principles of co-responsibility, cooperation, solidarity,  transparency […], honesty, effectiveness, efficiency, social responsibility, social control, equity, justice, and gender and social equality.” (art. 3, LCC)

A citizens’ assembly (Asemblea de ciudadanos y ciudadanas), “the grand decision-making body of communal councils” (art. 6, LCC), must consist of at least 20% of inhabitants from the age of 15 and over (Consejos comunales, Expresión del poder popular). The communal council defines its jurisdiction, and its members are not paid (art. 12, LCC). Its various areas of intervention are defined as follows: “Health, education, land management in towns or rural areas, housing, social protection and social equality, popular economy, culture, security, communication and information, leisure and sports, food, technical guidance on water, technical guidance on energy and gas,  services, and any other matter the community may decide useful to proceed with.” (Art. 9, LCC)


President Hugo Chávez set up communal councils back in 2006, as a way of introducing participation in the drafting and implementing of local policies. The government sets great hope in these councils, which it sees as “territorial grassroots units of popular participation and self-government. As the president said, this “revolutionary explosion of popular power” must be the realistic and sustainable basis for a new type of state, for “a socialism of the 21st century.” (…)

Talking about the 15,000 councils already extant in June 2007, Juan Leonel M. (FONDEMI, Microfinance Development Fund) does not hide the fact that relationships with municipalities are sensitive: “Actually the mayors, or at least many of them, are opposed to this new mode of election and way of organizing communities. They see the communal councils as organizations in competition with their own administrations. But the idea today is that the established power must move hand in hand with the constituent power of communal councils. The State is initiating a revolution within the State system. The people’s constituent power must be the motor of change. Communal councils are the cornerstone of municipal self-government where the people have direct access to power.” [6]


The 2006 law on communal councils is currently being changed. It is likely to be replaced shortly by a new law that is being drafted[7]. To know more about this experiment, read Martha Harnecker’s books on the subject. She lives in Venezuela and has devoted much time in the last few years to the experiment with communal councils.[8]



The PSUV Congress was held in several sessions from November 2009 to April 2010. The 772 delegates who took part in the Congress were elected in a secret ballot by rank-and-file party members (according to official figures, half of the 7,253,691 party members turned out for these internal elections). There were very few workers and company trade unionists among these delegates; on the other hand many delegates were employees who are answerable to the party or to local authorities and are therefore easily influenced. Even though Hugo Chávez, as president of the party, called on delegates to act in Congress as spokepersons for the popular base and social movements, with Congress composed as it was, it is hard to see how this could really lead to positive results.


In June 2009, the PSUV was the center of attention and debates, when thirty of the most eminent intellectuals invited by the Miranda International Center[9] discussed the progress of, and remaining obstacles to, the revolutionary process currently taking place.

The CIM published a summary[10] of these days for reflection entitled “Intellectuals, democracy and socialism: dead ends and paths to follow”.

Here are some extracts from the summary which give an idea of what is at stake in the party itself and beyond, if a genuine revolutionary project is to be implemented.

“What is the future of a party whose base rarely gets the opportunity to have their say? (…) Is this non-separation between State and party merely repeating a mistake of the 20th century socialist model? Was the PSUV created as a top-down structure out of a political necessity felt by the government, rather than a necessity felt by the base?

Another important aspect that came up several times was the need for collective leadership of the party, which is effectively based on grassroots social movements (and which does not merely use them as the government’s communication channel during election periods), thereby putting an end to harmful, partisan vote-catching. This would create the base of a true revolutionary party which recognizes the right to express criticism and which fosters greater democracy within the party.”

Among other issues debated: the nature of the new revolutionary State (“If the State was the instrument used by neo-liberalism to implement its own agenda, should it also be used to free us from neo-liberalism? Can this State put us on the path to socialism or, on the contrary, it is an obstacle to socialism?); the role of the media, both pro- and anti-Chávez; the characteristics of the revolution – it was said that it contained “many types of revolutions within it: student, farmer, worker, socialist, feminist, military and popular”, thus the need for a constant dialogue between these groups; the definition of 21st century socialism; popular participation, especially through communal councils (see box above), which were described as “a prime example of participation” but “not [playing] a sufficiently participatory role” in practice because “they run the risk of being co-opted by the party”.


The final issue considered during the meeting concerned the place and role of criticism in a revolutionary process, and the main question discussed was the following: “Is it possible for a revolution to succeed if it does not make criticism one of its main driving forces?” It was acknowledged that “criticism has lost some of its rightful place. In media that are sympathetic to the process, it is not difficult to find reactions reminiscent of 20th century socialism where those who openly criticize are accused of being “counter-revolutionaries” or “CIA agents”. This considerably weakens the process as it prevents the government from implementing changes when things are not working.” At the same time, the intellectuals said they “were pleased that the Executive had given them a space for criticism - something which had not happened in ten years. They also stressed the fact that this event proved that fear of criticism was unfounded. The claim made by the anti-Chávez opposition that there is a lack of freedom of expression in Venezuela is equally false.”

The controversy raised by this meeting showed how relevant these questions are. These days were broadcast live in full on a public channel (TVES) and then re-broadcast over a period of some 10 days. Important sectors of the government strongly criticized the CIM initiative as well as the content of these meetings. Among the critics were the Minister for Oil, Rafael Ramirez, and the Minister of Foreign Affairs, Nicolas Maduro, both of them important political figures in the PSUV. One of the pro-Chávez daily newspapers, VEA, published several articles condemning the CIM initiative and stating that, “they convene meetings amongst intellectuals whose positions are confused, whilst allowing them to let off steam at Chávez’s leadership which they describe as a “hyper-leadership” or “progressive autocracy”. Without a doubt, these are pro-Chavist supporters without Chávez, ashamed to show their true colors and get on the other side of the fence.” (published 6 June 2009 under the collective signature Grano de maíz).

After ten days of controversy, both in the pro-Chávez and the opposition press, Hugo Chávez, in his televised programme Aló Presidente of June 14, seemed to agree with those who criticized the International Miranda Centre (CIM). That merely served to increase public interest in the event: different trade union worker leaders as well as the Communist Party of Venezuela and “Homeland for All” (two parties which support the government while refusing to join the PSUV) have defended the CIM and stated that the critical contribution of revolutionary intellectuals was a positive event. It was feared that at some point the CIM would be brought to heel or even shut down but nothing of the sort has happened. This shows once again the complexity of the changes taking place in Venezuela, whose government cannot be considered as totalitarian.


Translated by Francesca Denley, Judith Harris, Stéphanie Jacquemont and Christine Pagnoulle

Next part: The Venezuelan economy: in transition towards socialism? (Part 3)

PART 1 “Venezuela. Nationalization, workers’ control: achievements and limitations” is online: http://www.cadtm.org/Venezuela-Nationalization-workers



[1] Eric Toussaint, Doctor in Political Science (University of Liege and University of Paris VIII), is president of CADTM Belgium (Committee for the Abolition of Third World Debt, www.cadtm.org ). He is the author of A diagnosis of emerging global crisis and alternatives, VAK, Mumbai, India, 2009, 139p; Bank of the South. An Alternative to the IMF-World Bank, VAK, Mumbai, India, 2007; The World Bank, A Critical Primer, Pluto Press, Between The Lines, David Philip, London-Toronto-Cape Town 2008; Your Money or Your Life, The Tyranny of Global Finance, Haymarket, Chicago, 2005.

[2] Officially, six million Venezuelans joined the PSUV at the time of the referendum on 2 December 2007. And yet the ‘Yes’ won only a little more than four million votes, some of which certainly did not come from  PSUV activists since the PCV (Partido Comunista de Venezuela, Communist Party of Venezuela) and the  PPT (Patria Para Todos, Homeland For All), among others, called for a ‘Yes’ vote. In fact, during the phase when the party was launched, ministries were given membership targets, which resulted in a flawed process and an artificial inflation of membership figures.

[3] Speech of Martha Harnecker on the occasion of the meeting “Intellectuals, democracy and socialism: dead ends and paths to follow organized by the CIM http://www.rebelion.org/noticia.php?id=88031

[4] Speech of Gonzalo Gómez on the occasion of the meeting “Intellectuals, democracy and socialism: dead ends and paths to follow organized by the CIM http://www.aporrea.org/actualidad/n136570.html

[6] Quoted in « Les conseils communaux au Venezuela : un outil d’émancipation politique ? », by Anne-Florence Louzé, in Olivier Compagnon, Julien Rebotier and Sandrine Revet (eds), Le Venezuela au-delà du mythe. Chávez, la démocratie, le changement social, Editions de l’Atelier/Editions Ouvrières, Paris, 2009, 238 p.

[8] See Martha Harnecker “De los consejos comunales a las comunas” http://www.rebelion.org/docs/83276.pdf. This 61 page  study includes a bibliography of Martha Harnecker’s 21 books  on the subject of popular participation. Read also, by the same author, “Las Comunas, sus problemas y cómo enfrentarlos” http://www.rebelion.org/docs/90924.pdf

[9] The Miranda International Center (CIM) is an official institution created by the Venezuelan presidency and financed by the Ministry of Higher Education.

[10] The complete summary (in French and Spanish) is online on the CADTM website at http://www.cadtm.org/Venezuela-premiere-synthese-de-la and http://www.cadtm.org/Primera-sintesis-del-encuentro

From Water Wars to the Fight for Climate Justice

Pablo Solón

 on the Lessons of Cochabamba

July 4, 2010


A Speech by Pablo Solón, Bolivia’s UN ambassador, to the Shout Out for Global Justice, attended by nearly 3,000 people on June 25 in Toronto.  Video of the event, which was sponsored by the Council of Canadians, can be viewed at rabbletv.

First of all, I think you [the MC who introduced Solón] have made a mistake. I am not the ambassador to the US, I am the ambassador to the UN, because we have kicked out the US ambassador in Bolivia and we don’t have an ambassador in the United States.

You know I met Maude Barlow and Vandana Shiva about 10 years ago. I remember it very well because it was at a meeting in Geneva after the water wars in Cochabamba in Bolivia, after we expelled the Bechtel corporation that was privatizing the water.

In those days I was a water warrior, now I am a water warrior ambassador. And now I only have a new possibility, that is to continue the fight we began more than 10 years ago. We have discussed very much with Maude, with Vandana and many of you, that there is something that we must do: We have to have water declared as a human right in the UN.

We have declared in the UN the right to food, the right to health, the right to education, the right to shelter, the right to development – but not the right to water. And we all know that without water we can’t live. So nobody can argue that it is not a basic and fundamental and universal human right, but despite this it has not been, until now, recognized as a human right.

So we have presented, two weeks ago, a draft resolution, so that this coming month, in July, we expect to have a vote in the General Assembly of the United Nations. And we want to see which countries are going to vote against that resolution, we want to vote to see which governments are going to say to humanity that water is not a human right. We want to expose, like sometimes you have to expose vampires, to public opinion.

Ten years ago we needed your help and you gave it to us. It was after the water war, when we expelled Bechtel, Bechtel sued Bolivia. They presented a demand to this arbitration panel of the World Bank. It was a demand for $30 to $100 million, even though they were only in Bolivia for six months. And, with a global campaign, we managed to have Bechtel at the end of five years saying ‘we are going to give up our demand, we are going to sell you everything.’ And they sold us everything for one dollar.

Why were we able to do that? Because in California, in Washington, in New York, here in Canada, in Europe – all around the world – activists, trade unions, social movements, NGOs, began to mobilize and say ‘it is unjust to put a suit against Bolivia for $30 to $100 million for the right of Bolivians to decide what they are going to do with their water service system in the city of Cochabamba.’

Now we need your support again. Because this resolution that declares the human right to water is not going to pass if we don’t build a global mobilization around the whole world, in Canada, in the United States, in Europe. We are discussing one of the key issues and it is necessary to have and to build this global political coalition now, and to act very strongly in the coming days. So, we are counting on you.

After the water war, for Bolivia, that was a very important moment. Because until the water war, we had lost all the battles in the social movements. We lost the battle against the privatization of social security, the battle against the privatization of the energy system, the privatization of gas, the privatization of railways, but when we won this battle against the privatization of water we said ‘we can do it.’

And we began to strengthen forces, the indigenous people, who are the majority in my country, came together with social movements, trade unions and we said ‘now we have to recover our natural resources’ that had been privatized, if we want to have another future.

And a big movement was built in order to nationalize the gas and oil company that was privatized. Before, when it was privatized, 82 percent of the revenues went to the companies and only 18 percent to the state.

So we built a movement and we realized that in order to accomplish the nationalization of the gas and oil company we also had to take control of the government. We had to nationalize our government.

And, after an election, an historic election, in the year 2005, President Evo Morales, with what we call the political instrument of the social movements, won for the first time with 54 percent of the votes.

Four months later, on May 1, we nationalized the gas and oil company. And when we nationalized it, then we said, ‘now 82 percent is going to be for the state and only 18 is going to be for the foreign investor.’

And they told us everybody’s going to run out, nobody is going to stay to administer that, but in the end we renegotiated 42 contracts under these new rules because even with 18 percent they have profits. And we have 82 [percent].

You know they have the G8/G20 model, but we have another model. If we take control, as a society, of our companies, of our resources, we can have enough money, first, to create more employment. In Bolivia, employment hasn’t decreased, it has increased. We have raised salaries, we have increased social benefits. Why was it possible? Because we control, now, the economic power of the country, not the corporations.

And we don’t have a fiscal deficit, we have a surplus. So there are two models, and this is the discussion that should have taken place. It’s not a discussion between stimulus package and austerity, between Europe and the United States, it’s a discussion between the society taking control of the economy, or the corporations. That is the main discussion. And the example of Bolivia shows that it’s possible. It is possible.

So for us, the main thing, our main lesson is that every time there is a problem we need to appeal to the people, to the social movements. For us, when we had this problem in Copenhagen, where they tried to impose this Copenhagen Accord – I remember it, at 3 o’clock in the morning, I was there. We said what are we going to do? Let’s call for a people’s world conference on climate change and Mother Earth rights. Because if we have to have a response, it has to be with the social movements of the world.

And between the 20th and 21st of April, we had this people’s conference and we discussed, what are we going to do? That’s the key: what is our agenda? We know what their agenda is. What’s our agenda?

And we said, ‘there is a problem here’. The problem is really very big with climate change. Because if emissions are not reduced in the short-term, not in the long-term, the temperature is going to rise – right now it’s more than 0.78 or 0.79 degrees more than it was in the pre-industrial era – if this keeps on we will see two, three degrees increase, four, five.

And what does that mean? Our glaciers are going to melt, Africa is going to burn, some island states are going to be beneath the ocean, food production is going to be reduced by about 40 percent, depending on how much the temperature increases.

And we only have these coming decades to act. Each year we lose is something like 35 or 40 gigatons of CO2 that is thrown into the atmosphere. So we need to act fast.

And we said in this people’s world conference, we want to have a reduction of 50 percent of greenhouse gas emissions, in a domestic way, without market mechanisms, without offset mechanisms, approved in the next negotiation on climate change that’s going to take place in Cancun, Mexico. And this is key. If we are not on board on this issue, we, our children, our grandchildren, are going to have a very bleak future. We must engage in this key issue if we want to change the future.

But another issue that is very important for us is the issue of Mother Earth rights. Why is this so important for us? Because in their agenda, what they say is that they have failed because privatization hasn’t gone further, to nature. So now is the time to privatize even nature – carbon markets, carbon rights, environmental services, water.

And we say No!, the alternative is not that, it’s precisely the opposite. We must recognize that there are things, beings, that cannot be commodified, that have rights as we have rights.

So we have presented, in the UN, a draft proposal of a resolution on the Declaration of the Universal Rights of Mother Earth – the right to live, the right to regenerate its biocapacity. That for us is key, it is the key thing of this century. That is why we have begun to build a movement to defend Mother Earth.

As [the MC] said, you are now all part of the Council of Canadians. I can say that you are now all part of the global movement for Mother Earth.

Just to finish with one very important message. What are we going to do with this plan of security, of authoritarianism, militarism. What is our alternative? We have also discussed this in Bolivia, and we said we must promote a global referendum, a worldwide referendum. We must call not G20, not only ‘G192′ – that is, the General Assembly of the UN, very important – but we have to call this 6 billion that Vandana [Shiva] was speaking about. A global referendum where we can ask the people: Do you agree, in the second commitment period of the Kyoto Protocol, to reduce greenhouse gas emissions by 50 percent? Do you agree with Mother Earth rights? Do you agree that military budgets should be redirected to solve climate change issues and not to promote war?

So the key thing, against authoritarianism, is democracy. Global democracy, all around the world. Thank you very much.

Ruling Class Offensive in Pakistan

Labour Leader killed for forming union in Faisalabad 

Mustansar Randhawa, a Labour Qaumi Movement leader in Faisalabad was killed today by unknown persons while he was sitting in the office of LQM Sarghoda Road Sector area. He has been receiving death threats from the power looms and textile mill owners for the last few days. His crime was to organise LQM in an area, no one dared to do that earlier. He was also president of National Trade Union Federation Faisalabad.
Labour Qaumi Movement had announced a strike of the textile sector on 6th July in a press conference on 4th July. On 5th July, the administration of Faisalabad called the union leaders for negotiations. LQM demanded wage increase according to the Minimum Wages Board notification, a 17 percent wage increase. The bosses was reluctant to do that. After late night negotiations which went on till 1.30am on 6th July, it was agreed to postpone the strike and bosses agreed to some demands. The negotiations were to start again today when the news came that Mustansar Rindhawa (35) is been killed by firing of unknown persons while he was sitting in the office. Two person came on motor cycle and fired at him in the office. He died on the spot. Another member of the union had just left to the next door to fetch water while he was shot at. He escaped luckily.
Mustansar Rindhawa was one of the proud participant of a trade union leadership workshop on 19/20 June in Faisalabad. In the picture attached, he is sitting with others on that occasion. The workshop was organised by Labour Education Foundation.
The LQM leadership in consultation with LPP is discussing the future actions in response to this incident. Workers are gathering at Faisalabad hospital where the body is been brought already. Labour Party Pakistan Labour secretary Nasir Mansoor, general secretary Nisar Shah and spokesperson Farooq Tariq has condemned this killing and demanded an immediate arrest of the murderers. They said in a joint statement that the labour movement in Faisalabad can not be silenced by such brutal actions. The workers of the Pakistan will respond by organizing strikes and demonstration to condemn this killing.
Farooq Tariq
Labour Party Pakistan
40-Abbot Road Lahore, Pakistan
Tel: 92 42 6315162 Fax: 92 42 6271149  Mobile: 92 300 8411945
This email address is being protected from spambots. You need JavaScript enabled to view it. www.laborpakistan.org www.jeddojuhd.com

ATTACK OF ISRAEL ON THE JOINT FLOTILLA - A premeditated crime that challenges the human conscience

It is not the first time that the Israeli State has launched such violent assaults on the inalienable rights of Palestinians to live in peace in their own land. For decades it has been ignoring the decisions of the international community which attempted to install a peace with justice in West Asia. Despite several UN resolutions to the contrary, Israel is building an ‘apartheid wall’ inside the Palestinian territory of West Bank making everyday lives difficult for the inhabitants. The Operation "Cast Lead" and the resultant slaughter unleashed by the Israeli armed forces at Gaza, eighteen months back,  have  established a permanent and inhuman blockade depriving people of essential elements for life and preventing them from rebuilding their homes destroyed during the military operation.

The latest in this series is an attack on the flotilla by a brigade of the elite Israeli Navy. It is utter shame that Israel could commit such an act of war against unarmed and unguarded civilians who, moved by feelings of solidarity and camaraderie came forward to assist the people of Gaza.  They were carrying with them 10 tons of food, medical equipments, construction materials and other inputs that had taken months to gather. Among the 750 in six boats, there were citizens of 30 countries, women with children, volunteers from various religions and nationalities, more than twenty MEPs, a former U.S. congressman, an Israeli intellectual committed to human causes, a Nobel Peace Prize winner and even a survivor of the Holocaust as well as leaders of organizations of solidarity and peace groups. It is a matter of complete disgrace that these people and their unarmed ships (earlier reviewed by relevant authorities at different ports of departure) were attacked in international waters, from warships, helicopters and boats using pump smoke, tear gas, batons and guns with lead bullets, leaving 16 dead and dozens of injuries, and the rest taken as prisoners by the Israelis. The Flotilla, which was attacked in international waters in violation of international law, was carrying relief supplies that Israel has persistently prevented from entering Gaza, including medical supplies, cement and food. Israel’s siege is considered a form of collective punishment, a war crime under Article 33 of the Geneva Convention.  All of the relief workers and activists on board the Gaza Flotilla ships were unarmed. In legal terms, Israel’s military assault against the Flotilla is an act of aggression against the countries whose flags the ships were carrying; politically, it is an assault against human politesse and all people of conscience around the world who support freedom and justice.

Over the days and the arrival of witnesses and new information, the initial shock gave way to deep limitless pain, outrage and, the need to reflect on what happened. How does the State of Israel audaciously challenge human conscience, flagrantly violating international law and basic norms of coexistence among nations? This is due to their positions of strength that is directly derived from the support they receive from Big Powers and in particular, to the US military aid. It is worth emphasizing that the State of Israel is the largest recipient of US military aid allowing it to be heavily armed and to have the most sophisticated military technology, including nuclear weapons. Diplomatically, the US aids Israel by its interventions. The US State Department nudges hostile countries to mitigate their opposition and unfriendly ones to reexamine their policies toward the Jewish state.

Under such unjustifiable use of force and violations of international and humanitarian laws, the protests from major powers that matter to the Israeli State have been feeble and meager. The UN Security Council condemned the fact but not the perpetrators, the European Union expressed concern and requested an investigation which is highly insufficient, it is not enough for President Obama and the US State Department to simply mourn the loss of human lives in what they call an "incident" while avoiding any condemnation of what was not an incident but an atrocious attack.

Israel’s impunity is the direct result of the international community’s failure to hold it accountable for its ongoing occupation, colonization and apartheid against the Palestinian people. Israel’s most recent war crimes committed in Gaza and documented in the Goldstone report as well as crimes committed in 2006 against the Lebanese people did not trigger any UN or official sanctions, entrenching Israel’s feeling of being above the law. In fact, Israel’s grave violation of international law was recently rewarded when the OECD voted unanimously to accept its membership.

Our stand in this issue can be summed up as follows:

  • We condemn the treacherous attack perpetrated on 31 May by the Israeli State against the humanitarian fleet, and we demand an independent international investigation.
  • We demand the lifting of the illegal and inhuman blockade of the people of Gaza.
  • We demand a damning statement of the UN, and other international organizations.
  • We demand on governments especially, the Indian government to take all necessary diplomatic measures to express the strongest condemnation of this intolerable crime and withdraw any form of support to Israel.


It is lamentable that the Government of India which for decades was a supporter of the Palestinian cause is currently sparing no efforts to woo Israel.  Post Cold-War the Indian government was brought in the US-axis. The Washington factor played a key role in Indian government’s decision in January 1992 decision to normalize relations with Israel. India announced the decision to establish full diplomatic relations, a few hours before the then Prime Minister Narasimha Rao left for the US to attend the summit meeting of the U.N. Security Council where he was slated to meet President George H.W. Bush. After the normalization of ties with Israel, India is an important market for Israel’s military-security exports and is currently part of a larger, ongoing “strategic dialogue” with Israel on topics ranging from Afghan terrorism to Iranian missile development. In the past decade, India has acquired Israeli weapons systems to the tune of $8 million. This relationship is spurred by a growing consensus on emerging ‘threats’ and an expanding agenda of shared regional interests; Israel and India have drifted closer together. The implications of this growing convergence are profound, both for the countries themselves and for the US, whose West Asian policy plays a major role in bringing these forces together. During the last decade, not only has Israel become the second largest exporter of defense hardware to India, extensive Israeli cooperation in non-defense sectors are on a rise—such as agriculture as Tel Aviv is a world leader in drip irrigation.

Arms sales form the backbone of the Israeli economy and massive Indian orders not only helped resuscitate its military industrial complex but also contributed to the perpetuation of Israel’s occupation. India not only purchases arms from the Israel but also engages Israeli military officers to train its army to counter insurgency in Indian administered Kashmir and the seven sister states in the Northeast – Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura.

We demand that India should cut off all its relations, diplomatic, trade or otherwise, with Israel and a case must be registered against it in the International court of justice. The Government of India must do an overhaul of its foreign policy and play an active role in demanding action against Israel for human rights violation and war crimes. The Government of India must take sincere efforts in ensuring that Israel immediately ends the unlawful blockade of the Gaza Strip and pressure Israel to guarantee unrestricted humanitarian access and freedom of movement of people and products into and out of the Gaza Strip. It should also raise the demand for bringing to justice all Israeli officials and military personnel who took the decision and/or implemented this latest massacre as well as earlier war crimes;

We express our deep appreciation to the volunteers who staged the bold joint initiative aimed at breaking the Israeli blockade of Gaza’s population, at the same time accompany the pain of relatives and colleagues of victims of the attack; We reiterate our firm solidarity with the Palestinian people claiming their  inalienable national rights based on respect for international law, including the right to the setting up of an independent Palestinian state that can live in peace with other people of the region; 
We also express our respect and solidarity with groups and individuals who, within the State of Israel, working for peace with justice and dignity for their own community and for all people of West Asia.

Finally, for the younger generations who have grown up knowning only the story narrated by the cictors of the Cold War, this attack by Israel should come as an eye opener. With this attack Israel has proved that it cares nothing for international legality, even if it is the legality of United Nations, the one that led to the creation of this colonial-settler state.At the same time, if only te legality of the UN is relied upon, then any struggle for the rehabilitation of the millions driven to the camps in Palestine will be restricted to palliatives, for the creation of a Zionist state implies creating Palestinians as a permanent underclass.  

This massacre has also evidenced that theZionist state of Israel is willing to ruthlessly murder not only the Palestinian people but also those who dare to help them out of the east of humanitarian motives. Nor is this a one off occurrence, as this was what happened to the American Jewish activist, Rachel Corrie, who peacefully opposed the destruction of Palestinian houses and was crushed by an Israeli bulldozer seven years ago.

Finally, this new massacre proves that there is no peaceful solution for Israel. They responded to the peaceful activists of the flotilla with killings. The hypocritical US comments, and those by other capitalist powers, do not mean anything. It is only through international solidarity struggles by ordinary people that any positive development can happen.

From Philanthropy to Human Rights: A Perspective for Activism in the Field of Health Care

Amar Jesani

This is the key note addresses at the Conference on “Towards people centred development”, for the celebration of the Diamond Jubilee of the Tata Institute of Social Sciences, Mumbai, November 1 to 4, 1996.*

In last three decades the campaigns on health issues have come to occupy a rightful place in the agenda of social activists and social workers. The efforts of health activists in this period have gradually brought health issues into the consciousness of a broader section of people. Some educational and training institutions have separate departments studying and teaching health and health care. New institutions, exclusively devoted to research, education, training, etc. in health and health care have been established. The popular media for long highlighted only the spectacular achievements of medical sciences. However, they too have started giving better coverage to the health issues which affect masses. There is increasing evidence to suggest that in coming time the health issues may figure more prominently in the national debates than ever.

Ironically, when health issues are emerging as issues of everybody’s concern, the activist organisations working specifically on health and which were in the first place responsible for bringing health on to the agenda of so many other organisations and movements, are showing signs of profound crisis and decline. This paradox is perhaps inevitable and points to the need for fresh thinking. Its inevitability flows from the very fact that the health issues have spread beyond the confines of the health activist groups, making the work on health by these organisations less prominent than it was in the past. The health activist groups are thus required to cope with new reality, reintegrate their efforts with others and develop a perspective that could knit multiplicity of efforts into a larger movement for changes in the health situation. The responsibility of other social forces and organisations dealing with health issues is equally daunting, for they have developed concerns on some of the health issues in the same line taken up by the health activist groups for so long. There is also a danger that their work on the health issues might remain episodic, devoid of real strategic significance in their struggle for social change. Thus, the need to understand lessons of last three decades of health activism and evolving an integrative perspective on health has become more urgent than ever.

What are health issues?

It has always been difficult to clearly define health. I take the easiest way by using the most quoted definition. The World Health Organisation (WHO) defines health as “a state of complete physical, mental and social well being and not merely absence of disease or infirmity”. This definition is widely accepted as it not only puts the health care intervention into proper perspective but also emphasises need to integrate all developmental efforts which could make healthy living possible. Thus, health is one of the essential goal of all developmental efforts. Taken from this angle, even when “health issues” did not separately appear in the development and in people’s struggles, those developments and movements were also for improving health. Struggle for better wages, for land, etc. and strategies for rural development, poverty alleviation, community development etc. were therefore also geared to the task of achieving better health status for people. Second point emerging from the WHO definition is that if the health is “a state of well being”, such a state cannot be static. So it is not possible to say that if one has achieved certain health status indicators, one has achieved health once and for all. Whenever certain health indicators are used as goal for achieving health, they only mean presently desirable or socially acceptable level of well being. The state of well being is thus very much a product of people’s perception and understanding of health and objectively, of the stage of development or the kind of socio-economic system that the development promotes.

Thus, improvement in health status or its deterioration is an invariable part of any development. And each achievement of a level of health status creates new state of well being which in turn lays foundation for further development for better health. That makes the whole debate on how and for whom the development should take place, essentially a debate on health. There are four terms, which provide key to the genuine development. They are equity, participation, empowerment and sustainability. The equity addresses to correction of the mal-distribution of control over and access to resources. The participation ensures equal opportunity and creation of conditions for utilisation of opportunities, and it is not only in terms of benefiting from the developmental programmes but in terms of participation in formulating and implementing development plans at the local and national levels through the democratic institutions. In a way, it also demands the extension of democracy from the political sphere to social and economic spheres. The equity and participation should be empowering in nature, that is, they should provide education, technique and skills for exercising and sustaining control over the development process by the people. And lastly, such genuine development should not be episodic, excessively dependent (thus perpetually at the mercy of outside forces), and has internal dynamism for sustaining it in the medium and long term. Going one step farther, one can even say that sustainability does not mean static sustenance at one point, but also the sustainability of the dynamic of development. Many societies and social systems initially showed great promise by reorganising their systems and by achieving good equity, but they collapsed simply because they could not develop a dynamic of growth at a level expected or demanded by people.

All these aspects of development apply to health, for the health is a part of the development, for it is both an outcome of the development as well as a condition for achieving development. The Alm Ata Conference (WHO, 1978) recognised that “health is dependent on social and economic development, and also contributes to it”. For example, the iniquitous social and economic development creates iniquitous health status of the people and iniquitous access to all necessary health care; and they in turn affect the quality of life of various strata of people. The proponents of market economy often see health primarily as productivity and contributor in creation of better productivity in the market economy. For instance, the World Development Report (World Bank, 1993), “Investing in Health”, 1993, identifies four ways in which the improved health contributes to economic growth: “it reduces production losses caused by worker illness; it permits the use of natural resources that had been totally or nearly inaccessible because of disease; it increases enrolment of children in school and makes them better able to learn; and it frees for alternative uses resources that would otherwise have to be spent on treating illness”. While contribution of health in development is a truism not needing more emphasis, to emphasis usefulness of health primarily for a particular system of economic organisation, the capitalism, is close to the kind of objectification of everything that market economy creates. For example, often women’s education is advocated for the purpose of reducing population, as if had the population come down by keeping women uneducated, they wouldn’t have considered it useful to educate them. In the market economy of health care, the system advocated by this report; there is no evidence that better health has reduced society’s proportionate expenditure on health. On the contrary, for example, as the developed countries became “healthier”, their health care expenditure have increased, particularly the market health care of the USA. Besides, such an approach to the health usually runs counter to the developmental and health care needs of the aged, the disabled, the unemployed, the dispossessed, the children - the strata of people considered non-productive. Since household work done by women is not considered a part of the productive economy of capitalism, a big proportion of women would also get less emphasis.

If the health is the state of well being of people, all efforts that go into caring and achieving better well being would automatically constitute health care. As explained above, such effort encompasses entire range of the pro-people developmental activity and change.

Narrowly defined, the health care would constitute those efforts that cure, prevent and promote people to have life without illnesses. This definition flows from the much maligned medical model of health care, and includes curative, preventive and promotive aspects of medical care. Since medical model is often more narrowly understood as curative care, the term health care is used to emphasise that all three components are given importance. Further, when we talk of increasing importance of health issues, we normally mean health care issues as narrowly defined here and at the most, those specific socio-economic issues, which have some direct implication on health and health care.

A focus of many debates in the past has actually been on to what extent the narrowly defined health care contributed to improving health status of people. The origin of these debates was in a reaction to the highly dominant medical model of health, the unprecedented increase in the power of medical profession and medical institutions, and they becoming the sole decision maker on everything about health. Interestingly, the ascendance of medical model started in the 19th century when the scientific medicine achieved hegemony in the Western Europe. Germs were discovered, the germ theory of disease became popular, and so were many other advances. And aboveall, the professionalisation of medicine took place. So it was natural that in that century only the first rigorous effort to show limits of medicine occurred. The pioneer of social medicine, Rudolf Virchow (1985), carried out intensive studies in communicable diseases and brought out the socio-economic determinant of health and illness. He indeed coined the slogan that “Medicine is a social science and politics nothing but medicine on a grand scale”. But Virchow worked at a time when scientific medicine was getting strengthened but had not yet produced tools to control diseases. So the best way that society could employ to combat illhealth was public health campaigns. The mid-19th century England thus witnessed great exposure of abysmal conditions of people and at the same time movements for legislations and regulations for controlling factory conditions, looking after indigent, providing education, public health, etc. Thus, some of Virchow’s revolutionary ideas were implemented by the state in non-revolutionary ways.

But as the medicine progressed in developing tools, particularly the discovery of antibiotics during the World War II, and the post-war boom in the economy with technological revolution producing effective remedies, it strengthened its position, and that of medical profession. This position of medicine was challenged only in 1960s and 1970s when strong critique of medical model reappeared. This was aided by the works of persons like Thomas Mckeown (1979), who by doing historical analysis concluded that though the clinical medicine has its own, but modest, place in health care, the other factors like nutrition, environment, behaviour etc. had long term impact on improving health status of people. Afterall, the developed countries had brought the communicable diseases under control long before the medicine to treat them were discovered.

The health issues discussed in this paper:

From what I have narrated so far it is clear that health and health care are not something that could be restricted to medicine and doctors. It would appear natural that our perspective should focus on the socio-economic determinants of health and not on the health care or medical care services. That is what I don’t intend to do. For in this conference, many other campaigns and issues are being taken up for discussion. They all have contributory or determining impact on health of people. Repeating those issues only to specifically connect them to health would not give the participants sufficient material to discuss on. This apart, there are, other important reasons for discussing health care issues in relation to formal health care services, including medicine.

(1) This is a somewhat neglected area of discussion, particularly by the non-health groups. The non-health activists often feel intimidated by medicine. They feel that since they do not understand its science in so well a way as health activists do, it would not be correct on their part to take it up on a big way. But it need not be so. It must be kept in mind that the activist health groups which have significantly contributed in making health issues everybody’s business were or are not constituted by the committed and socially oriented doctors alone.

(2) It would have been easy to under-emphasise health care had it been merely a collection of technologies and technocrats. They are there, but they are only a part of the social, economic and political organisation of health care. They derive their power, prestige and privileges from this system, and therefore, it is the society to ultimately decide on what kind of system it needs. The specific aim of health activism is to bring about changes in the organisation of health care services so that services are made accessible, they are brought under the control of people and finally, people are participants in the delivery and not just recipient.

(3) The developmental issues such as equity, participation, empowerment and sustainability are as valid for these services as for attaining better health status and the level of development.

(4) The correct emphasis on the socio-economic determinants has sometimes wrongly ignored the rightful place of medicine and health care services. While there are limits of medicine, there is also indispensable need for medicine and health care services for people and the society. While emphasising the prevention and promotion in health care, we must keep in mind that curative care is not ignored.

(5) Lastly, the health care services in India are likely to witness great upheavals in the next few years. As we will show later, the deliberate government policies have encouraged the mindless high cost growth of private sector. In the new economic drive for the market and privatisation, this private sector, operating both in provision of services and financing, is becoming more and more impatient to encroach and take over the public health care services. A balanced pro-people perspective for health activism in this area is therefore becoming an urgent need.

I. Health Care Services: A Brief History

The concern and work for health is as old as the human civilisation. The survival and good living have always been the prime concerns of human beings all the time. Thus, the development of civilisation also had an element of the development of health care. The health care was indeed conditioned and determined by the level of development, the knowledge, skill and technological base of the society at that point of time. Two other crucial elements played their part in the development of health care. One was the dominant ideology of the time and another was social and economic structure. They either helped in the development or retarded it. For instance, the Indian medicine made a transition to rational and scientific therapeutics very early in the history and showed great promise of scientific development. However, as Debiprasad Chattopadhyay (1977) has argued, the changes in social conditions of that time stifled the growth of its rational kernel. The entrenched priestly class and its “counter-ideology” showed prolonged contempt for medicine and its practitioners, and that seriously interfered with the development of Indian medicine. Only in the short spell of revolutionary Buddha period the medical science flourished again, but this spark was extinguished when Buddhism lost its revolutionary fervour and was eventually defeated. The Indian medicine, thereafter, could never come out of these fetters, the upheavals of medieval times and deliberate neglect as well as undermining of Indian medicine under the British rule crippled it further.

In terms of development of public health and services, there are some scanty evidences available. For instance, as per the archaeological evidence, in the earliest known Indian civilisation, the Indus Valley Culture (3000 to 2000 BC), the cities had well planned drainage system, almost all houses had bathrooms, many houses had latrines and most houses had wells for water supply (Sigerist, 1987, pp. 143). This indeed provides evidence of state’s involvement in public health. On the other hand, the evidence of state’s regulatory function on health care is available from Kautilya’s Arthashastra (written sometime between 4th Century BC and 150 AD). It provides evidence that the state exercised authority on doctors at the time of epidemics, it mandated reporting of treatment of severely wounded persons, and most importantly, it prescribed an elaborate system of granting monetary compensation for injuries due to treatment, particularly when the doctor had failed to provide information about the treatment involving danger to life (Kangle, 1972). On the other hand, our ancient text books of medicine, particularly Charaka-samhita is very elaborate on the internal ethical regulation of physicians. Similar involvement of the state in regulating health care is recorded elsewhere, the well-known of them being the Babylonian Code of Hammurabi (300 BC) wherein, the rights and duties of physician were provided and harsh punishment for negligence and causing injuries were prescribed. There were also other state sanctioned codes at that time such as the Assyrian laws, the Mosaic Code, the Code of Hitties etc. The best known code for internal regulation of doctor’s conduct was the Hippocratic Oath of Greek medicine.

Health care service system: While the points made above indicate concomitant development of medical science, codes of internal regulation and the state’s interest in regulating health care in early times, even all of them put together do not amount to the evidence of well organised system health care services. For the kingdoms were organised as a coalition of various powers under the rule of a kind, they were unstable and their boundaries were shifting. The medicine practised for people by the healers was very much a part of the social organisation at the local level, while that practised for the elite was better organised but its fame or discredit were based more on the outcome of healing rather than on the science behind it. For the science itself had not developed to that critical degree. The health care was practised as an occupation and trade, the state regulations, if any, only tried to provide few safeguards against the harm likely to be caused by the less qualified.

Modern health care system: Thus, the real development of the formally organised health care service system took place only in the modern time, and particularly in the Western Europe. In the 16th and 17th centuries, the European society underwent a change due to decline of feudalism and the rise of merchant capitalism (or early capitalism). The merchant capitalism resented feudalistic trade restrictions, so it created pressure for developing national economy and centralised nation states. This enabled them to mount expeditions, conquer “colonies” and bring back wealth from these colonies for developing their societies. All these created ideal social condition for the first industrial revolution in the late 18th century. The repercussion of these social changes started being felt on medical science and health care services from the early days of 19th century. Rapid developments took place in both fields. The doctors began their agitation for a uniformly recognised basic degree and state registration, leading to the passing of Medical Act in 1857 in the UK and thus, the medical profession emerged as an organised social force. Buoyed by scientific discoveries and the social power, the doctors gradually eliminated all competitors and became the sole authority in the field of health. They also brought under their authority the new cadre of health care, the nurses.

The state and public health: Increasing wealth of the European society made the problems of poverty more visible, and the working class entered as a major social force on the scene. In response, there arose the Benthamite collectivism whose utilitarian ideology was consistent with the social system of the time and made charity for indigent and labour for the poor able-bodied people a state policy. The poor laws, factory regulations, public health laws and massive public health campaigns were witnessed in this period in England both in response to people’s demand as well as due to the realisation of the elite that their own health and wealth were determined by the better public health in the society. By all accounts, it is clear that in this historical prime time of the classical laissez-faire, the state regulations and direct involvement in the health were rapidly increasing.

The state and medical care: The curative care or the system of medical care came under the purview of the state on a later date simply because, as stated earlier, it had not as yet developed good tools for treatment. The major institutionalised technology for curative care; the hospitals were in abysmal shape in the early-19th century. What existed were inadequately staffed, poorly trained health personnel and badly provisioned public workhouses (run by the government under the poor laws) for the pauper and the voluntary hospitals for the “deserving poor” financed by philanthropy. The hospitals flourished only when importance of asepsis was understood and adopted, and the trained nursing staff made entry. That also increased the cost of hospital care. As the philanthropy failed in adequately financing such care, the patient fees were gradually introduced. At the same time, as the effectiveness of hospital care became evident, for the first time in the history, the elite started demanding hospital care, and the private hospitals emerged on the scene. It should also be kept in mind that in the developed countries, the common infectious diseases were brought under control much before the real effective remedies were discovered. The general improvement in living standards and the public health campaigns were responsible for such achievements. But that reduced mortality and increased longevity. That means people needed medical care for longer duration of life than they were needing earlier, bringing many voluntary and working class run medical facilities under the financial crisis. Added to this was the fact that increasing industrialisation was demanding more productivity, which in turn needed healthy work force. High morbidity amongst workers and their families, causing loss of working time, loss of assets and above all increased indebtedness for buying medical care therefore became prime concerns for the state regulations and direct health care provision. (Jesani & Anantharam, 1989, Iyer & Jesani, 1995).

For European nations at that time, there was a model available to follow. That was the late 19th century Bismarkian model of welfare through insurance, in Germany. Thus, in the early part of the 20th century, the limited National Insurance spread in developed countries. The social scientists describe this transition of the state as a transition from the “night watchman” state to the “social service” state. For the purpose of our discussion the importance of this change is that it made health care an inseparable concern and function of the state. The present day popular perception that the state cannot leave health care of people to the mercy of market forces and the good will of providers, flows from these changes observed in the developed countries in the 19th and early 20th centuries. In the later part of the 20th century, there was a consolidation of this trend in what is known as the welfare state.

Welfare statism and universal entitlement to health care: The consensus on state welfarism changed the society’s understanding of health care. Health care came to occupy a prime place in the functions of the state. Just as the abject poverty had become an ethical and political issue under the social service states in the developed countries, the non-provision of universal access to health care became a political as well as ethical issue. For the welfarism was supposed to guarantee three things simultaneously: (1) a minimum income to individuals and families, irrespective of the market value of their work or property; (2) a system for narrowing down their insecurities and meet certain contingencies, such as sickness, old age, unemployment and so on; and (3) all citizens, without distinction of status or class are offered the best standards available in relation to certain agreed range of social services. Thus, the goal of social development was set as accomplishing a floor of social living for all citizens, irrespective of their capacity to pay, social status and class (Briggs, 1966).

Naturally, in the field of health care, these ideas led to massive struggles by people for having universal access to medicare and hospital care. These struggles affected all developed countries and all of them, without exception, carried out massive reorganisation of their health services. In each country where such reorganisation was carried out, there was a great opposition from the medical associations, private health insurance companies and other entrenched interests. For instance, in Canada, the doctors went on national level strike at least twice before such a system was put in place in the late 1960s (Taylor, 1978). The kind of specific system that emerged from such skirmishes was somewhat different in each country depending on the relative strength of the social strata joining the combat. But nevertheless each aimed at providing universal access. In all countries of the Western Europe and in Canada in North America, thus, some form of universal access systems were established. Only in the USA, where the demand for universal access to health care had weak social support base, the radical reorganisation was not carried out and the health care allowed to remain dominantly in the hands of private sector. However, the USA too could not avoid going half way. In the 1960s, it also introduced Medicare and Medicaid programmes and other state health care financing methods, thus starting massive health care financing by the state.

Health care financing in the developed countries: The Reaganism and Thatcherism in the developed countries made the most significant efforts to dismantle welfare states and in claiming a victory over all ideas and theories which advanced health care as a fundamental human right of people. However, the rhetoric apart, despite the long spell of such ideologies ruling those countries and the concerted efforts to dismantle universal access health care, the states in those countries pay for most of the health care expenditure of people. Perhaps no underdeveloped country in the free market set-up matches the scale of state health care financing provided in the developed countries .

In the USA, the state finances over 40% of total health care expenditure, which is the highest in terms of the proportion of GNP of any country in the world. If we take the Western European countries as examples, in the UK, Denmark, Finland and Sweden, the states finance 79% to 91% of the total health care expenditure of their people (Weiner, 1987). The similar figure obtains from Canada. The point to keep in mind is that, in all these developed market economy countries, the good access to health care for people, particularly for the underprivileged masses, has been achieved through the high involvement of the state in health care and not by withdrawal of the state from health care.

It should also be noted that, within this common phenomenon of state’s direct involvement or financing, those countries which, radically restructured their services have achieved better access to health care for people and control over cost of health care than those which did not. For instance, in the USA the massive state financing of the health care by the state was not accompanied by radical restructuring of the health care. The state increasingly used private sector for implementing its welfare schemes. All available evidence suggest that this strategy led to massive expansion of private health care business and industry (Himmelstein & Woolhandler, 1984) without actually achieving the universal access to health care for all the US citizens, and without bringing any control over the cost of health care. If one reads any health care literature on the USA, one would not fail to notice the plight millions of uninsured US people and debates on how to control the rising cost of health care, of course, without disturbing the sacred cow of private sector and the market. Interestingly, in the free-market USA, we find the highest number of regulations for controlling physical structures and financing of health care in the world. But despite being the richest, the most advanced in health care technology and so on, the health status indicators of the USA are less impressive than other advanced countries who comparatively spend less and less often use advanced technology.

Lastly, the new medical technologies and increasing demand from a section of people to make them available in health care have brought the health care systems of other advanced countries under pressure. However, the introduction of competition, in their National Health Services, limited user-fees etc. have still not completely overturned the universal access system. For any attempt to complete jettisoning of universal access system has met with strong resistance, and paradoxically in country like the UK even from the medical associations which had actually fought against the introduction of national health services in the 1940s. However, in many areas the collaborations have also taken place. Many political groups and medical association have collaborated in making the system more efficient by introducing competition and decentralised planning. Since the governments have no option but to explain to their people that the changes are for their good, for making system work better for them, they are finding it difficult to take the free market agenda to its logical conclusion.

II. Health Care in India

Two hundred years of colonial rule in India basically did two things for health care services:

Firstly, the colonial rulers did not do what they had done for their own people. None of the public health measures they took for their own people in England to improve their health conditions were seriously and consistently pursued in the colony. However, they did create their own islands (eg cantonments) of area where their officials and troops stayed and where the public health was maintained at the highest level. Since they were more interested in taking away the wealth of the country rather than reinvesting for the welfare of the people of this country, establishing such high level of public health throughout the country was found to be very costly and they used all excuses for not making such investment. However, one can clean such islands of all filth, but one can’t all the time stop the diseases of the filth originating from the area around from entering the islands. So what one finds is that instead of spending money on high achievement of public health, they devoted them to studying public health and tropical diseases so that selective and specific measures, both curative and preventive, are discovered to stop the spread of diseases. It should be noted that such public health research is necessary, should be pursued and attracted many committed and sensitive human being in the endeavour. However, all such efforts are less than effective if the places and environment which breed illnesses are left untouched or are only selectively improved.

And secondly, its policies resulted into gross underdevelopment of health care or medical services. On one hand the colonial state neglected the Indian medicine. As a result, it did not receive impetus and support from the state to develop a scientific basis of its own, or integrate the science of Western medicine in its understanding. On the other hand, the colonial power gave more attention to the grafting of the Western medicine in India. Since the primary purpose of developing the Western medicine was to cater to their officials, troops and the Indian elite, the investment was kept at the lowest level possible. Thus at the time of independence we inherited a health care service system which was grossly undeveloped and mal-distributed.

Post-independence developments: At the time when it became clear that the transfer of power was inevitable, the colonial government appointed a committee to survey and plan comprehensive health care services for the country. Its report, submitted in 1946 is well known as the Bhore Committee report (1946). The report was prepared at a time when in the UK the welfare statism was being established and the proposals for establishing the National Health Services were being debated. The Bhore committee report remains relevant for all of us for the following three among many more reasons:

(1) When one reads the Bhore committee report along with all subsequent reports, one is impressed by the fact that this is the only report which surveys the health care services in their entirety, and gives recommendations which are for the whole system. It bluntly recognises the underdeveloped nature of health care services and strongly recommends the investment that the state ought to make in order to provide health care to all. It is the only report to date which gives a comprehensive plan for such investments.

(2) It gives great emphasis to establishment of institutional structures for the delivery of health care services. The specific programmes for specific health problems are to be delivered from the platform of such structures and not without it.

(3) And lastly, keeping in mind the underdeveloped economy of India, poverty and the lessons learnt from the European history and the history of Soviet Union, it asserts that the only way to make the health care universally accessible is by making it available irrespective of one’s capacity to pay. These lessons also made it to suggest that for universal access it was essential to give leading role to the free public provision of basic health care.

While accepting the Bhore committee report in principle, its plan was considerably diluted, and this began from the 1st Five Year Plan document. The reason given for doing so was very simple - the lack of resources. The Bore Committee plan for building health care institutional structures had two important elements: Firstly, it did not separate the curative and public health functions. This was something different from the National Health Service (NHS), which was excluded from the main responsibility of the public health. The Bhore Committee believed that in order to produce the maximum results from the health care interventions, the preventive and curative works must be dovetailed. So the infrastructure recommended by it was to perform this dual function. Secondly, it also believed that this infrastructure must provide good curative services. That is, the curative service must be adequate, of optimum quality, physically accessible and without financial barrier. Thus, its first level referral centre, the Primary Health Centre (PHC) was to cover only 10,000 population, to have six doctors (including specialists), seventy five beds, and the public health staff for the preventive functions. This basic building block of the institutionalised health care delivery was kept incomplete.

At present, as a policy, the PHCs have only two doctors (sometimes one only), both of them are just graduates, and none of them is post-graduate or specialist, but often one of them is a non-allopathic graduate. The public health functions, of the PHCs are carried out by the auxiliary staff called multi-purpose workers or health workers, no public health nurse is appointed at the PHC. Not only that, the Nurse Midwives who were considered to be essential at the PHCs have been phased out and replaced by auxiliary nurses, thus the PHC does not have fully qualified graduate nurse at all. And lastly, but very important, the referral function of the PHC was completely undermined by not providing most of them with indoor curative beds. Thus, we have primary health centres, but they are without the capacity to provide real referral support for the village level primary health care. The referral support is available only at the Community Health Centre, a 30 bedded rural hospital for over 100,000 population. The dilution of the capacity of the PHCs was accompanied by the expansion of coverage, which in simple terms mean creating difficulty in accessing the PHC services. Between 1952 and 1983, only 5,954 PHCs were established. That is, in the first three decades after independence, on an average only about 200 PHCs with the highly reduced capacity than the ones recommended by the Bhore Committee were set up every year. Thus, in 1983, we had one such for an average of 88,000 rural population. In 1984 it was decided that one PHC will be established for 30,000 population and in no time the number of PHCs were quadrupled. Thus, on paper, in 1991 there were 20,450 PHCs, defining a ratio of one PHC for about 31,000 rural population. Although officially each PHC is supposed to have two doctors, in 1991 only 23,490 doctors were appointed at the PHC, defining a ratio of 1.2 doctors per PHC. In other words, in the government sector, there is only one doctor for about 26,000 of rural population.

The high population coverage by the PHCs have two negative effects. Firstly, its utilisation for the regular curative care remains confined to only few nearby villages. Thus, a big majority of the people supposedly catered to by the PHC actually have no physical access to the facility. Secondly, the staff providing in the outreach and public health services is spread too thin and lack supervision and support from the PHC. Thirdly, public health gets reduced to selective preventive and promotive targets. Given the over-riding emphasis on the family welfare, the non-curative work at the PHCs is overwhelmingly for the family welfare. And lastly, all these problems get compounded by the very low level of essential supplies, viz. medicines, equipments, transport facilities, etc.

III. Are Our Health Care Services Really Underdeveloped?

When this question is asked for our rural and the government health care services, the answer is yes, but when it is asked in relation to the health care available in the country as a whole, the answer is no.

This paradox is created by the existence a very large volume of health care services in the private sector.

We have on one-hand government health care services having too many bureaucratic fetters, too many targets, too many objectives and too many rules, all of them so many that, their efficiency is often compromised. On the other hand, we have private health sector wherein there do no exist even minimum standards for establishing a hospital and nursing home, the doctors do not need continuing medical education for renewing their license to practice, there is no price control over the fees charged, and so on. The following information would show that in India we have reasonably well developed health care services but they do not serve the deserving poor people simply because they are mal-distributed and are largely controlled by the private sector which does not care for the social goal of the services.

Health Care Human Power:

Doctors: India has one of the largest health care human powers in the world. Of them the doctors occupy a dominant position, numerically as well as otherwise. In the year 1990-91, the country had 9,28,072 doctor of all systems of medicine trained in the properly recognised training institutions. Of them, 3,94, 068 (43%) were allopathic or modern system, 3,37,966 (36%) ayurvedic, 1,48, 707 (16%) homeopathic, 35, 350 (4%) unani, 11,801 siddha (1%) and only 180 naturopathy doctors. At the 1991 Census population, the doctor population ratio defines at 1 doctor for 912 persons! If the ratio is calculated only for the allopathic doctors it comes to 1 allopathic doctor for the 2148 persons. The country also had 10,751 dentists in 1991. It should be noted here that another quarter to half a million non-qualified and non-registered doctors also practice medicine in our country, making the number of actually available doctors very high.

However, there is a gross mal-distribution of doctors between rural and urban areas and between the government health care sector and the private sectors. The rural urban distribution of doctors is available only from the census documents. From 1961 to 1981 (three censuses), the proportion of doctors located in the rural areas has declined from 49.6% to 41.2%. Indeed there appears to be a progressive “deruralisation” of doctors. The allopaths and ayurveds who together account for 79% of all doctors have shown greater affinity for locating their practice in the urban areas . Applying the 1981 census figures of rural urban distribution to the stock of doctors in 1990-91, we get the doctor population ratio for the rural areas as one doctor for 1644 persons and for the urban areas one doctor for 399 persons. Obviously, this maldistribution has made the ratio in the urban areas comparable to the developed countries while our people in the rural areas are grossly deprived of the doctors’ services. Further, there has been no regulatory attempts by the government to correct this maldistribution. The distribution of doctors between the government and private sectors is even worse than the rural urban disparity. In 1991, only 22,013 doctors were employed at the PHCs in the country. Another 39,466 were employed in other government institutions. According to our estimates, at the most only 15% of doctors of all systems of medicine are in the government sector, the rest directly provide service to the people in the completely non regulated market environment.

Nurses: As against the high production of doctors and contrary to the health care norms, the number of nursing human power is very less. In 1991, there were only 4,79,558 nurses of all categories in the country. Thus we have doctors almost twice in number than nurses, this is a far-cry from the norm of having two or three nurses for one doctor. Of the nurses, 3,11,235 (65%) were general nurse and midwives, 1,50,431 (31.4%) ANMs and the rest health visitors.

Health Care Infrastructure:

We have already discussed the underdevelopment of public sector services, the PHCs, Subcentres and CHCs in the rural areas. There is a gross maldistribution between rural and urban areas and public and private sectors of hospitals, dispensaries and beds. In absolute numbers in 1992 we had 11,174 hospitals and 6,42,103 hospital beds, defining a ratio of one hospital for 75,739 persons and one hospital bed for 1318 persons. However, their rural location was only 32% for hospitals (a ratio of one hospital for 1,76,163 rural persons) and only 20% for hospital beds (a ratio of one bed for 4970 rural persons). It should be kept in mind that the government is also responsible for locating much of the hospital care infrastructure in the urban areas and for neglecting rural areas. The belated beginning of establishing 30 bedded CHC are few compared to needs and many of those established are not optimally functional due to lack of specialist doctors and other problems.

In 1992, 57% of hospitals, 32% of beds and 60% of dispensaries were in the private sector. These data supplied by the government agency, CBHI (Central Bureau of Health Intelligence), are apparently deficient because the there is no proper registration system for the private hospitals and dispensaries in the country. As a consequence we suspect that there is a gross under reporting of private medical care infrastructure. For instance, in a survey done by the Director of Health Services (Andhra Pradesh) and the Andhra Vaidya Vidhan Parishad, it was found that in 1993 there were 2802 hospitals and 42,192 hospital beds in the private sector in Andhra Pradesh as against only 266 hospitals and 11,103 beds reported by the CBHI (whose data we have also used) in the Health Information of India, 1992. This survey showed that the CBHI data were underreporting the private hospitals by 10.5 times and beds by 3.8 times. This could be further buttressed by using the CBHI data that in the periods 1974-79, 1979-84 and 1984-88, the rate of growth of government hospitals was 6.37%, 1.02% and 2.61% respectively and that of beds was 11.35%, 1.92% and 3.29% respectively. On the other hand the private hospitals increased in the same periods by 43.07%, 12.06% and 17.21% respectively while the private beds increased by 20.09%, 3.86% and 6.81% respectively. Thus, if one were to correct the existing data for the underreporting, it would be found that in the hospital care sector too we have reasonably well developed infrastructure but its main drawback is gross maldistribution. This maldistribution makes it physically less accessible to a large number of people while the small number who have greater access are subjected to irrational and unnecessary medication (Phadke et el, 1995) in order to keep high level of profit in the unregulated market.

Health Care Financing and Expenditure:

As mentioned earlier, the presence of the private health sector is overwhelming. Therefore, it is natural that it also accounts for a larger part of health care expenditure. Unfortunately, at the macro level there is virtually no information on private health expenditures. In the recent years micro studies have provided a good deal of information on the private health sector, including expenditures. Various micro studies right from 1944 onwards to the most recent show that the share of the private sector in health care expenditures has always been around 80% of total health expenditures. The 1944 study by R.B. Lal quoted by the Bhore Committee Report showed private health expenditure to be Rs. 2.50 per capita as against a State health expenditure of Rs. 0.36 per capita. Similar studies in various states by S.C. Seal in the fifties showed private health expenditure to be between 83 and 88 percent of total health expenditure. In studies done in sixties and seventies also an average share of the private health sector was above 80%. Recent studies also show a similar pattern (Duggal & Amin, 1989). Thus, while the government was spending only Rs. 64 per capita per annum for health care in 1991 (including expenditure on water supply), people were spending from their pockets on health care Rs. 200 to 250 per capita. It is estimated that the total (public and private combined) health care expenditure in our country may be 5 to 7% of the GNP, a proportion close to many developed countries, but unlike them 80% of the same is accounted for by the private expenditure. The WHO has recommended that the government alone should be spending at least 5% of its GDP on health, but our government has normally spent much less than 2%.

The high level of private expenditure is taking toll of the poor households. The surveys show that on an average a household in India spends 5 to 6% of its income to buy curative care in the market. However, this expenditure is unevenly spread. Thus, the rural household spend a larger proportion of their income than the urban households. Similarly, the rich spend a smaller proportion of their total income on health care than the poor. The situation seems to be so bad that private expenditure for health care has emerged as one of the main causes of indebtedness, asset alienation and poverty.

Issues to be tackled:

From the above analysis the following issues become clear:

(1) The health care services have grown in India, so much so that in some respect it has resources comparable to some of the developed countries . Non-availability of good data, lack of interest in collating survey findings, turning Nelson’s eye to the burgeoning private sector and counting of only allopathic doctors have created a wrong impression that our health care sector is grossly underdeveloped.

(2) The reasonably well-developed health care sector is unreasonably mal-distributed . The lack of political will, to correct mal-distribution is responsible for pinning great hopes on the community health workers to serve 1000 people when we already have a trained doctor for 900 people but located more in the urban and private sectors.

(3) While it is true that the government sector needs more investment, the attention must not be diverted from the fact that high investment is already taking place in the health areas we need the least and that such process is creating more inequity and mal-distribution.

(4) The exclusive attention to the public health services for health care reform is both unwarranted and would be self-defeating . It is grossly unjustified to keep on experimenting with the small proportion of public services in the name of reaching health care to people when the big proportion of health care in the private health care is not even touched to meet the social goals. Nowhere in the developed country such a large and virtually unregulated private sector is allowed to exist as in India.

Thus, unless the public and private sector are both brought under the purview of national health care planning, there is no way we can ever meet the social goal of making health care universally accessible.

IV: Health Care Activism: Philanthropy and Service

Philanthropy and nationalism:

The health issues have never been a priority for political activists and parties. The health issues only occupied a secondary place in Indian political struggles. The first awakening on health issues came in the form of support to modern medical education and philanthropy. The leading figures of such awakening were the Indian business and educated elite. In the 19th century they were motivated by their concern for establishing the basic facilities for modern medical care and education. For instance, the J. J. Hspital and the Grant Medical College in Mumbai were established by coming together of the Indian elite and philanthropist Jamshetjee Jejeebhoy and the colonial administrator Sir Robert Grant. The aim of education in this pioneering institute was to produce medical graduates who were as good as those produced in the UK. The teaching faculty was dominated by the British doctors and doctors in the government services. Thus, in this kind of medical philanthropy, there was direct collaboration with the colonial power to create services in the government sector.

Thereafter, as observed in Mumbai city in the early 20th century, in response to the increasing militancy of nationalist movement, the colonial government was decentralising administration in the hands of local bodies. The municipal bodies were entrusted with the work of medical relief. Since these bodies also provided opportunity to Indians in the administration, they created an environment conducive to philanthropy aimed at creating medical care institutions run in cooperation with the local bodies. The establishment of the K.E.M. Hospital and the Seth G.S. Medical college took place in this way in 1925-6. It also catered to the nationalist feelings by stipulating that the professors and teachers employed there would be properly educated Indian and not the English government employees. Another example of the close collaboration between the philanthropists and nationalist movement took place when the movement for non-cooperation was launched and the youths were exhorted to leave the colleges. In medical field, this had an effect and the nationalist doctors-medical teachers began a separate college and hospital run primarily by the indigenous and non-governmental support. In Mumbai the The Topiwala National Medical College was born in this way.

This wave of philanthropy linked to nationalism also helped in revival of the Indian medical systems. Although we do not have good documentation on this subject to narrate here, it has been explained by others that many colleges and hospitals for the Indian systems were established during this period by the nationalist leaders and their medical supporters.

There were two important aspects of the philanthropy connected to the nationalism:

Firstly, it was highly motivated by the plight of Indian masses. They believed that their efforts were must in order to provide some medical relief to them. Thus, they created institutions and brought finances for them so that the poor could avail of services either free of cost or at a very cheap cost. Secondly, because of its connection to nationalism, it was almost always thought that after independence it would be our own government to finance it, so there will not be a great need to raise money from philanthropy. Interestingly, after independence most of such experiments ultimately handed over services to the government or contnued with the domianant component of the grant-in-aid from the government.

Philanthropy and constructive social work:

The Gandhian current in the nationalist movement gave strong emphasis to reconstruction. This sarvodaya movement gained momentum at the time of independence when Gandhi gave a call to serve masses in rural areas. Another set of voluntary action had developed as a part of Christian and non-Christian missionary activities. The former in particular gave more attention to the establishment of hospitals across the country, trained various categories of health workers and provided medical care to the needy masses. The non-Christian voluntary groups too gradually entered this area of work. For all of them, the health issues were primarily of medical relief and they were charity oriented. As the transfer of power seemed a reality, efforts were began to do planning for the reconstruction of Indian society and the experiments carried out by voluntary agencies provided experiences for designing the work in the welfare sector for Independent India. The Community Development Programmes (CDP) inaugurated with the First Five Year Plan, were designed using the experiences of Albert Meyer in Etawah district of U.P. and the Y.M.C.A. in Martandam in Tamil Nadu. These experiences and the CDP that followed, integrated the development of health care services (Jesani, Duggal & Gupte, 1996)

Thus, in the first decade of independence, the health activism, both community development oriented and charity oriented, tried to provide inputs into the reconstruction and development programmes of the government. The basic understanding was that the nationalist government was breaking away from the past and trying to gear its efforts to uplift the poor masses, that all medical charity for the poor and voluntary health development efforts should support and supplement such efforts of the government. If we compare this phenomenon with the welfare statist development in the developed country at that time, it becomes clear that there was an ideological identity between these voluntary groups and the government that India should realise its promise given in the Directive Principles of State Policy in the Constitution and should usher into a classical welfare state. The break-down of this ideological identity between the state and the voluntary group took place only in 1960s when the large-scale revolt of rural masses brought out in open the failure of the planning to look after the poor of this country. That began the new era of voluntary action under the new name, NGOs.

Philanthropy for the rich:

One may find it difficult to understand how can there be philanthropic activities directed at the rich. For the philanthropy is always associated with charity for the poor. The rich are regarded as the philanthropists and the poor as the recipient of relief and welfare. However, such understanding of philanthropy is very simplistic. In the market economy, the philanthropy does not remain an altruistic activity all the time. In the market set up, it is employed for various objectives. The philanthropy or a show of philanthropy has been used for the self-preservation, for providing scope for future business, to protect the business interests from getting split up, for saving taxes and so on. Often philanthropy is used for the dual purpose of providing relief or welfare for the poor and at the same time to create services for the rich. The hospital is the best place for obtaining such dual benefits. Here, one could create, by using philanthropic money, a good place for the free or cheap hospital care for the poor and at the same for the rich who are charged more for the services. This method is also described by health economists as a very practical way of financing health care. Since it takes more money from the rich to subsidise care for the poor, it is also called Robinhood method.

Thus, in our country, the philanthropy has acquired multiple functions. The Gandhian call for trusteeship was used both for altruistic purpose as well as for business purpose where the trustees do not earn profit, but their activities create a business climate for others to prosper. Sometime before and after independence, such activity in the medical care and hospital services created foundation for the development of private sector in India. A classical example of such development in health care is Mumbai city where one finds majority of the expensive hi-tech hospitals catering largely to the rich and upper strata of middle classes, operating as charitable trusts for the provision of medical relief. Indeed, amongst the big parivate hospitals in Mumbai there is hardly any one which is run as a private company or as a corporate sector enterprise. All of them are registered as trusts. Yet nobody in this city would dare to regard them as philanthropic institute catering to the poor. These hospitals receive all benefits that go to any philanthropic institute run for the altruistic purpose.

The tragedy of health research in India is that despite such great historic contribution made by philanthropy in establishing private health sector in India, there is hardly any study describing what were the initial motivations of those who donated money and how the institutes started with such genuine altruistic purposes have converted themselves into the profit making enterprises for the doctors working there, for the drugs and instrument supplying companies. Such historical research would contribute in our understanding of various strands of voluntary health activism a proper perspective.

V. NGO Activism and Issue Based Campaigns

As explained earlier, in the late 1960s when the failure of planning became evident and massive rebellion of the rural poor swept the country, a new and qualitatively different phase of health activism started. This period is characterised not only by the turmoil in India, but also in the international sphere. In the developed countries, the post-war boom of the economy had ended and radical students and working masses had come in the streets forcing numerous changes in the world.

Community health activism:

These developments were met by the planners and the government by making appropriate changes in the development strategies. New experiments were mounted to provide thrust to the new strategies. A meeting point for the social activism and to cater to the immediate needs of people was found in the community health activism. The community health combined the service with activism. Thus, this health work was not just medical relief provided by the professionals to people, but it was health work of professionals with people.

Some of the characteristics of the new health activism were as follows:

(1) Unlike the earlier attempts, this activism was highly disillusioned by the developmental model adopted by the government and at least initially did not believe that govenment can, on its own, fulfill the task of development.

(2) While many of the individuals in these groups or NGOs came from various political movements, they strive hard to establish non-party affiliated health care work. In fact, they often down-played politics and affiliation in order to survive their activities in the rural areas. In many ways this was useful, for that provided them a neutral space in the rural socio-political structure to negotiate contradiction and develop their health care work.

(3) Many of these NGOs disliked the concepts of philanthropy and welfare. One of the premises they worked on was that the community has capacity to look after itself provided skills are generated and support provided. The philanthropy and welfare make them dependent.

(4) Many of these NGOs embraced the community health approach. They saw the problems of health care delivery in the high level of bureaucratisation and professionalisation of services. Thus, their motto was to demystify medical care and deprofessionalise the work of health care providers. At higher philosophical plane some of them thought that such activity would integrate health care functions within the community and make it possible for people to look after themselves. Aboveall, it was believed that deprofessionalisation would create pressure on the professionals to reorient themselves.

(5) In order to make health care available to rural masses, the above ideas were put into practice in an innovative way. The village level health workers were trained, newer and cheaper methods of tackling common problems were devised and innovations were introduced in the methods of delivering primary health care.

(6) Some of these NGOs also experimented in devising newer methods of financing primary health care. Methods such as charging the rich to finance care for the poor (Robinhood method), user charges, social insurance by organising the community etc were tried out. However, barring a few exceptions, most of these NGOs always remained dependent on the external funding.

Successes: Began in the late 1960s, the community health activism struggled for awhile. However, the pioneers of this movement in no time showed to the world that their work could achieve a lot cheaply and in short time. By late 1970s, the community health activists have become well known nationally and internationally and the government was becoming more receptive to their ideas. The signing of Alma-Ata declaration privided the ultimate legitimacy, for it embodied many of the ideas developed in the community health projects.

While many of the experiences of community health projects were adopted in health policies but tardily implemented, the most important contribution made by them was the idea and practice of de-professionalised and demystified health care. They produced one of the best critiques of profession centred medical care model. The control exercised by the professionals, the vulnerability of people due to the mystification of medical care perpetuated by them and above all the over-medicalisation and iatrogenesis attending the commercialised medical care system were highlighted.

It should also be noted that the later year specific campaigns on drug prices, the campaign for rational drug policy, the campaigns against the misuse of medical technologies and so on were highly influenced by the works and ideas popularised by the community health activists. Thus, it would not be an exaggeration to say that without the committed work undertaken by these activists, many of the later day health campaigns would have either not taken off or would have remained incomplete.

Failures: The deprofessionalised health care model, the very strength of the community health activism, also turned out to be one of the key weakness of it. For, the period in which the community health activism was a its peak is also the period when the medical profession consolidated its position the most. This critique could not shake the power of the profession. The alternative agencies created for provision of primary health care were largely sabotaged or tamed under the control of the professionals. Interestingly, during this period the profession actually increased its numerical strength and control over the system. Ironically, sometimes the alternative efforts actually introduced “medicalisation” of health care where none existed, thus paving a way for the private medical professionals to reap the fruits of profit.

Secondly, in this period the greatest expansion of the private sector in health care took place. The community health activists instinctively believed that their model of health care could never be implemented in the for-profit private sector, so they had concentrated their advocacy efforts only on the government and more or less ignored the developments in the private sector. Their work in villages thus did not become a threat to the private providers, instead, it seems in some instances, actually helped the private sector in finding markets where none previously existed. They failed to understand that the precondition for the national level success of community health approach is re-organisation entire health care services so that both public and private resources are optimally utilised to provide simple but effective service to people. Indeed, an isolated emphasis on community approach only obscures the need for reform in the entire health care sector. If the community approach is applied and considered valid only for the public and voluntary sectors, it by default or design allows the professionals to flourish without self-regulation as well as external control in private sector.

Thus, in last three decades the community health care activism has patiently and through concrete devoted work in the under-served rural areas tried to persuade the policy makers, but it has not been possible for it the create a real threat to the established industrial and medical interests. This realisation prompted many of the community health activists to devote some of their time in building other campaigns. One of such campaign is for the rational drug policy.

Rational drugs campaign:

The control of pharmaceutical companies on doctors and the medical services is well documented. In our country, we have over 50,000 drug formulations in the market, while for most of our medical problems; the WHO recommends only 200-300 drugs. A bulk of these formulations are thus unnecessary, they contain irrational combination drugs, some of them are harmful and some of them are drugs which are banned elsewhere. In the early 1980s, the campaign for the rational drugs was started. This campaign actually originated from the community health activists’ concern for the rational therapeutics, demand for making available essential drugs at a cheap price etc.

In last over a decade, this campaign has achieved the following:

(1) It has indeed generated a vast amount of literature showing irrationality of the pharmaceutical scene and how the industry is wrongly educating doctors to adopt irrational and sometimes harmful therapeutics.

(2) It spurred activism amongst the consumer organisations on this issue too. Along with many organisations the campaign has been successful in getting over 40 harmful drugs banned in last one decade.

(3) The campaign has been aided by the NGO based alternative drug manufacturing unit established and successfully run in Baroda. This experiment has showed that the quality drugs could be produced cheap and provided to people if the doctors are also oriented to the rational therapeutics.

(4) Lastly the campaigned tried to bring focus on the need to control prices of the essential drugs so that they were made available at affordable price to the needy people.

Despite its national level concerted efforts, this campaign has actually failed in achieving the desired changes in drug policies. In fact, despite the campaigns, the price decontrol of drugs has been implemented and the drugs prices have only increased. This only points to the fact that the struggle against the mighty pharmaceutical industry is going to be very difficult and protracted. Besides, the campaign will have to find allies in other fields to strengthen its advocacy.

Campaigns against misuse of medical technologies:

Two major campaigns may be mentioned in brief here.

The first one against the misuse of sex determination tests for aborting female foetuses is well known and well documented. The second is the campaign against usafe contraceptives. Both these campaigns have achieved some successes.

It may be noted that success of both these campaigns was simply due to the entry of affected party, women in the movement. In fact these were the health camapigns undertaken by women’s groups and aided by the health groups. Such a situation provided strength to the campaign and helped in mobilising women to support the demands.

However, it seems that any success achieved in struggle against misuse of any one medical technology would only be temporary and transient. For instance the legislation against sex selection has on one hand reduced the selective abortions, but at the same time then machinery created to oversee the implementation of the legislation hardly functioned in an effective and efficient way. So much so that despite reports of illegal offering of sex determination tests being made by providers in some districts, the committees created under the act have not even investigated the matter. The point is that, it is perhaps difficult to create separate machinery to oversee different technologies. The only way some effective surveillance and regulation of medical technologies could be done is by bringing all medical technologies under a single regulatory control. This would also mean that the relevance and need for various technologies employed in the health care sector would be regularly assessed so that precious resources are not wasted in less useful technologies. In short, a mechanism to ensure use of appropriate technologies and to prevent their misuse is urgently needed.

Regulations over the private sector:

Although this campaign has not spread in many parts of the country, the efforts made at a few centres have gradually started bringing into the focus the unregulated operation of the private sector. This campaign is trying to show two things:

Firstly, it shows that unlike other sectors, in the health care the private sector has never been subjected to any license and permit raj (Jesani, 1996) Thus, deregulating private sector has no meaning for there do not exist any regulations. It further tries to show that nowhere in the developed world there is a private sector in health care devoid of basic regulation. It made a telling point by showing that the private nursing homes and hospitals are not required to adhere to any minimum medical standards, and thus the health of large number of people availing services from them is at risk. It also shows that in the absence of regulations, the private nursing homes and hospitals are employing unqualified nurses and that is not only creating health risks but also super-exploitation of those women working as the nurses.

Secondly, it shows that those who are clamouring for privatisation of public health services should first have a look at the average quality of care provided by the private sector health care institutions. In our country it is difficult to show that the average care provided in the private hospitals, having less than minimum scientific standards and largely non-qualified nursing staff, is much superior.

Consumer activism and campaigns for medical ethics:

The consumer activism is gradually growing in the health care. By making lots of noise on the consumer protection act, the medical profession actually helped in making people aware of the law. It also showed that the profession stands completely isolated on this issue. For no significant social strata has extended support to doctors demand on the subject. The consumer activism has brought spotlight on many issues, some of them are:

(1) It has continuously brought out the medical malpractices in public thus showing that everything is not so well within the medical profession. It has brought spotlight onto the self-regulatory bodies (medical councils) of the professions.

(2) It has brought out the fact that the medical care system has not developed minimum scientific standards in many fields, thus leaving people to the mercy of individual practitioners.

(3) It has established that patients have right to information and that they also have a right to get a copy of medical records.

(4) It is gradually forcing the profession to maintain proper medical records, issue receipts for the fees charged and so on.

The consumer activism has brought in the medical field; consumer activists, most of them are not doctors or health activists. This has provided impetus to this work. However, it also creates a danger of taking the consumerism too far, a danger that could add burden of defensive medicine over the consumers. Such a burden in our situation would be in addition to the burden of irrational and excessive health care. The tort laws, which govern the award of compensation in the medical malpractice litigations, have proved costly for the society in all countries where they are excessively used.

Thus, while the consumer activism is a natural reaction to the domination private market in health care, it could also have long-term negative consequences on the health care services. However, nowhere in the world this situation has been brought under control without undertaking the restructuring of entire health care services. In those developed countries where the market in health care has been reduced or brought under rigorous control, the negative consequences of malpractice litigations have been less. Further, where the legal reforms such as relying more on no-fault compensation schemes instead of tort legislations, are carried out, the negative impacts have been reduced even to greater extent.

Concluding Remarks

We had begun our narration with an attempt to understand the historical evaluation of health care in Indian and the developed countries and then tried to analyse the existing health care services in our country. The former tried to explain that it is not wise to get carried away by what the developed countries are doing today there, for they have come to that after several decades of health care reforms which made health care universally accessible to people. Besides, their current pro-market reforms in health care are only limited, they have not significantly reduced their health care expenditure and the objective of universal access has not be thrown over-board.

The issues raised on our health care service system were in order to understand the strength and weaknesses of the health care activism.

First of all it is clear that the health care activism as developed as separate issue based campaigns or as direct response to the health care needs of the poor. Both in the community health activism and the issue based campaigns, there haven’t appeared larger meeting grounds from which demand for thorough reorganisation of health services could be raised.

Secondly, the doctors as a professional body has not come under the sufficient pressure due to health activism. The community health activism attracted many doctors, but they preferred to stay clear of mainstream profession and hardly made any effort to create pressure for reforms from within. Only recent health campaigns on medical ethics, consumer activism etc have directed their attention to the mainstream profession.

Thirdly, the health workers have shown less motivation to struggle for larger health care issues or take up struggles for the benefit of their patients. For instance, the doctors and nurses would make all compromise in the quality of care simply because of lack of resources, but they would not feel that to do so is unethical and it is their ethical duty to demand resources from the government or their employer. The struggles of health workers have unfortunately remained confined to their trade union issues. As a result we observe that in all major health campaigns, the health workers have not participated as a mass force.

Fourthly, the health issues have failed to make prominent appearance in the struggles of various strata of people. The women groups are perhaps the only groups, which have raised the health issues of their concern consistently. While there is some activities on the occupational health problems, the organised working class movement has even failed to raise the demand for getting good quality care in services paid for by their members.

Health Movement: Thus, in the absence of any common programme for the reorganisation of health care of the country and that no significant organised strata of people have made reforms in health care a prominent demand, it is difficult to talk in terms of genuine health movement. The health activism of last three decades has raised people’s consciousness and concerns for the health issues. In last few years the activism has gradually shifted from experimentation in provision to the demand for better provision and the control over providers. This is gradually opening up avenues for expanding the base for health activism.

In the last analysis, if the health activism is to succeed, it must strive to encourage the emergence of health movement. And for such a movement, three areas will have to be given special attention:

(1) It needs to be stressed, and an alternative model for health care needs to be advanced, to persuade more and more people to the idea that universal access to basic health care is not only necessary to achieve, but is also feasible. A health movement must pursue a political programme, for without such a programme, it is difficult to create a political constituency of support.

(2) The specific health campaigns need to be connected to the programme for the reorganisation of health care services.

(3) The health campaigns should find place within the mass organisations to be successful. Thus, it is imperative that the health activists orient themselves to the organisations of people and strive to get health issues taken up by them. At the same time, similar efforts within the health workers, is important. For they occupy a crucial position in the health care delivery, and any success in drawing them to support issues relevant to people’s health would greatly aid in enlarging the scope of campaigns.

After all, the people and programme for the universal access to health care would together make the health movement.

(Acknowledgement: Dr. Sunil K. Pandya, Editor, Issues in Medical Ethics, for providing historical sketch of three public hospitals in Mumbai)


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* Published in the “Indian Journal of Social Work”, Special Issue: “Towards People-centred Development – Part 2”, Vol: 59, Issue: 1, January 1998, pages 291-320.