Marxists vs Paternalists vs Liberals: Where healthcare stands in India

How health as a right, investment and consumption regularly crops up in capitalist discourses 

By Sumanta Roy
Published: Monday 29 June 2020

Basic healthcare is one’s fundamental right for one’s social existence and is the state’s responsibility to provide the services to its citizens, irrespective of their capacity to afford them.

India’s health infrastructure has repeatedly undergone severe crisis and the novel coronavirus disease (COVID-19) pandemic has only made it worse. It is unfortunate that a consistently poor performance in hunger index accompanied with meagre allocation to health in the budget has not gained enough public attention so far.

State intervention in healthcare is driven by the principles of universality, equity and comprehensiveness that cannot be achieved in the market since individuals would be forced to take care of themselves individually. It also raises questions of equal accessibility and affordability.

“Concern for all” drives a normative value that calls for state intervention in the healthcare system. Thus, conceiving it as a public good has a spillover effect.

A regular debate that features in capitalist discourses is the necessity and feasibility of state intervention and investment in health. Classical economists such as Adam Smith and neo-classical schools have dealt with the issue.

Health as right / Marxists: This is a state-owned model where the role of the market is non-existent and health is socially produced. The state has a responsibility to provide the highest attainable standard of health to its people irrespective of race, religion, political beliefs, economic and social condition.

It is concerned with the issue of equity in health and healthcare. 

Intersectoral coordination is present in this form of healthcare. The National Health Service in the United Kingdom is within this idea of welfare state i.e. the state invested in the production, financing and the distribution of the health services through progressive taxation (use tax money to redistribute). However, there is no security of employment, housing or food. Moreover, wages were highly unequal, but the welfare provisioning is under the collective holding of the state. 

An essential difference between Marxists and socialists is that for the former, private property is the root of all evil; the latter seeks that the state should have well-defined redistribution policies.

Nordic countries have achieved the same through progressive taxation to equalise wealth in the society.

Health as investment / Paternalists: Investing in health means enhancing the productivity of labour. It is a state-plus and a market-minus model. From the lens of citizenship and citizen rights, every citizen irrespective of who they are must be protected. The notion of social solidarity is present here.

European capitalist countries, southern Europe (Italy, Greece, Spain), Germany, Scandinavian countries (Finland, Sweden, Norway) evolved with social solidarity (designing welfare schemes with no targets because targets break social solidarity, the “we feeling.” They designed universal health insurance instead of a targeted programme). Intersectoral coordination is absent here. 

Paternalists argue there is no ideal market in healthcare because it is not like any other commodity, power relationship and asymmetry of information. It states that health cannot be left out for individual action and that it requires a collective intervention, and therefore, cannot be left out to the market. Paternalism comes closer to a socialist understanding but is not socialism.

Paternalists are closer to comprehensive primary healthcare. They argue not to spill health services into public versus private, which, in the long run, is economically inefficient and minimises the role of markets.

For example, Britain has its own nationalised medical services, production, nationalised pharmaceuticals. In the health service system, the financing is done by the state with minimal role of private insurance. The question of values comes into the paternalist debate, “is it fair?” “Is it equitable?” “Are we protecting the most vulnerable section?” and which the market ignores (the notion of social solidarity and collective responsibility).

The difference between the Marxist and paternalist position of state intervention is that, first, paternalist think about healthcare and Marxist about health.

Second, in a Marxist set-up, the investment, production and administration of health services is in the hand of the state; in paternalist, the role of market is minimum. The whole idea of public health was far closer to the paternalistic understanding.

Health as consumption / Liberals: Health is like any other commodity that can be bought and sold in the market as a consumption good. It is a market-plus state-minus model.

Liberals believe the state is present but has a minimal or no role to play in the promotion of health. It is about individual choice whether to undergo treatment or from whom. In this, the market looks at medical care and the state only looks at preventive care.

For example, all immunisation programmes in the United States are done by local authorities. The primary level (preventive care) not primordial prevention was the responsibility of the government while the medical care part was the responsibility of the market.

If the curative part goes to the market and preventive part to the state, there will be fragmentation.

Liberals will say devices and pharmaceuticals will be market-driven. The whole notion of “are you willing to pay?” or “are you able to pay?” will find its equilibrium in the market. Here, they argue preventive services should be under the control of the state but curative services should be left to the market where individual choices can be exercised.

The paternalist argues that is not the most cost-effective way of planning health services because the moment medical care goes to the market, there will be an increase in malpractices as the greed and profit maximisation will eat out values of social solidarity and collectiveness. 

If we take an example of India and China in pre- and post-reform period, India began with the paternalist understanding with a considerable shift towards liberal understanding. We borrowed the idea of health as a right but never abolished the market interest.

In Mao’s China, land reforms and redistribution happened rapidly, and the state collectives took away the ownership of land. It began with the firm perspective of “right” (to cover the basic needs, assuring people’s rights) not the “rights” of the capitalist countries (individualism, no collective responsibility).

It moved towards investment and a cosy consumption of healthcare. Similarly, India also moved towards a cosy paternalist and consumer of healthcare.    

Even if we somehow manage the present crisis, there will be a distinct danger that another epidemic may hit us again, unless we take care to ensure proper sanitation, clean water and proper infrastructure to our masses in general.

The pandemic will take its own time to leave, but the future holds huge challenges for global health emergencies. The need of the hour is not only to fight COVID-19 but also to lay the foundations to save our healthcare system.

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