Prabir Purkayastha

18th April 2012

THE H5N1 CONTROVERSY

FOR the last two months, a raging controversy is going on amongst virologists around the world on whether the research done by two groups, one in Netherlands and the other in the US should be published in full or not. The National Science Advisory Board on Bio-security (NSABB) of the US has recommended that some parts of the research should not be published as it is too dangerous.  The two journals – Nature and Science – that were about to publish the results have been asked to take out some parts to reduce the risk of bio-terrorists using such information. However, another expert group, constituted by the WHO and consisting of leading flu researchers in the world have disagreed and have advised the full publication of the two papers. As of now, a final decision is still pending on the publication of the papers and there is also a voluntary moratorium amongst researchers on similar research.

Both the groups, one lead by Ron Fouchier, a virologist at the Erasmus Medical Centre in Rotterdam, and the other, Yoshihiro Kawaoka at University of Wisconsin, Madison had made the H5N1 virus -- commonly known as avian/bird flu – easily transmitted as any seasonal flu. As of now, this deadly strain does not transmit easily amongst human population. The modified virus has therefore the possibility of creating a pandemic killing millions. The popular press has called this virus Doomsday virus or the Armageddon virus.

The NSABB exists in order to examine the possibility of bio-terrorsism. The NSABB got into the act after Fouchier reported his findings in a conference and it was picked up by the science journalists and the popular press.

TROUBLING QUESTIONS

The avian flu has been raging in the poultry farms in South East and East Asia and has led to millions of chickens being slaughtered. While some infections have taken place amongst the human population, it has been restricted to only those who were in direct contact, that is only through bird to human contact route. As yet, there are no cases of its spread through human to human contact. If avian flu can be easily transmitted amongst the human population, it could have disastrous consequences as almost 60 per cent of the recorded cases of those who have contacted avian flu have died, making this the most virulent flu virus strain that we know. The great influenza epidemic of 1918 had a mortality rate of 2 per cent and killed an estimated 40 to 100 million people. If the avian flu virus becomes easily transmitted amongst human population, the resulting pandemic can be even more devastating.

This immediately raises some troubling questions. How easy would it be for the virus to mutate to become easily transmitted? And should we do such research, which itself could lead to the release of such lab made virus into the world? If such research is needed, then what is the bio-security level of the laboratories that would carry out such experiments?

The other controversy that has been raised as a spin off from the current controversy of the two papers is how dangerous is H5N1 avian flu to humans?

The two groups that did the research took two different paths. Both sets of virologists started with a virus that was not spreading through the airborne route and made a variant that had all the lethality of H5N1 and could also spread through air. Fouchier's experiments were particularly important as it showed that only a few mutations would transform the existing H5N1 virus into one that could cause a human pandemic. Both Fouchier and Kawaoka's groups used ferrets for the experiments. The results showed that ultimately the ferrets were being infected through the airborne route. As infections in ferrets and human population are similar, ferrets are generally the choice for such experiments.

This is not the first time such viruses have been created in laboratories. The 1918 influenza virus itself has been recreated in 2005 and the group showed that monkeys infected with this recreated virus showed symptoms very similar to that of the 1918 flu pandemic. Recently, Reuben Donis and his colleagues in Centers for Disease Control and Prevention (CDC) Atlanta, US have reported how they  have converted H5N1 to an easily transmissible form, though they concluded that such an evolution in nature was not likely. The importance of the two controversial papers is that they show that such a mutation is indeed easy and therefore likely to arise in the wild.

NSABB's position was that the papers can be published but the method used for creating the new variant should be taken out. This information would then be made available only to selected scientists and not to the general public. The board has 22 members and this was a unanimous decision.

Last month, the WHO's expert committee that met in Geneva, came to a unanimous decision that was diametrically opposite. It stated that there was no way for the journals or the authors to decide who should be given access to the information and who should not. It also felt that the papers were important in fighting the threat of a flu pandemic. It therefore recommended that the papers should be published in full.

LARGER ISSUES

Behind the two decisions is a much larger issue of what are the benefits of such a research as opposed to its risks. For the bio-security experts in NSABB, the risks outweigh the benefits. For the WHO flu experts, it is the benefits of such research – the belief that nature is the biggest bio-terrorist around and therefore we need to know more about what can happen to such strains that drove their decision.

Experts have argued that if the person has the requisite knowledge and access to a laboratory for making such a modified virus, then there is enough knowledge in public domain already for him to do so. In fact, a simple Google search shows that almost all the key elements of Fouchier's results are already available or can be easily reconstructed. The CDC paper which has already been published gives details of the methods that are necessary for creating the modified virus. Some of these experts have argued that what is required is to have better experts in NSABB who know the field of virology better and not such bans which serve little purpose.

Beyond the WHO and NSABB decisions are also critical issues of who are at risk and who decide what needs to be shared as information? The avian flu virus strains are shared with researchers by countries in the South East and East Asia where such virus outbreaks are taking place with guarantees that the results and benefits out of research would be made available to them. If now it is decided by a body sitting somewhere else that the results flowing out of such research will only be selectively shared, it will cause a breakdown in the way material and research is being done internationally. There is an asymmetry of power between those who provide the bio-materials and those who conduct the research.

Questions have also been raised where such research should be carried out in – Bio-Security Level (BSL) 4 containment or in enhanced BSL 3 laboratories. Canada has already issued directives that allow such research to be carried out only in BSL 4 labs. There is no question that such dangerous pathogens can escape from labs and have done so in the past. The pros and cons here are not as simple as they may appear. If only BSL4 labs are permitted, there are very few of these labs and therefore if this research is indeed important, confining it to BSL4 labs would simply reduce the chances of this work being done. We are back to the question -- how important is this research?

While the figures of 60 per cent mortality appears frightening, there is also a controversy that these figures are much higher than the actual survival rate from such infections. WHO figures are only for  reported and verified cases; an examination of the people involved in poultry seems to indicate a large number of unreported cases who have survived – therefore the mortality figures from an outbreak could be far lower. However, this might not provide too much consolation; there is little doubt that even a reduction by a factor of 10 of the mortality would still make it the most dangerous flu variant known.

The problem in science is what constitutes advanced research and tools become common place with time. The more we know, the more the possibility of finding cures as well as creating dangerous weapons. Unfortunately, both go hand in hand -- one cannot be separated from the other. If the Manhattan project that created the atom bomb could only be done by a handful of countries 50 years back, today 50 countries have the capability of making the bomb. Creating a  safe world by restricting dual use technology or dangerous knowledge is not going to work.

If bio-terrorism is a threat, what prevents the bio-terrorist to use older and more well-known agents? Why would they restrict themselves only to cutting edge research? Why would they not use chemical weapons that are easier to make, as was shown by Aum Shinrikyo in Tokyo in 1995?

Fouchier and Kawaoka have shown that the comfortable belief held by a number of virologists that H5N1 is unlikely to create a pandemic is wrong. Such experiments are then important to identify future threats. It is difficult not to agree with Fouchier that if all the five mutations that lead to the creation of this dangerous variant are already present in the wild individually, we need to know more and monitor this carefully. Prohibiting such research as some groups are asking and taking out parts of it from published results is not a viable answer.

What we need is a society that does not create terrorists,that allows people to control their own lives,that does not have burning injustices and inequalities. What we need is to cure society of its ills. Stopping the growth of scientific knowledge to control risks is not an option. Simply because it is like King Canute asking the tide to hold back. It did not work then, it will work now.

Prabir Purkayastha

18th April 2012

IT is now one year since the Fukushima disaster took place that saw three reactors in Tokyo Electric Power Company's (TEPCO) Dai-ichi nuclear plant suffering core melt-downs and explosions. On March 11,  2011, an earthquake of 9.0 on Richter scale took place 130 kilometres off the coast of Japan.  Within an hour, a tsunami of unprecedented magnitude struck Japan, the tidal wave of water and mud cutting a huge swath of death and destruction through the coastal areas of Japan.

According to TEPCO, the Fukushima Dai-ichi I nuclear plant initially did not face a problem, even though power lines to the outside world had snapped. The three running reactors – Dai-ichi 1, 2 and 3 had shut-down safely and the other three reactors Dai-ichi 4,5 and 6 were already in a cold shut-down mode. However, the 14 metre tsunami that struck the Dai-ichi I plant, took out the back-up generators, starting a cascading train of events that saw explosions in the reactor buildings 1, 3 and 4 and partial core melt-down in 1,2 and 3.

Some reports now indicate that unit 1 already had its cooling system affected due to the earthquake and was on its way to a meltdown even before the tsunami struck. There is however no question that tsunami made a situation, which would otherwise have been difficult, to what Yoichi Funabashi of Rebuild Japan Foundation calls an “existential crisis” for Japan.

Even a reactor that is shut-down, releases enormous amount of heat and needs the cooling system to work. With electrical backup systems not available, the inability to cool the reactor core meant extremely high temperatures, releasing of hydrogen as the hot fuel rods reacted with water and steam inside the reactor. Primary containment vessels were breached leading to radioactivity release, as well as of hydrogen. The hydrogen eventually ignited causing the explosions in units 1, 3 and 4 blowing off the roof of the reactor buildings. The disaster could have been much bigger if the plant superintendent, Masyao Yoshida had not disregarded the TEPCO management, continuing to pump seawater in the reactors.

Rebuild Japan Initiative Foundation released a 420 page report with independent experts showing how TEPCO at one point wanted to abandon Dai-ichi, which could have lead to a “demonic scenario” – large scale release of radio activity, causing other nuclear plants to also fail and the possible evacuation of Tokyo. Only direct orders from the then PM Naoto Kan, who stormed into TEPCO headquarters, prevented it from abandoning the plant and having the Fukushima disaster spiral completely out of control.

Though the plant is now in a cold shut-down and comparatively “stable”, it will take ten more years to seal the site from radioactive leakages from the plant. Decontamination will require radioactive top-soil to be removed from 2,400 square kilometres, with a three kilometres radius around the plant to be abandoned permanently. The plant will take a minimum of 40 years to decommission. It may be either entombed in cement like Chernobyl, after all the fuel rods have been taken out, or the reactor cores removed, and the reactor buildings dismantled piece by piece robotically, transporting all this to a radioactive waste storage facility.

The damages in Fukushima are estimated to be $52 billion already, and are projected to rise as the costly process of  decontamination and decommissioning is undertaken. It is still unclear how much of this will be borne by TEPCO, the operating company, the insurance companies and how much will be shelled out by the Japanese people through the government underwriting the expenses.

Rebuild Japan Initiative Foundation report also talks about Japan falling victim to a twisted myth of “absolute safety” propagated by the nuclear industry and its supporters. Funabashi, in a recent article in Financial Times has written, “At its core, Japan’s nuclear safety regulatory regime was phoney. Regulators pretended to regulate; utilities pretended to be regulated. In reality, the latter were far more powerful in expertise and clout.”

WARNINGS IGNORED

It is this cosy relationship between regulators and the nuclear industry that lead to all warnings including that of earthquakes and high tsunamis to be ignored. In Japan, the Nuclear and Industrial Safety Agency, the primary watchdog over the nuclear plants, was under the ministry economics, trade and industry (METI) and therefore lacked independent authority. Only after Fukushima, it has been moved to the environmental ministry.

There is little doubt that Fukushima has dampened the enthusiasm in the world about nuclear energy. A number of countries – Germany, Belgium, Switzerland – have decided to phase out their nuclear plants while others are reconsidering the introduction of nuclear energy in their country. In Japan, out of 54 reactors, only two are now on-line, the rest 52 being shut-down for stress tests and safety reviews. Instead of a nuclear renaissance, nuclear energy is now entering into the zone of a nuclear chill, if not a nuclear winter.

The problem with nuclear energy is that that more we learn about it, the more the need for new safety systems and upgradation of existing designs, adding to costs. The nuclear manufacturers then hike up the unit size to make the plants more economical. Increase in unit size, however, increases its complexity as well, creating again more chances of failure. This cycle of complexity, cost and large unit sizes, combined with a number of units in one location has multiplied the danger of possible accidents. If nuclear energy is to be a viable option, it must re-examine this paradigm and look at smaller, modular designs, and dispersing such units instead of 10,000 MW nuclear parks that it is currently promoting.

Indian nuclear energy program, as observed in Japan, suffers from a similar combination of technology hubris and cohabitation between the regulator and the nuclear plants.  In India, AERB is still a part of the Atomic Energy Commission and even in the new Act introduced in the parliament, it will be subservient to the commission. The Left has opposed these clauses in the standing committee of the parliament, but its voice has been overridden by the government and its supporters. The BJP has little stomach for engaging on any serious issue and chooses to play the role of a bystander when such matters come up.

On the safety of Indian plants, Dr A Gopalkrishnan, former AERB chairman has talked about the safety audit reports of AERB being kept secret. He has written that in the beginning of his tenure, he undertook a detailed safety audit. He states, “1995 AERB safety audit... detailed about 130 individual safety issues on which corrective actions were called for, of which 95 were of top safety significance...To date, no details are known about concrete corrective actions taken, if any, on each of these recommendations” (emphasis added).

It is true that India's Candu reactors do not suffer from the kind of problems that occurred in Fukushima. But India has GE Mark I vintage reactors in Tarapur, which not only have very similar problems  that were uncovered by the accident in Fukushima but also have been warned to be unsafe by GE and US experts. They are also well past their design life of 40 years as were the Fukushima plants.

COMPLEX ISSUES

On the Kudankulam plant, the no-holds barred debate has been considerably worsened by the PM and PMO's intervention virtually calling all opponents of the plant as foreign agents. This does not do justice to the complexity of the issues surrounding nuclear energy in the country.

There are 450 reactors operating in the world, out of which 22 are VVER's with similar design as Kudankulam. It is also true that in Kudankulam – based on public statements issued by Atomic Energy Commission – there are additional safety features than available for instance in Fukushima. By itself, this does not prove that Kudankulam is safe; neither is it possible to argue that by definition all nuclear plants are unsafe and should be abandoned, as the opponents of Kudankulam are doing.

The government does not appear to have any serious intention of discussing the nuclear energy program or the safety of nuclear plants. Instead, the dreaded “foreign hand” is being paraded to explain away the questions that are being raised on nuclear energy.

The foreign hand charge must make strange reading, that too of an American hand, coming as it does from a government that has surpassed even the BJP led NDA government it its love for the US. The commander of the US Pacific Command, Admiral Robert Willard in a recent Congressional hearing stated that American Special forces assist teams are stationed in India along with Nepal, Bangladesh, Sri Lanka and the Maldives. Admiral Willard went on to talk about the close relationships between the US and Indian forces on maritime security and also between “counter terrorism” operations. Though the UPA has denied Willard's statement, let us not forget that the India US nuclear deal was preceded by a defence agreement which offered precisely what Willard now says that India is providing.

The PM therefore claiming how the US is sabotaging India's development plans through some US funded NGO's, that too affiliated to the Catholic Church makes little sense. If this indeed is true, then he needs to come clean and break his cosy relationship with the US and not just go after the NGO's as he is doing. Then why this campaign?

This government for some time has been dealing with dissent in various ways. It does not want to engage with the actual issues, because it feels that it does not have the necessary credibility. Instead, it tries and uses underhand means to try and “control” dissent. We saw very similar methods being applied in cyber space, where major internet companies were called by Sibal, the IT minister and told to exercise private censorship regarding criticism of the Congress and its leaders. If they did not fall in line, then the provisions of IPC regarding hate speech, obscenity, etc, would be used against them. Once the discussions were leaked in international media, though Sibal backed off on pre-censorship, various private complaints have now been filed with the government providing tacit support to these complaints in court.

The nuclear agitation is a convenient tool to fire a shot across the bow of the NGO's. The signal is clear – fall in line, otherwise your funding will be in danger. And indications are that the NGO's will fall in line.

The nuclear energy issue needs an open discussion – not only with regards to safety but also its costs.  It beats all understanding why the cost of nuclear energy from Kudankulam and Jaitapur should be shrouded in such secrecy. The CEO of Areva is on record that the costs of the Areva reactors are being kept confidential at the behest of the Indian government. Similarly, in Kudankulam, the cost figures are ten years old. Why should the cost of nuclear energy, clearly a civilian issue, be a “State secret”?

It is precisely this mysterious secrecy that has created a distrust for nuclear energy. It is a sad day indeed that the prime minister of the country and all his nuclear experts cannot convince the people around Kudankulam regarding the safety of the plant. That a rag-tag band of NGO's have more credibility than the Indian government and all its experts is a sad commentary for Manmohan Singh and the UPA. It is this aspect of his governance that the PM must examine rather than searching for a mythical foreign hand in Kudankulam.

What is needed is a body of experts who have public credibility to go into safety aspects of Kudankulam in transparent way. Only such a procedure in which people are given access to information regarding the safety systems in Kudankulam and can raise their objections before such a body, can create a climate of trust within which India's nuclear program can go forward. State repression of the kind we are seeing in Jaitapur may win the government this round, but cannot sustain a long-term nuclear program.

Amit Sengupta

18th April 2012

IT would require a very brave person to argue that India has a functioning health care system. The country’s health sector has been the topic of several screaming headlines in the media in recent months. As horror stories of scandals, scams and denial of health care continue to make headlines, it is clear that a deep malaise affects the system.

At the heart of this malaise is the fact that India has one of the most privatised health systems in the world. While public funding on health has stagnated at just One per cent of GDP over the last two decades, huge out-of-pocket expenditures are incurred to access health care. Estimates indicate that over 70 per cent of health care costs are paid for directly by patients. Catastrophic expenditures on health care (i.e. expenditure that is in excess of 10 per cent of family expenditure) are a cause for an estimated 4 crore people being pushed below the poverty line every year. In spite of some progress made through implementation of the National Rural Health Mission (NRHM), huge gaps continue to exist in infrastructure creation and human resource utilisation and retention.

Nature abhors a vacuum and the private medical sector has moved in to fill the gap left by a non-existent or poorly performing public system. It has grown enormously over time and covers 60 per cent of in-patients and 80 per cent of out-patients. In spite of some sporadic attempts, the private sector remains largely unregulated. Costs in the private sector has grown by 300 per cent in the last two decades. Not only is private care expensive, it is often of poor quality and there are frequent allegations of unethical practices. The private sector is also undergoing a transformation, with large corporate run hospital chains forming an important segment of private care, especially in urban areas. In contrast, there is a huge pool of untrained and unqualified private providers, who are often the only source of medical care in rural areas. While public systems remain under-resourced, the private sector (especially the large and organised corporate controlled private sector) benefits from indirect subsidies it receives from the government.

FINANCING HEALTH SYSTEMS

The present state of the public health system is a result of decades old neglect by successive governments. The major issues that need to be addressed include issues of resources – both financial and human, and provisioning, i.e. mechanisms for making health care accessible to all. There is substantial global evidence as regards practices that help in building a good health care system. The positive examples – UK, France, Costa Rica, Cuba, Sri Lanka, Thailand in recent years -- straddle different situations, political systems and economic contexts but have one thing in common – they are all primarily built around the concepts of public financing and public provisioning of health services.

It is important, however, to understand that each country has to build systems that are tailored to its specific situation and needs. Models of public financing can include tax-based collection, a mix between tax-based collection and co-payments by citizens and employers, etc. In India it is difficult to consider a sustainable financial mechanism unless it is almost entirely drawn from tax revenue. Collection of co-payments from the work-place is almost impossible to implement, given that less than 7 per cent of the Indian work force is in the organised sector. The bottom line is that public funding in health care must increase from the abysmal 1 per cent of the GDP to at least approach the level recommended by the WHO (5 per cent of GDP).

HUMAN RESOURCES

Another key component of a health system is the availability of trained human resources, who are also deployed appropriately. In India a range of issues need to be addressed in this regard – medical education, the optimum mix of specialists and super-specialists and general physicians, the optimum mix of physicians and health workers, etc. The Indian education system is skewed heavily and favours the production of physicians, and further, specialists and super-specialists amongst them. Largely this is determined by ‘market forces’, and not by health needs. The situation is compounded by the rapid increase in private medical colleges, which often provide low quality of education and at the same time privilege people who can pay to receive education. Unless a strengthened public system challenges the ‘market based’ principles of the health sector, such distortions will continue to plague the Indian health care system.

While the services of specialists and even super-specialists are underutilised in urban areas, the deficit of specialists is as high as 80 per cent or more in the public health system, especially in rural areas. On the other hand, we subsidise the medical care needs of countries in Europe and North America by exporting trained physicians, most of whom are trained at public cost. The rapidly growing industry of medical tourism in India, now harnesses highly trained Indian medical professionals to treat rich medical tourists from developed nations. While our public health system remains grossly understaffed, we do not train an adequate number of other health workers. While we are unable to utilise doctors and super-specialists churned out by the medical education system, the proportion of other health workers to physicians in India, is much lower than in countries with much better health services – Thailand and Malaysia for example, within Asia.

To adequately address our needs, human resource development in health must be based on: increased public funding for medical education; a major expansion of training and deployment of different kinds of health workers whose skills are suited to the tasks they need to perform; and restructuring of health systems with judicious task shifting to ensure that physicians and specialists are deployed in situations where their skills are best used.

REGULATION OF PRIVATE SECTOR

The growth of the private medical sector in India has not been based on any planned attempt to address health needs. Being ‘private’, by definition the sector has to function in accordance with the logic of the market. The market (for all goods and services) does not, in the long term, allow the survival of the ‘inefficient’ entrepreneur. In the medical sector the efficient entrepreneur is not necessarily one who provides the best service, but often the one whose profit margins are the healthiest.

The logic of the market, in the medical care sector, has produced a situation where now huge corporate chains are replacing smaller players. It has brought in its wake more centralisation of services, and a higher degree of pooling of skills and expertise in fewer centres. This goes against the established tenets of public health and primary health care, where it is understood that better health outcome is a function of a wide spread of facilities and care providers, across the entire population.

India is one of the few large countries in the world (except for the United States, which by all evidence has one of the most wasteful and inefficient health systems) where the private medical sector is so large and organised.  While we aspire to be counted among the most powerful nations of the world, it would be instructive to look at the experience of most of the developed world in the health sector. Across Europe, Canada and Japan, the private sector is tightly regulated and functions within a broader vision of health care. Thus, while we need to build and develop a public system, we also need to regulate the private sector in a manner that locates its functioning within well defined public health goals.

All the above measures, of course, have to be accompanied by a vastly strengthened public health care system that is accessible to all and provides comprehensive health care to all.

REJECT PLANNING COMMISSION’S RECOMMENDATIONS

Recently, the government has declared its intention to remedy the present situation by initiating major reforms in the health system. While there is broad agreement that immediate and urgent measures are necessary to remedy the situation, several areas of disagreement remain. There are differing perceptions regarding the concrete contours of a restructured health system in India. These relate to both, how such a system is to be financed, and how the actual provision of health services will be structured. While there appears to be a broad consensus that public financing needs to be expanded, there are differences in views as regards the quantum and source of such funding. For example, we now have considerable experience as regards one model of financing and provisioning – the social health insurance schemes such as the Rajeev Gandhi Swasthya Bima Yojana (RSBY) at the national level and several similar schemes at the state level. Largely, these schemes provide limited cover for in-patient care, depend on public financing and are largely dependent on private provisioning. By and large these schemes harness public resources but out-source actual services to private institutions. This is done with the plea that we do not have adequate public facilities. So, instead of using the finances to build public facilities, public money is being used to create a captive clientele for the private sector. This is not a unique model – we see the same neoliberal model in operation in the case of other public utilities such as water supply and electricity.

As a lead up to the formulation of the Twelfth Five Year Plan, the government had set up a “High Level Expert Group’ (HLEG), tasked with the formulation of a plan for Universal Access to Health Care (UAHC). The HLEG has made several well intentioned recommendations, including:

• Increase in public expenditures on health from the current level of 1.2 per cent of GDP to at least 2.5 per cent by the end of the 12th  plan, and to at least 3 per cent of GDP by 2022. (though inadequate in our view, there is at least a positive recommendation to increase public expenditure)
• Ensure availability of free essential medicines by increasing public spending on drug procurement.
• Use of general taxation as the main source of healthcare financing.
• Advise not to use insurance companies or any other independent agents to purchase health care services on behalf of the government.
• Reorientation of health care provision to focus significantly on primary health care.

The Planning Commission of India has used inputs from the HLEG report and from other committees to develop its first draft ‘Report of the Steering Committee on Health for the 12th Five Year Plan’. Unfortunately this draft report betrays a clear attempt to dilute the positive recommendations of the HLEG report and to imbue the recommendations with an entirely different ‘spin’. The attempt is to pay lip service to the report on one hand, but institutionalise the public-private partnership model of health care delivery, on the other. The report is replete with references to the private sector, and to how important it is to make it part of the country’s health system.

While agreeing that, “Equally worrying is the growing reliance on private providers..” the Planning Commission draft goes on to argue that “With 80 per cent of doctors, 26 per cent of nurses, 37 per cent of beds and 80 per cent of ambulatory services, the private sector has to be partnered for health care delivery”. The draft, further goes on to assert that, “In order to spur competition, and make the providers responsive families need to be provided a choice to opt for a health provider from a panel of public, private or not-for profit providers”.

A feature of new-liberal economics has been to promote primitive accumulation of capital through the privatisation of public services. The Planning Commission’s intent is clearly to follow this prescription. It is not designed to promote health care access but to use the health care sector as another medium of capital accumulation by the private sector. These proposals need to be exposed for