- INSAAF's report - the statistics
- Book on healthcare released,     Tribune, Jan 2, 2002.
- Order this report
Yellow cards for the poor.
INSAAF International reports on the difference between rhetoric and action on public health in Punjab.
Mail this page to a friend

The evidence

The poor before PHSC
  • No charges for most services if monthly income is less than Rs.1000 per month.
  • No charge for normal child delivery, subsidized charges for low income persons.
  • No charge for a unit of blood used
  • Pay bribe to get treated
The poor after PHSC
  • Charges for normal child delivery exceed Rs 1000.
  • Charges for a unit of blood: Rs. 250
  • Pay bribe + user fee to get treated
  • NO exemptions granted to any poor person treated between July-December 2000, by a referral hospital in Bhatinda, serving 1.1 million.
  • NO exemption cards issued since 1996 in Bhatinda, a city of 270,000.
  • 44 yellow cards renewed in the same city since 1998.
  • ONE in 150 city slum women have heard vaguely about yellow cards - INSAAF survey.
The hospitals after PHSC
  • 20% reduction in hospital occupancy
  • 20-40% reduction in outpatient cases
Other eligble for exemptions
  • Members of Parliament
  • Members of Punjab Legislative Assembly
  • Employees of Punjab Vidhan Sabha
  • All Punjab Government employees
  • Exemption card income qualification: Monthly income less than Rs.300 per family member
WB funds to buy cars
  • PHSC officials bought 6 cars for themselves using Rs 2.03 million rupees of WB funds.
  • The state High Court ruled against the officials on Sep 17, 1997.
Other countries where user fees have failed
  • Zimbabwe, Nigeria, Kenya, Ghana.
INSAAF International
Kishori Ram Hospital Building,
Basant Vihar, Bhatinda, Punjab,
Phone : 91-164-215400
Fax : 91-164-214500
E-mail: vineetag@sancharnet.in
January 2002: It is no secret that public health care in India lies in a state of neglect, with some states marginally better off than others. Given this scenario, a revamping of the health care delivery system in Punjab with World Bank funding, should bring hope. The introduction of a user fee system meant to finance expansion of the health care system and make better-off citizens subsidize costs for the poorer sections of society was indeed promised as a cure for Punjab's public health system.

And yet, for the past five years, millions of Punjab's economically marginalized sections have been suffering from a drastic deterioration in the public health services available to them. This threat to the people's right to health is a direct effect of the World Bank sponsored and mandated changes in the state's health policies. The most harmful of these changes is the very aspect that was supposed to upgrade the system. User fees for previously free and corrupt health services.

So what went wrong? The endemic problems of corruption, lack of information and institutional apathy have made it almost impossible for the poor to access public health care. So it should come as no surprise that in a scathing indictment of these reforms, Dr.Vineeta Gupta of INSAAF International says with alarming lucidity that this seems to be another case of touted cure being worse than the disease.

Kamla, 32 and severely anemic, leaves a Bhatinda hospital and lies down on the road outside. Her husband and two children helplessly watch her suffer. Kamla has been told by the hospital staff that she must pay to get her treatment, but Kamla has no money. Luckily, a local aid worker spots her and gets Kamla admitted to the hospital with his own funds. Few of the thousands get so lucky. [Reproduced from INSAAF's report]

Before the involvement of the World Bank, the public health system of Punjab was managed solely by the state government. Patients were classified into three categories based on their income and the poorest category were completely exempt from fees, enabling them some access to basic health care, despite the corruption. In other words, services were "free" for the poor, with the exception of bribes. Private health care, though well-developed, is urban-oriented and primarily targets those at the middle and upper income levels.

Under the World Bank sponsored India-State Health Systems Development Project-II, the Punjab Health Systems Corporation (PHSC) was setup in October 1995. This para-statal health organization has taken charge of over 150 public health care institutions and imposed user fees on all patients irrespective of income level. The poorer patients are supposed to be able to get exemptions from user fees by getting a yellow card issued by the government. However, most poor patients don't know about the exemption card. Even if they do, the complex procedure for getting and continuosly retaining a card effectively excludes most of them from benefiting from the exemptions. Thus the poor are no longer able to access public health care and are pushed towards quacks. The effect is felt even more by poor women, who have traditionally suffered from socio-economic discrimination.

Dr. Vineeta Gupta, a doctor and human rights activist working in Punjab for the past 15 years, has compiled a report documenting the effects of the World Bank sponsored corporatization of Punjab's health care. The report, entitled "World Bank Funded Health Care : A Death Certificate for the Poor", has been termed a "must-read for people wishing to understand the interaction of government policy, World Bank pressure and market forces in violation the basic human rights of poor and needy Indian citizens". The report is available for a price of Rs 50/- (including postage) from INSAAF International.

The picture describing this woeful state of affairs is complete when you read about what some of the influential people, bureaucrats and officials are doing. They consult with private practioners like most middle and upper income level people do. But then instead of buying their medicenes from the open market, they send their prescriptions to local health authorities to get medicenes dispensed from the public hospitals, tapping into the user-fee revenue. Who is subsidizing whom?

In response to criticism of the user fee system during a panel discussion in the United States, a WB official stated that the analysis of the issue is restricted to Punjab where the stake of WB is negligible as compared to billions invested in rest of India. "Lives of human beings cannot be valued in terms of stakes of World Bank money", states Dr.Gupta in the report.

Shailabh Nagar
January 2002

[This article is based on INSAAF International's report released on Jan 2, 2002, by Justice Kuldeep Singh, former Chief Justice of India, at a press conference in Chandigarh. Dr.Vineeta Gupta is the author of the report.]
Ordering this report
From India, write to:
INSAAF International
Kishori Ram Hospital Building,
Basant Vihar, Bhatinda, Punjab,
Cost: Rs 50/- including S&H
Send check or money order.
From USA, write to:
Center for Economic Justice
1830 Connecticut Ave. NW
Washington, DC 20009
(202) 299-0020
Cost: $2 plus S&H

  • Related: More statistics from INSAAF's report
  • Health
  • Feedback: Tell us what you think of this page.