International trade & health equity: have benefits of medical tourism 'trickled down' to India's poor?

• Author: Gola, Swati

1. Introduction

   Since the late 1990s, the tension between neoliberalism led international trade and social redistributive justice is becoming more and more apparent. While the World Trade Organisation is trying to regulate the world trade order through dictating hegemonic global economic rules, a subaltern or anti-hegemonic globalisation is emerging centred around concerns of social and global justice (O'Connell 2007). It is true that a State surrenders some sovereignty when it becomes signatory to an international agreement, nevertheless, it cannot surrender welfare concerns solely to market forces (Higgott & Weber 2005). Although there is no accepted standard definition, (1) 'welfare state' is understood as a State built around social rights guaranteed to all citizens. Thus while states are obligated to follow the world economic regimen, they are equally required to mitigate the adverse social consequences of open markets.

   As noted above, safeguarding health and provision of healthcare services is an indispensable feature of a welfare state. With the nature of healthcare services transforming from a social good to premium tradable commodity, the present paper aims to enquire whether India has been able to achieve its Constitutional objective of becoming a welfare state focusing on health and healthcare services. In order to meet the stated objective, the present paper will examine the gradual change in India's healthcare policies moving towards liberalisation in the health sector including policies promoting medical tourism. Medical tourism is promoted in India on the basis that the increased medical tourist traffic will generate revenues and economic benefits that will trickle down to the most disadvantaged strata in terms of good quality, widely available free of cost medical services. Thus the present investigation will assess whether it is delivering what it claimed to deliver i.e. economic welfare for everyone? To that end, it will centre on the financing of healthcare services in the post-liberalisation era. In the end, the status of healthcare services delivery in the era of medical tourism will be analysed within the framework 'welfare state' to ascertain the proposed enquiry. To begin with, the present investigation first encapsulates the importance of health and healthcare in social justice discourse.

2. Why Health and Healthcare?

   'Health' is a multivalent construct that includes psychosocial as well as physical aspects that varies in different contexts (Ruger 2010). As opposed to a biomedical definition of health as absence of diseases or abnormalities, the World Health Organisation defines health as 'a state of complete physical, mental and social well-being, and not merely the absence of diseases or infirmity'. This expanded notion, as an expansive understanding of health forming the foundation for prevention and treatment is not without its critique. Regarded as being too broad and muddling the distinction between health and well-being, such a conception is denounced for potentially medicalising social problems and resulting in finding a technical solution unsuitable for a political problem. The medical approach is criticised (2) for directing attention only to diseases and their remedy and, thus, losing sight of issues such as meaning or importance of good health for people and the broader social context in which these issues are constructed. A social sciences approach, (3) on the other hand, puts health problems in a social context and aims to understand the social and economic factors responsible for health problems (Peter 2001).

   Importance of health and healthcare services is increasingly being recognised in academic scholarship on social justice. Venkatapuram (2012) views health as both intrinsically and instrumentally valuable since good health constitutes well-being as well as makes possible the planning, pursuing and revising of life plans. Harris (2009) on the other hand regards health, among other things, as liberating. He argues that while sickness either confines or makes a person immobile, health is what liberates her from that confinement. Daniels (1982) values health for its role in equality of opportunity and healthcare for its function in restoring 'normal species functioning,' which is an important component of opportunity range (i.e. the array of life plans that are reasonable to pursue within the conditions prevalent in a given society).

   Since the late 1980s, 'health equity' started to gain credence as an important policy consideration. As a concept, equity in health reflects concern for unequal opportunities and distribution of public resources for health and well-being of disadvantaged groups (based on socio-economic status, gender, race, geographic location, age, ethnicity or religion) within a given society and for eliminating systematic health disparities (Braveman 1996). Mooney (1987) noted that, in the absence of a clear definition and policy objectives, resources may be wasted or misdirected. Braveman & Gruskin (2003) noted that a technical definition of equity in health is further needed to guide measurement of actions and hence accountability for the effects. Whitehead (1992) was the first to define 'health inequities' in as differences in health which are unnecessary and avoidable and, in addition, are also considered unfair and unjust. While this definition raised awareness and stimulated the debate, it was not a technical definition and left many questions concerning what is avoidable, how to judge unfairness and injustice, etc., unanswered (Peter 2001). Braveman (1996) proposed a definition of health equity as 'the absence of systematic disparities in health (or its social determinants) between more and less advantaged social groups'. In the proposed definition, social advantage means attributes that group people in social hierarchies, and health inequities result in diminishing opportunities to be healthy, subsequently putting disadvantaged groups at further disadvantage. This definition attempts to compare health disparities between identifiable social groups, like the health of different ethnic groups with each other, or health of men and women with similar health conditions (Braveman & Gruskin 2003).

   Pereira (1989) argued that health equity is not health equality, though the terms have been used interchangeably at times. Whereas equity is a value-based normative concept, equality is more concerned with equal share in distribution of goods or resources. Since not all health disparities are unfair (for example, young adults are healthier than elderlies or men are prone to prostate problems and women to breast cancer), equity in health focuses attention on only those health inequalities that are unfair or unjust (for example, differences in immunisation levels or nutritional status between girls and boys or difference in appropriate treatment on the basis of ethnicity or religion) (Braveman & Gruskin 2003). Sen (2002) posits that health equity cannot be established by looking at inequalities in health and healthcare alone, but by taking into account how resource allocation and social arrangements link health with other features of the state-of-affairs. Referring to Dworkin's (1981) distinction of equality of welfare from equality of resources, and argument for equalising the resources available to people and not their welfare, Pereira (1989) highlights flaws inherent in this distinction. For instance, does equality of resources require only equality of access or use of resources in equal quantities? Is this equality applicable only to healthcare provided by States, or across all resources, public and private? He thus argues that being too vague a concept as a principle of distribution, equality is unable to provide a rigorous and consistent solution.

   Fox & Thomson (2012) hold that Sen's capability approach is the most plausible approach for health justice as it views health as an intrinsic part of human flourishing and all aspects of flourishing are impossible or limited in the presence of ill-health. Capability, as the substantive freedom or practical possibility of being or doing something X, reflects the interaction of an individual's internal biological and mental endowment with external physical and social environment (Venkatpuram 2012). Sen (2002) maintains that the justice of social arrangements cannot be deliberated in absence of health equity at its epicentre. Giving the example of basic healthcare, Sen (2009) argues that an opportunity to access socially supported healthcare gives people capability to enhance their state of health. Thus, even if a person chooses not to make...