SOCIAL ACTION AND ADVOCACY FOR HEALTH CARE REFORMS
Amar Jesani
Social activists have been demanding reforms in health care services for a very long time. The new economic policy (NEP) and the structural adjustment programmes (SAP), officially stated by the government since 1991, have only made the need to take action in the field of health care very urgent. The international experiences of SAP have conclusively shown that health care is one of the important components of the social sector which is getting adversely affected by the governments attempt to reduce its expenditure. In our country there are several reasons why such an adverse impact on health care is going to be very severe. Such an impact is as much due to the kind of health service system that exists as the high level of existing poverty. We shall not fo into the latter, namely how the NEP and SAP could accentuate poverty and the problems of the poor. We shall explain briefly what it could do and is doing to make health care accessible to the people. That will be followed by our suggestions on the strategy that the social activists could employ.
STATE OF HEALTH CARE SERVICES
The public health care services have always been in the spotlight. However, little consideration is given to the fact that the public sector is not he main provider of health care services in India. It is the private sector that dominates health care service. In terms of the number of health care professionals, hospitals and nursing homes, dispensaries and clinics, the private sector accounts for almost three fourths of the share. More than seventy percent of the total health care expenditure of our country is financed privately or paid for directly by the people from their own resources
As compared to the private sector, the share of services of the public sector, particularly in the rural areas, is very low. Whatever infrastructure that the government has been able to establish suffers from paucity of funds, equipment, drugs and adequate trained human power. For the health professionals it is more lucrative to work in the private sector than in public sector, many of them practice privately to increase their earnings.
Thus when one talks about the lack of access to health care services, it is not sufficient to say that there are areas where no government facility is available, or that there are no sufficient resources allocated for the government facilities. It is equally important to take into consideration the fact much of our health care resources are in the private sector and these resources are not sufficiently accessible to people. For in order to make private health care accessible people need purchasing power. The cost of health care has increased phenomenally, ad there is no price control over the health care cost. Over and above that, while the NEP talks of deregulation and decontrol over the health care sector there is nothing to deregulate and decontrol as firstly there are hardly any regulations and controls and secondly, whatever mild regulations were brought in these were never implemented. For example, in Maharahtra there was a law called Bombay Nursing Homes Registration Act, 1949. However, this applied in only four cities (Mumbai, Pune, Sholapur, Nagpur) and it is hardly implemented. When a health activists group, the Medicao Friencd Circle, filed a Public Interest Litigation in the Bombay High Court for the proper implementation of the Act, it was discovered that the Municipal Corporation was not registering all nursing homes. In the course of the hearing and later under pressure of the court and the court appointed committee, the corporation revised its figure of 526 to more than 900 nursing homes in the city Secondly while it registers the nursing home in the city it has no standards laid down to ensure that they have scientifically minimum facilities available in order to provide patient care. If this is the situation in the city of Mumbai one can imagine the situation in other parts if the state.
In short, the private sector which is dominant in health care creates barriers to accessibility by its high cost and yet, to the paying public, there is no guarantee that they would get quality care. This flows from lack of government regulation on the private sector. Instead of the much maligned license and permit raj what we witness is a jungle raj, or no social gal and n accountability, in the private health care sector.
Further, there is a growing body of evidence suggesting that since the starting of the NEP and the SAP, there has been further deterioration of the public sector health care services and the cost of health care has increased several fold. A study done in Gujarat has shown that in the last few years, the poor people have been forced to spend high amounts to get private health care as free government service is not available. Further the poor are spending on this cost of health care by taking credit from informal sources (e.g money lenders) thus getting trapped into the debt. In our recent study of patients in a public hospital in Mumbai we discovered that the middle classes and high-income groups hardly use the hospital, the chief users are the poor. Thus, whenever government services are available, despite all bad publicity of the quality if care given, the poor are using it as when it is not available, they are forced to buy it from the private sector. In the process they ruin themselves economically.
STRATEGIC ISSUES FOR ADVOCACY AND ACTION IN THE HEALTH CARE SECTOR
It follows from our description of the health care scenario that if one wants to make basic health care available to all people in our country. It is no use just reforming the public sector alone. Whatever is done in the public sector due to its smaller share of health care resources, it would remain inadequate to meet the needs of all. Of the public sector alone is asked t meet the social goal, it would get over burdened resulting in more inefficiency. Thus, the first important issue in framing a strategy for action in the health sector is that the strategy must be holistic, encompassing all sectors, public, private and voluntary.
The second issue is that all sectors must work together to meet the goal. In other words, the health care planning should not be limited to the public sector (as has been hitherto done), but it must also bring the private and voluntary sectors under its perview.
Thirdly, past experiences have shown that if our advocacy relies only on the bureaucrats, health professionals and private providers for achieving goals, then the red-tapism corruption profits-motives would invariably defeat all the good work undertake, There is no way in which one can make health care pro-people without directly bringing some amount of peoples control over the health care providers.
Thus, within the wider and comprehensive national health plan, one needs to decentralise and provide a role for the users in the management of health care institutions.
Fourthly, the empowerment of people, by formalising their rights vis-à-vis health care providers is a must for motivating people to take initiative. Here, the struggle for patients rights, action for getting compensation from the providers when they are negligent, pressure on the professionals to self-regulate themselves as per their code of the ethics etc., are the most important areas for social activists to gradually strengthen the peoples movement in the field of health care.
The fifth issue is concerned with the larger goal of making health care a fundamental human right of people. At present such constitutional rights have not been given by most of the countries including India, to their people. In our laws, particularly those concerning municipalities there is a stipulation that they should be providing some health care. The courts have also upheld pleas that such local bodies cannot stop making provision of health care under any pretext. However, since ht quality, and coverage of health to be provided have not been legislated, the authorities are able to frustrate the law by making the public health care least attractive to people for use. Thus, a principle that a defined minimum quantity and quality if health care should be a fundamental right of people must be made acceptable.
A CHALLENGING FIELD OF WORK
The activists have often complained that unlike the issue such as food and housing, health care is an issue, which makes mobilizing people difficult. They say that it is not on the people's list of priorities. This perhaps true as one has yet to see a demonstration of people demanding health care. However, it is also equally true that health care is one of the basic needs of all. The fact that people fell overwhelmed by the mystery of medicine, the mannerisms of doctors and the impending threat of death due to disease do not mean that there is no way out. The work done by a large number of voluntary organisations in the community health have shown that medicine can be demystified to become equal partners in health care. In nay case, the issue related t distribution and access to health care services are not a technical medical issue, but a purely social, economic and political issue. All of them only make the task of social activists more challenging. This is a field, which demands more innovations and long term commitments from the activists. We hope more of them would integrate action and advocacy on health care in future.
Perspectives in Social Work, Vol. XI, No. 2, May-Aug 1996, pp. 16-18
************************************************************************************************************************
Order this publication - A54
Sitemap
© Copyright Centre for Enquiry into Health and Allied Themes