Operationalising Right to Healthcare in India

By Ravi Duggal

Preamble: Health is one of the goods of life to which man has a right; wherever this concept prevails the logical sequence is to make all measures for the protection and restoration of health to all, free of charge; medicine like education is then no longer a trade - it becomes a public function of the State ...

Henry Sigerist

More than half a century’s experience of waiting for the policy route to assure respect, protection and fulfillment for healthcare is now behind us. The Bhore Committee recommendations which had the potential for this assurance were assigned to the back-burner due to the failure of the state machinery to commit a mere 2% of the Gross Domestic Product at that point of time for implementation of the Bhore Plan (Bhore, 1946). The experience over the nine plan periods since then in implementing health plans and programs has been that each plan and/or health committee contributed to the dilution of the comprehensive and universal access approach by developing selective schemes or programs, and soon enough the Bhore plan was archived and forgotten about. So our historical experience tells us that we should abandon the policy approach and adopt the human rights route to assuring universal access to all people for healthcare. The State is today talking of health sector reform and hence it is the right time to switch gears and move in the direction of right to health and healthcare.

The right to healthcare is primarily a claim to an entitlement, a positive right, not a protective fence.[i] As entitlements rights are contrasted with privileges, group ideals, societal obligations, or acts of charity, and once legislated they become claims justified by the laws of the state. (Chapman, 1993) The emphasis thus needs to shift from ‘respect’ and ‘protect’ to focus more on ‘fulfill’. For the right to be effective optimal resources that are needed to fulfill the core obligations have to be made available and utilized effectively.

Further, using a human rights approach also implies that the entitlement is universal. This means there is no exclusion from the provisions made to assure healthcare on any grounds whether purchasing power, employment status, residence, religion, caste, gender, disability, and any other basis of discrimination.[ii] But this does not discount the special needs of disadvantaged and vulnerable groups who may need special entitlements through affirmative action to rectify historical or other inequities suffered by them.

Thus establishing universal healthcare through the human rights route is the best way to fulfill the obligations mandated by international law and domestic constitutional provisions. International law, specifically ICESCR, the Alma Ata Declaration, among others, provide the basis for the core content of right to health and healthcare. But country situations are very different and hence there should not be a global core content, it needs to be country specific.[iii] In India’s case a certain trajectory has been followed through the policy route and we have an existing baggage, which we need to sort out and fit into the new strategy.

Specific features of this historical baggage are:

• a very large and unregulated private health sector with an attitude that the existing policy is the best one as it gives space for maximizing their interests, a complete absence of professional ethics and absolute disinterest in organizing around issues of self-regulation, improvement of quality and accountability, and need for an organised health care system
• a declining public health care system which provides selective care through a multiplicity of schemes and programs, and discriminates on the basis of residence (rural-urban) in providing for entitlements for healthcare
• existing inequities in access to healthcare based on employment status and purchasing power
• inadequate development of various pre-conditions of health like water supply and sanitation, environmental health and hygiene and access to food[iv]
• very large numbers of unqualified and untrained practitioners
• declining investments and expenditure in public health
• adequate resource availability when we account for out-of-pocket expenses
• humanpower and infrastructure reasonably adequate, though inequitably distributed
• wasteful expenditures due to lack of regulation and standard protocols for treatment

Thus the operationalisation of the right to healthcare will have to be developed keeping in mind what we have and how we need to change it.

Framework for Right to Healthcare

The quote used as the Preamble is very relevant to the notion of right to healthcare. Sigerist said this long ago and since then most of Europe and many other countries have made this a reality. And today when such demands are raised in third world countries, India being one of them, it is said that this is no longer possible - the welfare state must wither away and make way for global capital! Europe is also facing pressures to retract the socialist measures, which working class struggles had gained since 19^th century. So we are in a hostile era of global capital which wants to make profit out of anything it can lay its hands on. But we are also in an era when social and economic rights, apart from the civil and political rights, are increasingly on the international agenda and an important cause for advocacy.

Thus health and health care is now being viewed very much within the rights perspective and this is reflected in Article 12 “The right to the highest attainable standard of health” of the International Covenant on Economic, Social and Cultural Rights to which India has acceded. According to the General Comment 14 the Committee for Economic, Social and Cultural Rights states that the right to health requires availability, accessibility, acceptability, and quality with regard to both health care and underlying preconditions of health. The Committee interprets the right to health, as defined in article 12.1, as an inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health, such as access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health. This understanding is detailed below:

The right to health in all its forms and at all levels contains the following interrelated and essential elements, the precise application of which will depend on the conditions prevailing in a particular State party:

(a) Availability. Functioning public health and health-care facilities, goods and services, as well as programmes, have to be available in sufficient quantity within the State party. The precise nature of the facilities, goods and services will vary depending on numerous factors, including the State party's developmental level. They will include, however, the underlying determinants of health, such as safe and potable drinking water and adequate sanitation facilities, hospitals, clinics and other health-related buildings, trained medical and professional personnel receiving domestically competitive salaries, and essential drugs, as defined by the WHO Action Programme on Essential Drugs.

(b) Accessibility. Health facilities, goods and services have to be accessible to everyone without discrimination, within the jurisdiction of the State party. Accessibility has four overlapping dimensions:

Non-discrimination: health facilities, goods and services must be accessible to all, especially the most vulnerable or marginalized sections of the population, in law and in fact, without discrimination on any of the prohibited grounds.

Physical accessibility: health facilities, goods and services must be within safe physical reach for all sections of the population, especially vulnerable or marginalized groups, such as ethnic minorities and indigenous populations, women, children, adolescents, older persons, persons with disabilities and persons with HIV/AIDS. Accessibility also implies that medical services and underlying determinants of health, such as safe and potable water and adequate sanitation facilities, are within safe physical reach, including in rural areas. Accessibility further includes adequate access to buildings for persons with disabilities.

Economic accessibility (affordability): health facilities, goods and services must be affordable for all. Payment for health-care services, as well as services related to the underlying determinants of health, has to be based on the principle of equity, ensuring that these services, whether privately or publicly provided, are affordable for all, including socially disadvantaged groups. Equity demands that poorer households should not be disproportionately burdened with health expenses as compared to richer households.

Information accessibility: accessibility includes the right to seek, receive and impart information and ideas concerning health issues. However, accessibility of information should not impair the right to have personal health data treated with confidentiality.

(c) Acceptability. All health facilities, goods and services must be respectful of medical ethics and culturally appropriate, i.e. respectful of the culture of individuals, minorities, peoples and communities, sensitive to gender and life-cycle requirements, as well as being designed to respect confidentiality and improve the health status of those concerned.

(d) Quality. As well as being culturally acceptable, health facilities, goods and services must also be scientifically and medically appropriate and of good quality. This requires, inter alia, skilled medical personnel, scientifically approved and unexpired drugs and hospital equipment, safe and potable water, and adequate sanitation. (Committee on Economic, Social and Cultural Rights Twenty-second session 25 April-12 May 2000)

Universal access to good quality healthcare equitably is the key element at the core of this understanding of right to health and healthcare. To make this possible the State parties are obligated to respect, protect and fulfill the above in a progressive manner:

The right to health, like all human rights, imposes three types or levels of obligations on State parties: the obligations to respect, protect and fulfill. In turn, the obligation to fulfill contains obligations to facilitate, provide and promote. The obligation to respect requires States to refrain from interfering directly or indirectly with the enjoyment of the right to health. The obligation to protect requires States to take measures that prevent third parties from interfering with article 12 guarantees. Finally, the obligation to fulfill requires States to adopt appropriate legislative, administrative, budgetary, judicial, promotional and other measures towards the full realization of the right to health. (Ibid)

(Further) State parties are referred to the Alma-Ata Declaration, which proclaims that the existing gross inequality in the health status of the people, particularly between developed and developing countries, as well as within countries, is politically, socially and economically unacceptable and is, therefore, of common concern to all countries. State parties have a core obligation to ensure the satisfaction of, at the very least, minimum essential levels of each of the rights enunciated in the Covenant, including essential primary health care. Read in conjunction with more contemporary instruments, such as the Programme of Action of the International Conference on Population and Development, the Alma-Ata Declaration provides compelling guidance on the core obligations arising from Article 12. Accordingly, in the Committee's view, these core obligations include at least the following obligations:

(a) To ensure the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups;

(b) To ensure access to the minimum essential food which is nutritionally adequate and safe, to ensure freedom from hunger to everyone;

(c) To ensure access to basic shelter, housing and sanitation, and an adequate supply of safe and potable water;

(d) To provide essential drugs, as from time to time defined under the WHO Action Programme on Essential Drugs;

(e) To ensure equitable distribution of all health facilities, goods and services;

(f) To adopt and implement a national public health strategy and plan of action, on the basis of epidemiological evidence, addressing the health concerns of the whole population; the strategy and plan of action shall be devised, and periodically reviewed, on the basis of a participatory and transparent process; they shall include methods, such as right to health indicators and benchmarks, by which progress can be closely monitored; the process by which the strategy and plan of action are devised, as well as their content, shall give particular attention to all vulnerable or marginalized groups.

The Committee also confirms that the following are obligations of comparable priority:

(a) To ensure reproductive, maternal (pre-natal as well as post-natal) and child health care;

(b) To provide immunization against the major infectious diseases occurring in the community;

(c) To take measures to prevent, treat and control epidemic and endemic diseases;

(d) To provide education and access to information concerning the main health problems in the community, including methods of preventing and controlling them;

(e) To provide appropriate training for health personnel, including education on health and human rights. (Ibid)

The above guidelines from General Comment 14 on Article 12 of ICESCR are critical to the development of the framework for right to health and healthcare. As a reminder it is important to emphasise that in the Bhore Committee report of 1946 we already had these guidelines, though they were not in the 'rights' language. Thus within the country's own policy framework all this has been available as guiding principles for now 56 years.

Before we move on to suggest the framework it is important to review where India stands today vis-à-vis the core principles of availability, accessibility, acceptability and quality in terms of the State's obligation to respect, protect and fulfill.

In Table 1 we see that the availability of healthcare infrastructure, except perhaps availability of doctors and drugs - the two engines of growth of the private health sector, is grossly inadequate. The growth over the years of healthcare services, facilities, humanpower etc.. has been inadequate and the achievements not enough to make any substantive impact on the health of the people. The focus of public investment in the health sector has been on medical education and production of doctors for the private sector, support to the pharmaceutical industry through states own participation in production of bulk drugs at subsidized rates, curative care for urban population and family planning services. The poor health impact we see today has clear linkages with such a pattern of investment:

• the investment in medical education has helped create a mammoth private health sector, not only within India, but in many developed countries through export of over one-fourth of the doctors produced over the years. Even though since mid-eighties private medical colleges have been allowed, still 75-80% of the outturn is from public medical schools. This continued subsidy without any social return[v] is only adding to the burden of inequities and exploitation within the healthcare system in India.
• public sector participation in drug production was a laudable effort but soon it was realized that the focus was on capital goods, that is bulk drug production, and most supplies were directed to private formulation units at subsidized rates. It is true that the government did control drug prices, but post mid-seventies the leash on drug prices was gradually released and by the turn of the nineties controls disappeared. Ironically, at the same time the public pharmaceutical industry has also disappeared – the little of what remains produces a value of drugs lesser than their losses! And with this withering away of public drug production and price control, essential drugs availability has dropped drastically. Another irony in this story is that while today we export 45% of our drug production, we have to import a substantial amount of our essential drug requirements.[vi]
• Most public sector hospitals are located in urban areas. In the eighties, post-Alma Ata and India ratifying the ICESCR, efforts were made towards increasing hospitals in rural areas through the Community Health Centres. This was again a good effort but these hospitals are understaffed by over 50% as far as doctors are concerned and hence become ineffective. Today urban areas do have adequate number of beds (including private) at a ratio of one bed per 300 persons but rural areas have 8 times less hospital beds as per required norms (assuming a norm of one bed per 500 persons). So there is gross discrimination based on residence in the way the hospital infrastructure has developed in the country, thereby depriving the rural population access to curative care services.[vii] Further, the declining investment in the public health sector since mid-eighties, and the consequent expansion of the private health sector, has further increased inequity in access for people across the country. More recently a facility survey across the country by the Ministry of Health and Family Welfare clearly highlights the inadequacies of the public health infrastructure, especially in the rural areas.[viii] This survey is a major indictment of the underdevelopment of the public healthcare system - even the District Hospitals, which are otherwise well endowed, have a major problem with adequacy of critical supplies needed to run the hospital. The rural health facilities across the board are ill provided. (MOHFW, 2001)
• Family planning services is another area of almost monopolistic public sector involvement. The investment in such services over the years has been very high, to the tune of over 15% of the total public health budget. But over and above this the use of the entire health infrastructure and other government machinery for fulfilling its goals must also be added to these resources expended. This program has also witnessed a lot of coercion[ix] and grossly violated human rights. The hard line adopted by the public health system, especially in rural areas, for pushing population control has terribly discredited the public health system and affected adversely utilization of other health programs. The only silver lining within this program is that in the nineties immunisation of children and mothers saw a rapid growth, though as yet it is still quite distant from the universal coverage level.

Then there are the underlying conditions of health and access to factors that determine this, which are equally important in a rights perspective. Given the high level of poverty and even a lesser level of public sector participation in most of these factors the question of respecting, protecting and fulfilling by the state is quite remote. Latest data from NFHS-1998 tells the following story:

• Piped water is available to only 25% of the rural population and 75% of urban population
• Half the urban population and three-fourths of the rural population does not purify/filter the water in any way
• Flush and pit toilets are available to only 19% of the rural population as against 81% of those in towns and cities
• Electricity for domestic use is accessible to 48% rural and 91% urban dwellers
• For cooking fuel 73% of villagers still use wood. LPG and biogas is accessed by 48% urban households but only 6% rural households
• As regards housing 41% village houses are kachha whereas only 9% of urban houses are so
• 21% of the population chews paan masaala and/or tobacco, 16% smoke and 10% consume alcohol

Besides this environmental health conditions in both rural and urban areas are quite poor, working conditions in most work situations, including many organized sector units, which are governed by various social security provisions, are unhealthy and unsafe. Infact most of the court cases in India using Article 21 of the Fundamental Rights and relating it to right to health have been cases dealing with working conditions at the workplace, workers rights to healthcare and environmental health related to pollution.

Other concerns in access relate to the question of economic accessibility. It is astounding that large-scale poverty and predominance of private sector in healthcare have to co-exist. It is in a sense a contradiction and reflects the State’s failure to respect, protect and fulfill its obligations by letting vast inequities in access to healthcare and vast disparities in health indicators, to continue to persist, and in many situations get worse. Data shows that out of pocket expenses account for over 4% of the GDP as against only 0.9 % of GDP expended by state agencies, and the poorer classes contribute a disproportionately higher amount of their incomes to access health care services both in the private sector and public sector. (Ellis, et.al, 2000; Duggal, 2000; Peters et.al. 2002). Further, the better off classes use public hospitals in much larger numbers with their hospitalization rate being six times higher than the poorest classes[x], and as a consequence consume an estimated over three times more of public hospital resources than the poor. (NSS-1996; Peters et.al. 2002)

Related to the above is another concern vis-à-vis international human rights conventions’ stance on matters with regard to provision of services. All conventions talk about affordability and never mention ‘free of charge’. In the context of poverty this notion is questionable as far as provisions for social security like health, education and housing go. Access to these factors socially has unequivocal consequences for equity, even in the absence of income equity. Free services are viewed negatively in global debate, especially since we have had a unipolar world, because it is deemed to be disrespect to individual responsibility with regard to their healthcare. (Toebes, 1998, p.249) For instance in India there is great pressure on public health systems to introduce or enhance user fees, especially from international donors, because they believe this will enhance responsibility of the public health system and make it more efficient (Peters, et. al.,2002). In many states such a policy has been adopted in India and immediately adverse impacts are seen, the most prominent being decline in utilization of public services by the poorest. It must be kept in mind that India's taxation policy favours the richer classes. Our tax base is largely indirect taxes, which is a regressive form of generating revenues. Direct tax revenues, like income tax is a very small proportion of total tax revenues. Hence the poor end up paying a larger proportion of their income as tax revenues in the form of sales tax, excise duties etc.. on goods and services they consume. Viewed from this perspective the poor have already pre-paid for receiving public goods like health and education from the state free of cost at the point of provision. So their burden of inequity increases substantially if they have to pay for such services when accessing from the public domain.

The above inequity in access gets reflected in health outcomes, which reflect strong class gradients. Thus infant and child mortality, malnutrition amongst women and children, prevalence of communicable diseases like tuberculosis and malaria, attended childbirth are between 2 to 4 times better amongst the better off groups as compared to the poorest groups. (NFHS-1998) In this quagmire of poverty, the gender disparities also exist but they are significantly smaller than the class inequities. Such disparity, and the consequent failure to protect by the state the health of its population, is a damning statement on the health situation of the country. In India there is an additional dimension to this inequity – differences in health outcomes and access by social groups, specifically the scheduled castes and scheduled tribes. Data shows that these two groups are worse off on all counts when compared to others. Thus in access to hospital care as per NSS-1996 data the STs had 12 times less access in rural areas and 27 times less in urban areas as compared to others; for SCs the disparity was 4 and 9 times, in rural and urban areas, respectively. What is astonishing is that the situation for these groups is worse in urban areas where overall physical access is reasonably good. Their health outcomes are adverse by 1.5 times that of others. (NFHS-1998)

Another stumbling block in meeting state obligations is information access. While data on public health services, with all its limitations, is available, data on the private sector is conspicuous by its absence. The private sector, for instance does not meet its obligations to supply data on notifiable, mostly communicable, diseases, which is mandated by law. This adversely affects the epidemiological database for those diseases and hence affects public health practice and monitoring drastically. Similarly the local authorities have miserably failed to register and record private health institutions and practitioners. This is an extremely important concern because all the data quoted about the private sector is an under-estimate as occasional studies have shown.[xi] The situation with regard to practitioners is equally bad. The medical councils of all systems of medicine are statutory bodies but their performance leaves much to be desired. The recording of their own members is not up to the mark, and worse still since they have been unable to regulate medical practice there are a large number of unqualified and untrained persons practicing medicine across the length and breadth of the country. Estimates of this unqualified group vary from 50% to 100% of the proportion of the qualified practitioners. (Duggal, 2000; Rhode et.al.1994) The profession itself is least concerned about the importance of such information and hence does not make any significant efforts to address this issue. This poverty of information is definitely a rights issue even within the current constitutional context as lack of such information could jeopardize right to life.

Finally there are issues pertaining to acceptability and quality. Here the Indian state fails totally. There is a clear rural-urban dichotomy in health policy and provision of care; urban areas have been provided comprehensive healthcare services through public hospitals and dispensaries and now even a strengthened preventive input through health posts for those residing in slums. In contrast rural areas have largely been provided preventive and promotive healthcare alone. This violates the principle of non-discrimination and equity and hence is a major ethical concern to be addressed.

Medical practice, especially private, suffers from a complete absence of ethics. The medical associations have as yet not paid heed to this issue at all and over the years malpractices within medical practice have gone from bad to worse. In this malpractice game the pharmaceutical industry is a major contributor as it induces doctors and hospitals to prescribe irrational and/or unnecessary drugs.[xii] All this impacts drastically on quality of care. In clinical practice and hospital care in India there exist no standard protocols and hence monitoring quality becomes very difficult. For hospitals the Bureau of Indian Standards have developed guidelines, and often public hospitals do follow these guidelines. (BIS, 1989; Nandraj and Duggal, 1997) But in the case of private hospitals they are generally ignored. Recently efforts at developing accreditation systems has been started in Mumbai (Nandraj, et.al, 2000)[xiii], and on the basis of that the Central government is considering doing something at the national level on this front so that it can promote quality of care.

To establish right to healthcare with the above scenario certain first essential steps will be compulsory:

• equating directive principles with fundamental rights through a constitutional amendment
• incorporating a National Health Act (similar to Canada Health Act) which will organize the present healthcare system under a common umbrella organization as a public-private mix governed by an autonomous national health authority which will also be responsible for bringing together all resources under a single-payer mechanism
• generating a political commitment through consensus building on right to healthcare in civil society
• development of a strategy for pooling all financial resources deployed in the health sector
• redistribution of existing health resources, public and private, on the basis of standard norms (these would have to be specified) to assure physical (location) equity

As an immediate step, within its own domain, the State should undertake to accomplish the following:

• Allocation of health budgets as block funding, that is on a per capita basis for each population unit of entitlement as per existing norms. This will create redistribution of current expenditures and reduce substantially inequities based on residence.[xiv] Local governments should be given the autonomy to use these resources as per local needs but within a broadly defined policy framework of public health goals
• Strictly implementing the policy of compulsory public service by medical graduates from public medical schools, as also make public service of a limited duration mandatory before seeking admission for post-graduate education. This will increase human resources with the public health system substantially and will have a dramatic impact on the improvement of the credibility of public health services
• Essential drugs as per the WHO list should be brought back under price control (90% of them are off-patent) and/or volumes needed for domestic consumption must be compulsorily produced so that availability of such drugs is assured at affordable prices and within the public health system
• Local governments must adopt location policies for setting up of hospitals and clinics as per standard acceptable ratios, for instance one hospital bed per 500 population and one general practitioner per 1000 persons. To restrict unnecessary concentration of such resources in areas fiscal measures to discourage such concentration should be instituted.[xv]
• The medical councils must be made accountable to assure that only licensed doctors are practicing what they are trained for.[xvi] Such monitoring is the core responsibility of the council by law which they are not fulfilling, and as a consequence failing to protect the patients who seek care from unqualified and untrained doctors. Further continuing medical education must be implemented strictly by the various medical councils and licenses should not be renewed (as per existing law) if the required hours and certification is not accomplished
• Integrate ESIS, CGHS and other such employee based health schemes with the general public health system so that discrimination based on employment status is removed and such integration will help more efficient use of resources. For instance, ESIS is a cash rich organization sitting on funds collected from employees (which are parked in debentures and shares of companies!), and their hospitals and dispensaries are grossly under-utilised. The latter could be made open to the general public
• Strictly regulate the private health sector as per existing laws, but also an effort to make changes in these laws to make them more effective. This will contribute towards improvement of quality of care in the private sector as well as create some accountability
• Strengthen the health information system and database to facilitate better planning as well as audit and accountability.

Carrying out the above immediate steps, for which we need only political commitment and not any radical transformation, will create the basis to move in the direction of first essential steps indicated above. In order to implement the first-steps the essential core contents of healthcare have to be defined and made legally binding through the processes of the first-steps. The literature and debate on the core contents is quite vast and from that we will attempt to draw out the core content of right to health and healthcare keeping the Indian context discussed above in mind.

The Core Content of Right to Healthcare

Audrey Chapman in discussing the minimum core contents summarises this debate, “Operatively, a basic and adequate standard of healthcare is the minimum level of care, the core entitlement, that should be guaranteed to all members of society: it is the floor below which no one will fall.[xvii] (Chapman, 1993). She further states that the basic package should be fairly generous so that it is widely acceptable by people, it should address special needs of special and vulnerable population groups like under privileged sections (SC and ST in India), women, physically and mentally challenged, elderly etc., it should be based on cost-conscious standards but judge to provide services should not be determined by budgetary constraints[xviii], and it should be accountable to the community as also demand the latter’s participation and involvement in monitoring and supporting it. All this is very familiar terrain, with the Bhore Committee saying precisely the same things way back in 1946.

We would like to put forth the core content as under:

Primary care services[xix] should include at least the following:

• General practitioner/family physician services for personal health care.
• First level referral hospital care and basic specialty services (general medicine, general surgery, obstetrics and gynaecology, paediatrics and orthopaedic), including dental and ophthalmic services.
• Immunisation services against all vaccine preventable diseases.
• Maternity and reproductive health services for safe pregnancy, safe abortion, delivery and postnatal care and safe contraception.
• Pharmaceutical services - supply of only rational and essential drugs as per accepted standards.
• Epidemiological services including laboratory services, surveillance and control of major diseases with the aid of continuous surveys, information management and public health measures.
• Ambulance services.
• Health education.
• Rehabilitation services for the physically and mentally challenged and the elderly and other vulnerable groups
• Occupational health services with a clear liability on the employer
• Safe and assured drinking water and sanitation facilities, minimum standards in environmental health and protection from hunger to fulfill obligations of underlying preconditions of health[xx]

The above listed components of primary care are the minimum that must be assured, if a universal health care system has to be effective and acceptable. And these have to be within the context of first-steps and not to wait for progressive realisation – these cannot be broken up into stages, as they are the core minimum. The key to equity is the existence of a minimum decent level of provision, a floor that has to be firmly established. However, if this floor has to be stable certain ceilings will have to be maintained toughly, especially on urban health care budgets and hospital use (Abel-Smith,1977). This is important because human needs and demands can be excessive and irrational. Those wanting services beyond the established floor levels will have to seek it outside the system and/or at their own cost.

Therefore it is essential to specify adequate minimum standards of health care facilities, which should be made available to all people irrespective of their social, geographical and financial position. There has been some amount of debate on standards of personnel requirements [doctor: population ratio, doctor: nurse ratio] and of facility levels [bed: population ratio, PHC: population ratio] but no global standards have as yet been formulated though some ratios are popularly used, like one bed per 500 population, one doctor per 1000 persons, 3 nurses per doctor, health expenditure to the tune of 5% of GDP etc.. Another way of viewing standards is to look at the levels of countries that already have universal systems in place. In such countries one finds that on an average per 1000 population there are 2 doctors, 5 nurses and as many as 10 hospital beds (OECD, 1990, WHO, 1961). The moot point here is that these ratios have remained more or less constant over the last 30 years indicating that some sort of an optimum level has been reached. In India with regard to hospital care the Bureau of Indian Standards (BIS) has worked out minimum requirements for personnel, equipment, space, amenities etc.. For doctors they have recommended a ratio of one per 3.3 beds and for nurses one per 2.7 beds for three shifts. (BIS 1989, and 1992). Again way back in 1946 the Bhore Committee had recommended reasonable levels (which at that time were about half that of the levels in developed countries) to be achieved for a national health service, which are as follows:

• one doctor per 1600 persons
• one nurse per 600 persons
• one health visitor per 5000 persons
• one midwife per 100 births
• one pharmacist per 3 doctors
• one dentist per 4000 persons
• one hospital bed per 175 persons
• one PHC per 10 to 20 thousand population depending on population density and geographical area covered
• 15% of total government expenditure to be committed to health care, which at that time was about 2% of GDP (Bhore, 1946)

The first response from the government and policy makers to the question of using the above norms in India is that they are excessive for a poor country and we do not have the resources to create such a level of health care provision. Such a reaction is invariably not a studied one and needs to be corrected. Let us construct a selected epidemiological profile of the country based on whatever proximate data is available through official statistics and research studies. We have obtained the following profile after reviewing available information:

• Daily morbidity = 2% to 3% of population, that is about 20-30 million patients to be handled everyday (7 - 10 billion per year)
• Hospitalisation Rate 20 per 1000 population per year with 12 days average stay per case, that is a requirement of 228 million bed-days (that is 20 million hospitalisations as per NSS -1987 survey, an underestimate because smaller studies give estimates of 50/1000/year or 50 million hospitalisations)
• Prevalence of Tuberculosis 11.4 per 1000 population or a caseload of over 11 million patients
• Prevalence of Leprosy 4.5 per 1000 population or a caseload of over 4 million patients
• Incidence of Malaria 2.6 per 1000 population yearly or 2.6 million new cases each year
• Diarrhoeal diseases (under 5) = 7.5% (2-week incidence) or 1.8 episodes/child/year or about 250 million cases annually
• ARI (under 5) = 18.4% (2-week incidence) or 3.5 episodes per child per year or nearly 500 million cases per year
• Cancers = 1.5 per 1000 population per year (incidence) or 1.5 million new cases every year
• Blindness =1.4% of population or 14 million blind persons
• Pregnancies = 21.4% of childbearing age-group women at any point of time or over 40 million pregnant women
• Deliveries/Births = 25 per 1000 population per year or about 68,500 births every day

(Estimated from CBHI, WHO, 1988, ICMR, 1990<a>, NICD, 1988, Gupta et.al.,1992, NSS,1987)

The above is a very select profile, which reflects what is expected out of a health care delivery system. Let us take handling of daily morbidity alone, that is, outpatient care. There are 30 million cases to be tackled every day. Assuming that all will seek care (this usually happens when health care is universally available, in fact the latter increases perception of morbidity) and that each GP can handle about 60 patients in a days work, we would need over 500,000 GPs equitably distributed across the country. This is only an average; the actual requirement will depend on spatial factors (density and distance). This means one GP per about 2500 population, this ratio being three times less favourable than what prevails presently in the developed capitalist and the socialist countries. Today we already have over 1,300,000 doctors of all systems (550,000 allopathic) and if we can integrate all the systems through a CME program and redistribute doctors as per standard requirements we can provide GP services in the ratio of one GP per 700-1000 population.

Organising the Universal Healthcare System[xxi]

The conversion of the existing system into an organised system to meet the requirements of universality and equity and the rights based approach will require certain hard decisions by policy-makers and planners. We first need to spell out the structural requirements or the outline of the model, which will need the support of legislation. More than the model suggested hereunder it is the expose of the idea that is important and needs to be debated for evolving a definitive model.

The most important lesson to learn from the existing model is how not to provide curative services. We have seen above that curative care is provided mostly by the private sector, uncontrolled and unregulated. The system operates more on the principles of irrationality than medical science. The pharmaceutical industry is in a large measure responsible for this irrationality in medical care. Twenty thousand drug companies and over 60,000 formulations characterise the over Rs. 260 billion drug industry in India.[xxii] The WHO recommends less than 300 drugs as essential for provision of any decent level of health care. If good health care at a reasonable cost has to be provided then a mechanism of assuring rationality must be built into the system. Family medical practice, which is adequately regulated, along with referral support, is the best and the most economic means for providing good health care. What follows is an illustration of a mechanism to operationalise the right to healthcare, it should not be seen as a well defined model but only as an example to facilitate a debate on creating a healthcare system based on a right to healthcare approach. This is based on learnings from experiences in other countries which have organized healthcare systems which provide near universal health care coverage to its citizens.

Family Practice

Each family medical practitioner (FMP) will on an average enroll 400 to 500 families; in highly dense areas this number may go upto 800 to 1000 families and in very sparse areas it may be as less as 100 to 200 families. For each family/person enrolled the FMP will get a fixed amount from the local health authority, irrespective of whether care was sought or no. He/she will examine patients, make diagnosis, give advise, prescribe drugs, provide contraceptive services, make referrals, make home-visits when necessary and give specific services within his/her framework of skills. Apart from the capitation amount, he/she will be paid separately for specific services (like minor surgeries, deliveries, home-visits, pathology tests etc..) he /she renders, and also for administrative costs and overheads. The FMP can have the choice of either being a salaried employee of the health services (in which case he/she gets a salary and other benefits) or an independent practitioner receiving a capitation fee and other service charges.

Epidemiological Services

The FMP will receive support and work in close collaboration with the epidemiological station (ES) of his/her area. The present PHC setup will be converted into an epidemiological station. This ES will have one doctor who has some training in public health (one FMP, preferably salaried, of the ES area can occupy this post) and a health team comprising of a public health nurse and health workers and supervisors will assist him. Each ES would cover a population between 10,000 to 50,000 in rural areas depending on density and distance factors and even upto 100,000 population in urban areas. On an average for every 2000 population there will be a health worker and for every four health workers there will be a supervisor. Epidemiological surveillance, monitoring, taking public health measures, laboratory services, and information management will be the main tasks of the ES. The health workers will form the survey team and also carry out tasks related to all the preventive and promotive programs (disease programs, MCH, immunisation etc..) They will work in close collaboration with the FMP and each health worker's family list will coincide with the concerned FMPs list. The health team, including FMPs, will also be responsible for maintaining a minimum information system, which will be necessary for planning, research, monitoring, and auditing. They will also facilitate health education. Ofcourse, there will be other supportive staff to facilitate the work of the health team.

First Level Referral

The FMP and ES will be backed by referral support from a basic hospital at the 50,000 population level. This hospital will provide basic specialist consultation and inpatient care purely on referral from the FMP or ES, except of course in case of emergencies. General medicine, general surgery, paediatrics, obstetrics and gynaecology, orthopaedics, ophthalmology, dental services, radiological and other basic diagnostic services and ambulance services should be available at this basic hospital. This hospital will have 50 beds, the above mentioned specialists, 6 general duty doctors and 18 nurses (for 3 shifts) and other requisite technical (pharmacists, radiographers, laboratory technicians etc..) and support (administrative, statistical etc..) staff, equipment, supplies etc. as per recommended standards. There should be two ambulances available at each such hospital. The hospital too will maintain a minimum information system and a standard set of records.

Pharmaceutical Services

Under the recommended health care system only the essential drugs required for basic care as mentioned in standard textbooks and/or the WHO essential drug list should be made available through pharmacies contracted by the local health authority. Where pharmacy stores are not available within a 2 km. radial distance from the health facility the FMP should have the assistance of a pharmacist with stocks of all required medicines. Drugs should be dispensed strictly against prescriptions only.

Rehabilitation and Occupational Health Services

Every health district must have a centre for rehabilitation services for the physically and mentally challenged and also services for treating occupational diseases, including occupational and physical therapy

Managing the Health Care System[xxiii]

For every 3 to 5 units of 50,000 population, that is 150,000 to 250,000 population, a health district will be constituted (Taluka or Block level). This will be under a local health authority that will comprise of a committee including political leaders, health bureaucracy, and representatives of consumer/social action groups, ordinary citizens and providers. The health authority will have its secretariat whose job will be to administer the health care system of its area under the supervision of the committee. It will monitor the general working of the system, disburse funds, generate local fund commitments, attend to grievances, provide licensing and registration services to doctors and other health workers, implement CME programs in collaboration with professional associations, assure that minimum standards of medical practice and hospital services are maintained, facilitate regulation and social audit etc... The health authority will be an autonomous body under the control of the State Health Department. The FMP appointments and their family lists will be the responsibility of the local health authority. The FMPs may either be employed on a salary or be contracted on a capitation fee basis to provide specified services to the persons on their list. Similarly, the first level hospitals, either state owned or contracted private hospitals, will function under the supervision of the local health authority with global budgets. The overall coordination, monitoring and canalisation of funds will be vested in a National Health Authority. The NHA will function in effect as a monopoly buyer of health services and a national regulation coordination agency. It will negotiate fee schedules with doctors' associations, determine standards and norms for medical practice and hospital care, and maintain and supervise an audit and monitoring system. It will also have the responsibility and authority to pool resources for the organized healthcare system using various mechanisms of tax revenues, social and national insurance funds, health cess etc..

Licensing, Registration and CME

The local health authority will have the power to issue licenses to open a medical practice or a hospital. Any doctor wanting to set up a medical practice or anybody wishing to set up a hospital, whether within the universal health care system or outside it will have to seek the permission of the health authority. The licenses will be issued as per norms that will be laid down for geographical distribution of doctors. The local health authority will also register the doctors on behalf of the medical council. Renewal of registration will be linked with continuing medical education (CME) programs which doctors will have to undertake periodically in order to update their medical knowledge and skills. It will be the responsibility of the local health authority, through a mandate form the medical councils, to assure that nobody without a license and a valid registration practices medicine and that minimum standards laid down are strictly maintained.

Financing the Health Care System

We again reemphasise that if a universal health care system has to assure equity in access and quality then there should be no direct payment by the patient to the provider for services availed. This means that the provider must be paid for by an indirect method so that he/she cannot take undue advantage of the vulnerability of the patient. An indirect monopoly payment mechanism has numerous advantages, the main being keeping costs down and facilitating regulation, control and audit of services.

Tax revenues will continue to remain a major source of finance for the universal health care system. In fact, efforts will be needed to push for a larger share of funds for health care from the state exchequer. However, in addition alternative sources will have to be tapped to generate more resources. Employers and employees of the organised sector will be another major source (ESIS, CGHS and other such health schemes should be merged with general health services) for payroll deductions. The agricultural sector is the largest sector in terms of employment and population and at least one-fourth to one-third of this population has the means to contribute to a health scheme. Some mechanism, either linked to land revenue or land ownership, will have to be evolved to facilitate receiving their contributions. Similarly self-employed persons like professionals, traders, shopkeepers, etc. who can afford to contribute can pay out in a similar manner to the payment of profession tax in some states. Further, resources could be generated through other innovative methods - health cess collected by local governments as part of the municipal/house taxes, proportion of sales turnover and/or excise duties of health degrading products like alcohol, cigarettes, paan-masalas, guthkas etc.. should be earmarked for the health sector, voluntary collection through collection boxes at hospitals or health centres or through community collections by panchayats , municipalities etc... All these methods are used in different countries to enhance health sector finances. Many more methods appropriate to the local situation can be evolved for raising resources. The effort should be directed at assuring that at least 50% of the families are covered under some statutory contribution scheme. Since there will be no user-charges people will be willing to contribute as per their capacity to social security funding pools.

All these resources would be pooled under a single body, the national health authority, and payments to providers of services would also be made by this body. In order to do this standardized protocols of treatment and charges will have to be evolved and this itself will have a major impact on both quality of care as well as on efficient use of resources.

Projection Of Resource Requirements

The projections we are making are for the fiscal year 2000-2001. The population base is one billion. There are over 1.3 million doctors (of which allopathic are 550,000, including over 180,000 specialists), 600,000 nurses, 950,000 hospital beds, 400,000 health workers and 25,000 PHCs with government and municipal health care spending at about Rs.250 billion (excluding water supply).

An Estimate of Providers and Facilities

What will be the requirements as per the suggested framework for a universal health care system?

Ø Family medical practitioners = 500,000

Ø Epidemiological stations = 35,000

Ø Health workers = 500,000

Ø Health supervisors = 125,000

Ø Public health nurses = 35,000

Ø Basic hospitals = 20,000

Ø Basic hospital beds = 1 million

Ø Basic hospital staff :

Ø general duty doctor = 120,000

Ø specialists = 100,000

Ø dentists = 20,000

Ø nurses = 360,000

Ø Other technical and non-technical support staff as per requirements (Please note that the basic hospital would address to about 75% of the inpatient and specialist care needs, the remaining will be catered to at the secondary/district level and teaching/tertiary hospitals)

One can see from the above that except for the hospitals and hospital beds the other requirements are not very difficult to achieve. Training of nurses, dentists, public health nurses would need additional investments. We have more than an adequate number of doctors, even after assuming that 80% of the registered doctors are active (as per census estimates). What will be needed are crash CME programs to facilitate integration of systems and reorganisation of medical education to produce a single cadre of basic doctors. The PHC health workers will have to be reoriented to fit into the epidemiological framework. And construction of hospitals in underserved areas either by the government or by the private sector (but only under the universal system) will have to be undertaken on a rapid scale to meet the requirements of such an organised system.

An Estimate of the Cost

The costing worked out hereunder is based on known costs of public sector and NGO facilities. The FMP costs are projected on the basis of employed professional incomes. The actual figures are on the higher side to make the acceptance of the universal system attractive. Please note that the costs and payments are averages, the actuals will vary a lot depending on numerous factors.

Projected Universal Health Care Costs (2000-2001 Rs. in millions)

Type of Costs

Ø Capitation/salaries to FMPs

(@ Rs.300 per family per year

x 200 mi families) 50% of FMP services 60,000

Ø Overheads 30% of FMP services 36,000

Ø Fees for specific services 20% of FMP services 24,000

Ø Total FMP Services 120,000

Ø Pharmaceutical Services

(10% of FMP services) 12,000

Ø Total FMP Costs 132,000

Ø Epidemiological Stations

(@ Rs.3 mi per ES x 35,000) 105,000

Ø Basic Hospitals (@ Rs.10 mi per

hospital x 20,000, including drugs,

i.e.Rs.200,000 per bed) 200,000

Ø Total Primary Care Cost 437,000

Ø Per capita = Rs. 437; 2.18% of GDP

Ø Secondary and Teaching Hospitals,

including medical education and

training of doctors/nurses/paramedics

(@ Rs.2.5 lakh per bed x 3 lakh beds) 75,000

Ø Total health services costs 512,000

Ø Medical Research (2%) 10,240

Ø Audit/Info.Mgt/Social Res. (2%) 10,240

Ø Administrative costs (2%) 10,240

Ø TOTAL RECURRING COST 542,720

Ø Add capital Costs (10% of recurring) 54,272

Ø ALL HEALTH CARE COSTS 596,992

Ø Per Capita = Rs. 596.99; 2.98% of GDP

(Calculations done on population base of 1 billion and GDP of Rs. 20,000 billion; $1 = Rs.45, that is $13.24 billion)

Distribution of Costs

The above costs from the point of view of the public exchequer might seem excessive to commit to the health sector given current level of public health spending. But this is less than 3% of GDP at Rs.597 per capita annually, including capital costs. The public exchequer's share, that is from tax and related revenues, would be about Rs.400 billion or two-thirds of the cost. This is well within the current resources of the governments and local governments put together. The remaining would come from the other sources discussed earlier, mostly from employers and employees in the organised sector, and other innovative mechanisms of financing. As things progress the share of the state should stabilise at 50% and the balance half coming from other sources. Raising further resources will not be too difficult. Part of the organized sector today contributes to the ESIS 6.75% of the salary/wage bill. If the entire organized sector contributes even 5% of the employee compensation (2% by employee and 3% by employer) then that itself will raise close to Rs.250 billion. Infact the employer share could be higher at 5%. Further resources through other mechanisms suggested above will add substantially to this, which infact may actually reduce the burden on the state exchequer and increase contributory share from those who can afford to pay. Given below is a rough projection of the share of burden by different sources:

Projected Sharing of Health Care Costs (2000-2001 Rs. in millions)

Type of Source

Central State/ Organised Other

Govt. Muncp. Sector Sources

1. Epidemiological services 70,000 25,000 7,000 3,000

2. FMP Services 5,000 65,000 45,000 5,000

3. Drugs (FMP) -- 5,500 5,500 1,000

4. Basic Hospitals -- 100,000 85,000 15,000

5. Secondary/Teaching Hospitals 20,000 30,000 20,000 5,000

6. Medical Research 8,000 1,000 1,000 240

7. Audit/ Info. Mgt./ Soc.Research 5,000 5,000 240 --

8. Administrative Costs 3,000 7,000 240 --

9. Capital Costs 25,000 25,000 4,000 272

ALL COSTS 136,000 263,500 167,980 29,512

Rs.596,992 million

Percentages 23 44 28 5

Creating a consensus on the right to health care

We are at a stage in history where political will to do something progressive is conspicuous by its absence. We may have constitutional commitments and backing of international law but without political will nothing will happen. To reach the goals of right to health and healthcare discussed above civil society will have to be involved in a very large way and in different ways.

The initiative to bring healthcare on the political agenda will have to be a multi-pronged one and fought on different levels. The idea here is not to develop a plan of action but to indicate the various steps and involvements which will be needed to build a consensus and struggle for right to healthcare. We make the following suggestions:

· Policy level advocacy for creation of an organized system for universal healthcare

· Research to develop the detailed framework of the organized system

· Lobbying with the medical profession to build support for universal healthcare and regulation of medical practice

· Filing a public interest litigation on right to healthcare to create a basis for constitutional amendment

· Lobbying with parliamentarians to demand justiciability of directive principles

· Holding national and regional consultations on right to healthcare with involvement of a wide array of civil society groups

· Running campaigns on right to healthcare with networks of peoples organizations at the national and regional level

· Bringing right to healthcare on the agenda of political parties to incorporate it in their manifestoes

· Pressurizing international bodies like WHO, Committee of ESCR, UNCHR, as well as national bodies like NHRC, NCW to do effective monitoring of India’s state obligations and demand accountability

· Preparing and circulating widely shadow reports on right to healthcare to create international pressure

The above is not an exhaustive list. The basic idea is that there should be widespread dialogue, awareness raising, research, documentation and legal/constitutional discourse.

To conclude, it is evident that the neglect of the public health system is an issue larger than government policy making. The latter is the function of the overall political economy. Under capitalism only a well-developed welfare state can meet the basic needs of its population. Given the backwardness of India the demand of public resources for the productive sectors of the economy (which directly benefit capital accumulation) is more urgent (from the business perspective) than the social sectors, hence the latter get only a residual attention by the state. The policy route to comprehensive and universal healthcare has failed miserably. It is now time to change gears towards a rights-based approach. The opportunity exists in the form of constitutional provisions and discourse, international laws to which India is a party, and the potential of mobilizing civil society and creating a socio-political consensus on right to healthcare. There are a lot of small efforts towards this end all over the country. Synergies have to be created for these efforts to multiply so that people of India can enjoy right to healthcare.

Table 1: HEALTHCARE DEVELOPMENT IN INDIA 1951-2000

				1951	1961	1971	1981	1991	1995	1996	1997	1998	2000
1	Hospitals		Total	2694	3054	3862	6805	11174	15097	15170	15188		17,000
			% Rural	39	34	32	27		31	34	34
			%Private				43	57	68	68	68
2	Hospital & dispensary beds		Total	117000	229634	348655	504538	806409	849431	892738	896767		1,000000
			% Rural	23	22	21	17		20	23	23
			%Private				28	32	36	37	37
3	Dispensaries			6600	9406	12180	16745	27431	28225	25653	25670
			% Rural	79	80	78	69		43	41	40
			% Private				13	60	61	57	56
4	PHCs			725	2695	5131	5568	22243	21693	21917	22446	23179	24,000
5	Sub-centres					27929	51192	131098	131900	134931	136379	137006	140,000
6	Doctors		Allopaths	60840	83070	153000	266140	395600	459670	475780	492634	503947	550,000
			All Systems	156000	184606	450000	665340	920000			1080173	1133470	1,250000
7	Nurses			16550	35584	80620	150399	311235	562966	565700	607376		700,000
8	Medical colleges		Allopathy	30	60	98	111	128		165	165	165	170
9	Out turn		Grads	1600	3400	10400	12170	13934	*	*	*	*	20,000
			P. Grads		397	1396	3833	3139			3656		5,000
10	Pharmaceutical production		Rs. in billion	0.2	0.8	3	14.3	38.4	79.4	91.3	104.9	120.7	165.0
11	Health outcomes		IMR/000	134	146	138	110	80	74/69	72	71	72	70
			CBR/000	41.7	41.2	37.2	33.9	29.5	29	27	27	27	26
			CDR/000	22.8	19	15	12.5	9.8	10	9	8.9	9	8.7
	Life Expectancy	years		32.08	41.22	45.55	54.4	59.4	62	62.4	63.5	64	65
	Births attended by trained practitioners		Percent				18.5	21.9		28.5		42.3
12	Health Expenditure Rs. Billion		Public Private@ CSO estimate pvt.	0.22 1.05	1.08 3.04 2.05	3.35 8.15 6.18	12.86 43.82 29.70	50.78 173.60 82.61	82.17 233.47 279.00	101.65 329.00	113.13 399.84 373.00	126.27 459.00	178.00 833.00
	Health Expenditure as percent of GDP		Public Private CSO	0.25	0.71 1.34	0.84 1.56	1.05 2.43	0.92 1.73	0.95 3.25	0.91 2.95	0.88 2.94	0.81 2.98	0.87 4.07
	Health Expenditure as % to Govt. Total		Public	2.69	5.13	3.84	3.29	2.88	2.13	2.98	2.94	2.7	2.9

@ Data from - 1951:NSS 1^st Round 1949-50; 1961: SC Seals All India District Surveys,1958; 1971: NSS 28^th Round 1973-74; 1981: NSS 42^nd Round 1987; 1991 and 1995: NCAER – 1990; 1995: NSS 52^nd Round 1995-96; 1997: CEHAT 1996-97

*Data available is grossly under-reported, hence not included

Notes: The data on hospitals, dispensaries and beds are underestimates, especially for the private sector because of under-reporting. Rounded figures for year 2000 are rough estimates.

Source : 1. Health Statistics / Information of India, CBHI, GOI, various years; 2. Census of India Economic Tables, 1961, 1971, 1981, GOI 3.OPPI Bulletins and Annual reports of Min. of Chemicals and Fertilisers for data on Pharmaceutical Production 4. Finance Accounts of Central and State Governments, various years 5. National Accounts Statistics, CSO, GOI, various years 6. Statistical Abstract of India, GOI, various years 7. Sample Registration System - Statistical Reports, various years 8. NFHS - 2, India Report, IIPS, 2000

References

Abel-Smith,Brian, 1977 : Minimum Adequate Levels of Personal Health Care, in Issues in Health Care Policy, ed.John Mckinlay, A Milbank Reader 3, New York

Andreassen, B, Smith, A and Stokke, H, 1992: Compliance with economic and Social Rights: Realistic Evaluations and Monitoring in the Light of Immediate Obligations in A Eide and B Hagtvet (eds) Human Rights in Perspective: A global Assessment, Blackwell, Oxford

Bhore, Joseph, 1946 : Report of the Health Survey and Development Committee, Volume I to IV, Govt. of India, Delhi

BIS, 1989 : Basic Requirements for Hospital Planning CIS:12433 (Part 1)-19883, Bureau of Indian Standards, New Delhi

BIS, 1992 : Basic Requirements for a 100 Bedded Hospital, A Draft Report, BIS, New Delhi

CBHI, various years : Health Information of India, Central Bureau of Health Intelligence, MoHF&W, GOI, New Delhi

Chapman, Audrey, 1993: Exploring a Human Rights Approach to Healthcare Reform, American Association for the Advancement of Science, Washington DC

Duggal, Ravi, 2000: The Private Health Sector in India – Nature, Trends and a Critique, VHAI, New Delhi

Duggal, Ravi 2002: Resource Generation Without Planned Allocation, Economic and Political Weekly, Jan 5, 2002

Ellis, Randall, Alam, Moneer and Gupta, Indrani, 2000: Health Insurance in India – Prognosis and Prospectus, Economic and Political Weekly, Jan.22, 2000

General Comment 3…

General Comment 14…

Gupta, RB et.al.,1992 : Baseline Survey in Himachal Pradesh under IPP VI and VII, 3 Vols., Indian Institute of Health Management Research, Jaipur

ICESCR….

ICMR, 1990 <a>: A National Collaborative Study of High Risk Families - ICMR Task Force, New Delhi

MoCF, 2001: Annual report, Dept. of Chemicals and Petrochemicals, Ministrof Chemicals and Fertilizers, GOI, New Delhi

MoHFW, 2001: India Facility Survey Phase I, 1999, IIPS, Ministry of Health and Family Welfare, New Delhi

Nandraj, Sunil and Ravi Duggal, 1997 : Physical Standards in the Private Health Sector, Radical Journal of Health (New Series) II-2/3

NFHS-1998, 2000: National Family Health Survey –2: India, IIPS, Mumbai

NICD, 1988: Combined Surveys on ARI, Diarrhoea and EPI, National Inst. of Communicable Diseases, Delhi

NSS-1987 : Morbidity and Utilisation of Medical Services, 42^nd Round, Report No. 384, National Sample Survey Organisation, New Delhi

NSS-1996 : Report No. 441, 52^nd Round, NSSO, New Delhi, 2000

OECD, 1990 : Health Systems in Transition, Organisation for Economic Cooperation and Development, Paris

Phadke, Anant, 1998: Drug Supply and Use – Towards a rational policy in India, Sage, New Delhi

Rhode, John and Vishwanathan, H, 1994: The Rural Private Practitioner0, Health for the Millions, 2:1, 1994

Toebes, Brigit, 1998: The Right to Health as a Human Right in International Law, Intersentia – Hart, Antwerp

WHO, 1961 : Planning of Public Health Services, TRS 215, World Health Organisation, Geneva

WHO, 1988 : Country Profile - India, WHO - SEARO, New Delhi

WHO,1993: Third Monitoring of Progress, Common Framework, CFM3, Implementation of Strategies for Health for All by the Year 2000, WHO, Geneva,

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[i] In the 18^th century rights were interpreted as fences or protection for the individual from the unfettered authoritarian governments that were considered the greatest threat to human welfare. Today democratic governments do not pose the same kind of problems and there are many new kinds of threats to the right to life and well being. (Chapman, 1993) Hence in today’s environment reliance on mechanisms that provide for collective rights is a more appropriate and workable option. Social democrats all over Europe, in Canada, Australia have adequately demonstrated this in the domain of healthcare.

[ii] A human rights approach would not necessitate that all healthcare resources be distributed according to strict quantitative equality or that society attempt to provide equality in medical outcomes, neither of which would in any case be feasible. Instead the universality of the right to healthcare requires the definition of a specific entitlement be guaranteed to all members of our society without any discrimination. (Chapman, 1993)

[iii] Country specific thresholds should be developed by indicators measuring nutrition, infant mortality, disease frequency, life expectancy, income, unemployment and underemployment, and by indicators relating to adequate food consumption. States should have an immediate obligation to ensure the fulfillment of this minimum threshold. (Andreassen et.al., 1988 as quoted by Toebes,1998)

[iv] Efforts to prevent hunger have been there through the Integrated Child Development Services program and mid-day meals. Analysis of data on malnutrition clearly indicates that where enrollment under ICDS is optimal malnutrition amongst children is absent, but where it is deficient one sees malnutrition. Another issue is that we have overflowing food-stocks in godowns but yet each year there are multiple occasions of mass starvation in various pockets of the country.

[v] Compulsory public medical service for a limited number of years for medical graduates from the public medical schools is a good mechanism to fulfill the needs of the public healthcare system. The Union Ministry of Health is presently seriously considering this option, including allowing post-graduate medical education only to those who have completed the minimum public medical service, including in rural areas.

[vi] Data on availability of essential drugs show that in 1982-83 the gap in availability was only 2.7% but by 1991-92 it had walloped to 22.3%. This is precisely the period in which drug price control went out of the window. (Phadke,A, 1998)

[vii] NFHS-1998 data shows that in rural areas availability of health services within the village was as follows: 13% of villages had a PHC, 28% villages had a dispensary, 10% had hospitals, 42% had atleast one private doctor (not necessarily qualified), 31% of villages had visiting private doctors, 59% had trained birth attendants, and 33% had village health workers

[viii] This first phase of this survey done in 1999, which covered 210 district hospitals, 760 First Referral Units, 886 CHCs and 7959 PHCs, shows the following results: Percent of Different Units Adequately Equipped

Units	Infrastructure	Staff	Supply	Equipment	Training
Dist. Hospitals	94	84	28	89	33
FRUs	84	46	26	69	34
CHCs	66	25	10	49	25
PHCs*	36	38	31	56	12

*Only 3% of PHCs had 80% or more of the critical inputs needed to run the PHC, and only 31% had upto 60% of critical inputs (India Facility Survey Phase I, 1999, IIPS, Ministry of Health and Family Welfare, New Delhi, 2001)

[ix] It must be noted that coercion was not confined only to the Emergency period in the mid-seventies, but has been part and parcel of the program through a target approach wherein various government officials from the school teacher to the revenue officials were imposed targets for sterilization and IUCDs and were penalized for not fulfilling these targets in different ways, like cuts and/or delays in salaries, punishment postings etc.

[x] The poorer classes have reported such low rates of hospitalization, not because they fall ill less often but because they lack resources to access healthcare, and hence invariably postpone their utilization of hospital services until it is absolutely unavoidable.

[xi] A survey in Mumbai in 1994 showed that the official list with the Municipal Corporation accounted for only 64% of private hospitals and nursing homes (Nandraj and Duggal,1997). Similarly, a much larger study in Andhra Pradesh in 1993 revealed extraordinary missing statistics about the private health sector. For that year official records indicated that AP had 266 private hospitals and 11,103 beds, but the survey revealed that the actual strength of the private sector was over ten times more hospitals with a figure of 2802 private hospitals and nearly four times more hospital beds at 42192 private hospital beds. (Mahapatra, P, 1993)

[xii] Data of 80 top selling drugs in 1991 showed that 29% of them were irrational and/or hazardous and their value was to the tune of Rs. 2.86 billion. A study of prescription practice in Maharashtra in 1993 revealed that outright irrational drugs constituted 45% of all drugs prescribed and rational prescriptions were only 18%. The proportion of irrationality was higher in private practice by over one-fifth. (Phadke, A, 1998)

[xiii] In Mumbai CEHAT in collaboration with various medical associations and hospital owner associations have set up a non-profit company called Health Care Accreditation Council. This body hopes to provide the basis for evolving a much larger initiative on this front.

[xiv]To illustrate this, taking the Community Health Centre (CHC) area of 150,000 population as a “health district” at current budgetary levels under block funding this “health district” would get Rs. 30 million (current resources of state and central govt. combined is over Rs.200 billion, that is Rs. 200 per capita). This could be distributed across this health district as follows : Rs 300,000 per bed for the 30 bedded CHC or Rs. 9 million (Rs.6 million for salaries and Rs. 3 million for consumables, maintenance, POL etc..) and Rs. 4.2 million per PHC (5 PHCs in this area), including its sub-centres and CHVs (Rs. 3.2 million as salaries and Rs. 1 million for consumables etc..). This would mean that each PHC would get Rs. 140 per capita as against less than Rs. 50 per capita currently. In contrast a district headquarter town with 300,000 population would get Rs. 60 million, and assuming Rs. 300,000 per bed (for instance in Maharashtra the current district hospital expenditure is only Rs. 150,000 per bed) the district hospital too would get much larger resources. To support health administration, monitoring, audit, statistics etc, each unit would have to contribute 5% of its budget. Ofcourse, these figures have been worked out with existing budgetary levels and excluding local government spending which is quite high in larger urban areas. (Duggal,2002)

[xv] Such locational restrictions in setting up practice may be viewed as violation of the fundamental right to practice one’s profession anywhere. It must be remembered that this right is not absolute and restrictions can be placed in concern for the public good. The suggestion here is not to have compulsion but to restrict through fiscal measures. In fact in the UK under NHS, the local health authorities have the right to prevent setting up of clinics if their area is saturated.

[xvi] For instance the Delhi Medical Council has taken first steps in improving the registration and information system within the council and some mechanism of public information has been created.

[xvii] This implies that the health status of the people should be such that they can atleast work productively and participate actively in the social life of the community in which they live. It also means that essential healthcare sufficient to satisfy basic human needs will be accessible to all, in an acceptable and affordable way, and with their full involvement. (WHO, 1993)

[xviii] General Comment 3 of ICESCR reiterates this that the minimum core obligations by definition apply irrespective of the availability of resources or any other factors and difficulties. Hence it calls for international cooperation in helping developing countries who lack resources to fulfil obligations under international law.

[xix] Most of atleast the curative services will of necessity have to be a public-private mix because of the existing baggage of the health system we have but this has to be under an organized and accountable health care system.

[xx] These services need not be part of the health department or the national health authority that may be created and may continue to be part of the urban and rural development departments as of present.

[xxi] The following discussion is an updated version based on work done by the author earlier at the Ministry of Health New Delhi as a fulltime WHO National Consultant in the Planning Division of the Ministry. An earlier version was published as “The Private Health Sector in India – Nature, Trends and a Critique” by VHAI, New Delhi, 2000

[xxii] In addition to this there is a fairly large and expanding ayurvedic and homoeopathy drug industry estimated to be over one-third of mainstream pharmaceuticals

[xxiii] The discussion in this paper is restricted to primary care services but they are not the only component of the core content; higher levels of care are needed as support and these already exist to a fair extent though they need to be reorganized. Thus district level hospitals and metropolitan and teaching hospitals are also part of the core content.