Written by K. Sujatha Rao
In 1947, post-colonial India set off with the ambition of building a modern state on the principles of equality where citizens, by virtue of their birth in the country, would be entitled to a life of dignity. While the Constitution provided the rights to life, liberty, nutritional standards and maternity care, it did not explicitly state health as a fundamental right. Access to good quality healthcare was, and continues to be, a privilege, enjoyed by those fulfilling conditions of wealth, location and social status. This was so despite India being a signatory to the WHO’s Constitution of 1946 which envisaged the ideal of ensuring “the highest attainable standard of health as a fundamental right of every human being” by allocating the “maximum available resources”.
The discourse on health as a human right was amplified when the HIV/AIDS pandemic led to the creation of global civil society coalitions that pressured governments to make HIV treatment and sexual freedoms fundamental to human rights. In the last decade, the increasing cost of care and consequent impoverishment of those seeking medical treatment added momentum to the debate by demanding universal health coverage (UHC) to build societal resilience to the devastating impacts of ill health.
Since UHC is based on the principle of equality and non-denial of care on grounds of affordability, the two ideas of health as a human right and UHC converged to be translated into state policy for creating a “legal obligation to ensure access to timely, acceptable and affordable healthcare of appropriate quality as well as to providing the underlying determinants of health such as safe potable water…..” resulting in its inclusion in the 2015 Sustainable Development Goals (SDG) to be realised by 2030.
India has not been immune to these global developments. But given the compulsions of addressing multiple development challenges, “allocating the maximum available resources” for health has always been a major issue. Public health spending as a percentage of GDP has hovered around an average of 1 per cent against the global average of 8 per cent, constraining the building of a rights-based healthcare system. In 2018, India’s public health spending as a percentage of total health expenditures was 26.95 per cent, against the global average of 59.54 per cent with just 20 countries spending less than India. At 62.67 per cent out-of-pocket expenditure on health, such spending in India was the 13th highest in the world.
In addition to low public health spending, key barriers to universalising access to healthcare are the inadequate availability of services, particularly in rural areas, a severe shortage of human resources and the rising cost of care due to more intensive use of technologies alongside changing perceptions of quality. So, while low public spending is seen as the root cause, a study of catastrophic health expenditures (10 to 25 per cent of household income) in 133 countries brought out two interesting insights with policy implications — one, the positive partial correlation between income inequality and catastrophic spending at all income levels and two, absence of evidence that the mere increase in health spending or channeling it through private insurance and non-profit institutions provided financial protection.
Since a decade, concerted attempts have been made by civil society organisations to persuade governments to enact laws making health a human right. The manifestos of the CPM and Congress in 2019, however, are the first instance of a clear political commitment towards promoting such a rights-based policy.
The COVID pandemic brought to the surface the inadequacies of the health system and the denial of basic care, where even basic public health functions like testing or contact tracing and behaviour change required the whole and exclusive attention of the district administration. Coping with this one infection has not only meant denying care to non-COVID patients but also the inability to treat all as per protocol due to limited infrastructure in public and private sectors, provoking the Rajasthan government to expedite its intention to introduce the Rajasthan Model of Public Health (RMPH) in its budget for 2021-22, embedding in it a public health law making access to health a right.
For realising this aspiration, Rajasthan has proposed doubling its budget, setting up medical and nursing colleges, establishing and upgrading primary health centres and substantially improving the delivery of services by expanding access to free medicines and diagnostics, besides adding 1,000 beds and establishing institutions of excellence for cardiology, virology, cancer and maternity and childcare. New features to its current health insurance programme are three — expansion of the eligibility criteria to cover two-thirds of the population, providing 50 per cent subsidy for the non-poor sections to avail of the health insurance programme by providing them cover for Rs 5 lakh worth of cashless treatment in government and accredited private hospitals, and assuring coverage of not just inpatient but also outpatient treatment.
The intention is laudable. But for achieving the goal of arresting catastrophic expenses, it would be essential to sequence investments over the next decade, starting with ensuring universal access to social determinants and primary healthcare services by focusing on malnutrition and filling gaps in accessing toilets, safe water and basic health services. This would require an uncompromising attention to substantially and expeditiously improving the primary healthcare infrastructure in terms of buildings, human resources and technology. If strict prioritisation is not maintained, much of the scarce resources can get diverted to providing expensive hospital treatment for the not-so-rich but more vocal people in urban areas, widening existing inequities and not reducing catastrophic expenditures.
The COVID pandemic has deepened poverty and set back the economy by a decade. In such a desperate situation, the state is faced with a paradox of addressing the need for a rights-based policy. This, however, requires doubling of resources that are unavailable, necessitating reviewing interventions so as to remove waste, promote efficiencies and a more rational use of the limited resources. It is a bumpy road ahead but today, as never before, state intervention is required to ensure health security to all, as an anti-poverty measure, particularly aimed at the poor and marginalised.
The writer is former Union health secretary.
Courtesy - The Indian Express.
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