Operationalising right to healthcare
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Operationalising Right to Healthcare
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Operationalising right to healthcare
- 1. Operationalising Right to Healthcare in India Brought to you by
- 2. Healthcare in India īŽ Entitlements by policy and not rights īŽ Focus on preventive and promotive care īŽ Grossly under-provided facilities īŽ Poor investments hitherto īŽ Declining public expenditures and new investments īŽ SAPping the healthcare system Brought to you by
- 3. Rural-Urban Disparities â India īŽ RURAL (per 1000 population) īŽ Hospital Beds = 0.2 īŽ Doctors = 0.6 īŽ Public Expenditures = Rs.80,000 īŽ Out of pocket = Rs.750,000 īŽ URBAN (per 1000 ____________________ īŽ IMR = 74/1000 LB īŽ U5MR = 133/1000 LB īŽ Births Attended = 33.5% īŽ Full Immunz.=37% īŽ Median ANCs=2.5 population) īŽ Hospital Beds = 3.0 īŽ Doctors = 3.4 īŽ Public Expenditures = Rs.560,000 īŽ Out of Pocket = Rs.1,150,000 ____________________ īŽ IMR = 44/1000 LB īŽ U5MR = 87/1000 LB īŽ Births Attended = 73.3% īŽ Full Immunz.= 61% īŽ Median ANCs=4.2 Brought to you by
- 4. Expenditure Patterns īŽ Public expenditures âdeclining trends īŽ LPG and growth of private capital and stagnation of public investment īŽ Reduced public spending īŽ Out of pocket â increasing burden, especially the poor and in rural areas Brought to you by
- 5. Character of Health Expenditures īŽ Public Domain īŽ Rural/Urban divide īŽ Preventive/Curative dichotomy īŽ Plan/Non-plan expenditures īŽ Centre, State and Local governments īŽ Private Domain īŽ Curative only- pharma industry driving force īŽ Irrational practices, malpractice, unregulated, lack of professional ethics īŽ Supply induced demand Brought to you by
- 6. Facts & Figures - Health Spending īŽ Public Domain īŽ Centre: Rs.35 bi (0.13% GDP) īŽ State: Rs.186 bi (0.72% GDP) īŽ Local: Rs.25 bi estimated (0.10% GDP) īŽ Social Insurance: Rs. 12 bi (0.05% GDP) īŽ Private Domain īŽ Out-of-pocket: Rs.1200 bi (4.62% GDP) īŽ Insurance (public sector) Rs.8 bi (0.03% GDP) īŽ Pharma Industry Rs. 250 bi (0.96% GDP) Brought to you by
- 7. Healthcare Financing â Rs. billion 1993 -94 1994- 95 1995- 96 1996- 97 1997- 98 2000- 01 2002- 03BE Public Centre 7 11 12 13 14 23 35 State 68 72 89 99 113 156 186 Total 75 83 101 112 127 179 %Govt 2.91 2.13 2.98 2.94 2.70 2.91 %GDP 0.87 0.81 0.86 0.83 0.83 0.81 221 3.17 0.85 Private %GDP 195 2.27 279 2.75 329 2.77 373 2.73 459 3.00 982 4.46 1200 4.62 Source: Public Expenditures - Finance Accounts upto 2001 and Budget for 2003; Private â CSO estimates on Consumption Expenditure 1985 series; BE = Budget Estimate Brought to you by
- 8. Basic Care Framework īŽ What constitutes basic health services īŽ Family physician services, supported by paramedics and community health workers īŽ First level referral hospital with basic specialties and ambulance services īŽ Epidemiological services, including information management and health education īŽ Maternity services for safe pregnancy, abortion, delivery and postnatal care īŽ Immunisation services against vaccine preventable diseases īŽ Pharmaceutical and contraceptive services Brought to you by
- 9. Operational Mechanism īŽ Restructuring and Reforms īŽ Organising a system īŽ Creating an autonomous health authority īŽ Referral system īŽ Standards and regulation īŽ Structured financing Brought to you by
- 10. Operational Mechanism... īŽ Priorities for making it work īŽ An Act of Parliament - Health Authority īŽ Tackling the medical profession īŽ Licensing, registration, minimum standards īŽ Integration of systems īŽ Continuing medical education īŽ Pricing mechanisms īŽ Raising substantial additional resources īŽ Consensus building in civil society Brought to you by
- 11. Financing the System īŽ Resource Requirements īŽ Present public spending on health care is less than 1% of GDP and out-of-pocket is 4% īŽ Reorganised system will need totally 3% of GDP īŽ Costs will be shared by governments at all levels, employers, employees, earmarked taxes and cesses, insurance funds etc.. Brought to you by
- 12. Innovations in Financing īŽ Using existing resources efficiently and effectively īŽ Decentralised governance (Panchayati Raj) īŽ Block funding or global budgeting īŽ Leads to equity in access to resources īŽ PHC level resources tripled īŽ CHC and district level resources doubled Brought to you by
- 13. Innovations in FinancingâĻ īŽ Generating additional resources īŽ Increased allocations within the existing budget īŽ Payroll taxes for health like profession tax īŽ Health cess on health degrading products, polluting industry and luxury products īŽ Compulsory public service by those graduating from public medical schools īŽ Social security levies on land revenues Brought to you by
- 14. Consensus Building īŽ Policy level advocacy for UHC īŽ Research to develop framework īŽ Lobbying with medical profession īŽ Filing of PIL for RTHH īŽ Lobbying MPs to demand justiciability of directive principles īŽ National and regional consultations on RTHH involving civil society Brought to you by
- 15. Consensus BuildingâĻ īŽ Campaigns on RTHH with networks of peopleâs organisation īŽ Bringing RTHH on manifestoes of political parties īŽ Pressurising international bodies like Committee of ESCR, WHO,UNCHR.. And national bodies like NHRC, NCW.. To monitor state obligations and demand accountability īŽ Shadow reports on RTHH Brought to you by
- 16. Summary and Conclusions īŽ Rural â Urban disparities across the board īŽ Reduced investments and expenditures on health care in the nineties has impacted access and health outcomes īŽ Allocative inefficiencies coupled with SAP only makes the crises of public healthcare worse īŽ Overall health outcomes not very good because of the worsening access to healthcare âuser charges and privatisation īŽ Lack of accountability īŽ The need for a right to healthcare perspective Brought to you by
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Editor's Notes
- Abstract Rationale: More than half a centuryâs experience of waiting for the policy route to assure respect, protection and fulfillment for healthcare is now behind us. The Bhore Committee recommendations of 1946 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. Over the nine plan periods since then in implementing health plans and programs there has been dilution of the comprehensive and universal access approach by developing selective schemes or programs, and soon enough the Bhore plan was archived. 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. Objectives: The right to healthcare is primarily a claim to an entitlement. The emphasis thus needs to shift from ârespectâ and âprotectâ to focus more on âfulfillâ. Further, using a human rights approach also implies that the entitlement is universal. This means there is no exclusion on any grounds for provisions made to assure healthcare. 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. CEHAT is undertaking a right to health initiative to bring this on the national agenda.. Description and Outcomes: The paper discusses the operationalisation of the right to healthcare in India in the above context and builds a framework to realize the right to healthcare drawing from international experience and the General Comment 14 of ICESCR. The framework is constructed keeping in mind a minimum core content of healthcare services and determinants of health. Further the paper critically evaluates the existing healthcare scenario and suggests a mechanism to reorganize the healthcare system into a public-private mix that assures right to a well defined set of basic healthcare services universally and equitably. The paper also estimates the resource requirements for such a system and suggests mechanisms to raise appropriate resources. The paper ends with suggestions on how a consensus can be built to move towards right to healthcare in India. This paper is one of the initial inputs for the right to healthcare initiative, which CEHAT in collaboration with civil society groups and networks is in the process of evolving through its research and advocacy program on right to health. This program is in the ground-work stage and its outcomes like making right to health a national agenda, constitutional amendment, reorganization of health services, improved financing strategies etc. will be realized over the next five years progressively.
- Healthcare in India With some roots embedded in the Bhore Committee Report the health policy process in India mandated specific entitlements for public healthcare services in India, especially for rural areas. Of course the entitlements which the Bhore Committee had recommended, and that too within a rights framework, are not even on the mind of the State. What we have is a very diluted version which got consolidated under the Minimum Needs Program started in the seventies. The infrastructural entitlements are very minimal, a sub-centre with two health workers for 2500-5000 population, a 4-10 bedded primary health center with one doctor and various paramedic staff for 10,000-30,000 population, and a 30 bedded Community Health Centre with six doctors including basic specialists for every 5 PHCs. Apart from this there are sub-district and district hospitals for secondary level reference. At the PHC and sub-centre level the focus is preventive and promotive services like disease surveillance, family planning, immunisation for children and ante-natal care for pregnant women. Data shows that even this minimal provision is grossly underprovided. The MoHFWâs own RCH-RHS facility survey indicts severely the inadequacies within the public health system,especially primary healthcare. This state of affairs is largely due to poor investments being committed to primary healthcare over the years. And what is worse new investments have virtually stopped, expenditures are declining, especially so since India committed to the Structural Adjustment Program under World Bank dictat. In the nineties public health expenditures have declined rapidly both in terms of proportion to govt. spending as well as as a ratio to GDP. In contrast private health investments and expenditures have grown rapidly. This scenario of healthcare is not very encouraging for a country like India which suffers widespread poverty and under-nourishment, especially in rural areas as evidenced by highly adverse health outcomes.
- Rural Urban Disparities Disaggregated data reveals very severe disparities in distribution of healthcare resources as well as health outcomes across rural and urban areas. The situation in urban India is close to developed country averages, whereas the rural scenario in India is one of the worst in the world. The disparity in infrastructure is indeed very severe with difference in availability of hospital beds being as much as 15 times less in rural areas and public expenditures 7 times less. In case of health outcomes the urban areas do nearly twice better than rural areas. The critical factor here is the investment of resources in rural and urban areas. Urban areas have received relatively adequate resources over the years and hence its infrastructure and facilities are reasonable both in numbers and qualitative terms. Rural areas have been neglected historically and the main inputs have been only for preventive and promotive services, especially family planning and more recently immunisation services. The rural infrastructure had got a boost during the 5th and 6th Five Year Plans under the Minimum Needs program. But since then there has been a declining trend in new investments and slowing down of growth in expenditures, infact decline as a percent to both total govt. expenditures and as a proportion of GDP. The only way to remedy this gross disparity is more resources for the health sector at one level and greater equity in distribution of resources between rural and urban areas at another level.
- Expenditure Patterns In the late seventies and the first half of the eighties the Central government supported a massive expansion of the rural health infrastructure through the Minimum Needs Program. This helped states mainstream modern health care in the rural areas. Since then the Central government has abdicated its responsibility. Their only interest remains supporting medical care in Delhi and some union territories and promoting aggressively family planning in the rest of the country, especially the villages. The little support it gives for public health programs like tuberculosis, AIDS, leprosy, blindness control etc.. are increasingly coming from international borrowings and serving the agenda of international agencies like World Bank and the USAID. Capital expenditures have disappeared and grant in aid to states, which largely supports preventive care programs like the National Disease Control Programs, is also declining as a ratio within the Central health budget. This is clearly an indication that the Central government is cutting back expenditures in the health sector. The situation of the state governments is not very different from that of the central government. One sees the same declining trends. The state governmentâs expenditures too are mostly on urban health care â teaching hospitals, district hospitals and health administration â and on family planning in the rural areas. One sees a drastic decline of expenditures by state governments on medical care, part of which is absorbed by family planning. Capital expenditures, which were low in the seventies and eighties when the big rural infrastructure expansion took place under the Minimum Needs Program (largely supported by the Centre), also show a declining trend. The fifth pay commission has put a further strain on resources and further worsened the allocative inefficiencies. All this puts great burden on out-of-pocket expenses on households, especially the poor and the rural population because it is in the latter that public investment and expenditures have suffered the most.
- Character of Health Expenditures In the public domain bulk of resources allocated in rural areas are for preventive and promotive care like disease surveillance, family planning, immunisation and ante-natal care. Eighty percent of the curative care budget, especially hospital care is spent in urban areas. As a consequence of this the out-of-pocket burden on the rural population is tremendous. Data reveals that in urban areas out-of-pocket expenditures are twice that of public spending but in rural areas people spend a whopping ten times more than what the state spends on healthcare in rural areas. This adequately demonstrates the gross inequities of our healthcare system and when we correlate this information with the large-scale prevalence of rural poverty the severe handicap in accessing healthcare faced by rural India becomes very evident. Another issue in public finance is that rural health budgets largely come from plan expenditures, usually as part of vertical programs sponsored by the Centre. Unlike non-plan funds plan funds are not internalised expenditures and hence may not have long term commitment. This makes rural public funding highly precarious. Further urban areas also have municipal finances, a substantial chunk of which goes for public health expenditures. Rural local bodies have negligible commitments for public health, despite decentralisation of primary healthcare under Panchayat Raj. The private domain is totally curative oriented and is strongly driven by the pharmaceutical industry which is responsible for a large volume of irrational and unnecessary expenditures. The penetration of modern drugs is seen in the remotest of areas, and national survey data has adequately revealed that it is a myth that a large part of rural and tribal areas are still dependent on traditional and/or herbal remedies! Further the private health sector operates completely unregulated, lacks professional ethics and indulges widely in irrational practice and malpractice which adds considerably to the cost of healthcare. Also because of lack of any regulation and minimum standards of practice the private health economy is largely fueled by induced demand.
- Bringing Basic Health Care Back On Agenda Post Independence the Indian State had committed itself to comprehensive health care for all irrespective of the capacity to pay. We even had an elaborate national health plan in the form of the Bhore Committee Report. But as we have seen earlier over the years there has been clear process of dilution of the basic health care package. Basic health care has to be viewed as a right. Today the world has moved beyond only political rights being fundamental and increasingly social and economic rights are acquiring such recognition. Thus we would like to view health care in a rights perspective and frame priorities accordingly. Basic health care, or primary health care as it is referred to today, must begin with family physician services and have adequate support of referral services for specialty and hospital care. This should be under an organised system which in todayâs given reality best exists as a public-private mix.
- Restructuring A system based on a public-private mix would be most suitable for the reality in India. The State has to play a central role in helping develop an organised system of health care as against the prevailing laissez-faire approach. The existing health care services will have to be restructured under a defined system and its financing organised and controlled by an autonomous body. To facilitate such restructuring a well defined system of rules and regulations will have to be put in place so that minimum standards and quality care are assured under such a system. There will be a lot of resistance to implementing such a system but it is here that the State will have to demonstrate its guts.
- Priorities For Making It Work To organise such a system we need a policy statement to begin with, that is there has to be a political will to carry out such restructuring and reorganisation as well as the strength to fight resistance from vested interests of the existing system. While the ideal would be to see an organised system in place with an Act of Parliament, the reality is that the political will is missing. The latter is due to health care as a right not being a priority issue in civil society as yet. However, there is adequate interest and concern to take up piecemeal reforms and here the priorities are clear. Improvements and accountability of the existing system, both public and private. People are demanding quality care and with the consumer courts on their side are increasingly confronting bad medical practice. The medical profession has also awakened to the existing mess and is organising to put its house in order - minimum standards, accreditation are emerging on their agenda. In the public domain there is pressure for privatisation via introduction of user charges. This is fiercely being resisted by civil society groups in a number of places. This battle has the potential of taking health care into the arena of a rights perspective and expedite the process towards an organised system of health care.
- Resources Public spending on health care is barely 1% of GDP as it stands today. This infact is a decline over earlier years, especially the mid-eighties when it was 1.27% of GDP. Nearly 70% of state spending goes to urban areas, mostly hospitals. The balance 30% in rural areas is spent mostly on family planning services. Private out-of-pocket expenditures on health care are not available in any organised way. At best estimates can be made based on sample surveys of household expenditures and indirectly by extrapolating on the basis of the strength of the private health sector. It is today estimated to be about 4% of GDP, more than double that of estimates available for the sixties and seventies. A restructured public-private mix would need much less resources. Estimates calculated for the basic health care package, including existing public secondary and tertiary services would cost around 3% of the GDP. This would mean a whopping saving of 40% of what is spent overall now and coupled with much better quality and more effective services. In terms of sharing costs the public share would definitely need to go up and private resources would be channelised through employers, employees and insurance funds. The State would have to raise additional resources through earmarked taxes and cesses for the health sector. This would mean a greater burden on those with capacity to pay but there would be an overall saving of out-of-pocket expenses for all but especially for the poor.
- Innovations in Financing While much more resources need to be allocated for the public health sector, it is also clear that allocative efficiencies have to be looked into. One way of doing this in an equitous manner is global budgeting or block funding. To illustrate this, taking the Community Health Centre (CHC) area of 150,000 population as a âhealth districtâ at current budgetary levels under global budgeting this âhealth districtâ 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. Of course, these figures have been worked out with existing budgetary levels and excluding local government spending which is quite high in larger urban areas. Given larger resource allocations as per the NHP 2001 recommendations, the per capita funds available would be much higher. Such reorganization of fund allocations will be a step in the direction of removing the inadequacies of the public health system as highlighted in the policy.
- Additional Resources The NHP 2001 recommends the need to enhance the budgetary allocations to the health sector. But apart from this it expresses the practical need to levy reasonable user charges for certain secondary and tertiary health care services. User-charges is a regressive means of recovering costs and given the overall conditions of poverty it is also not an appropriate means of collecting revenues. Those who have the capacity to pay must be made to pay through other means. All persons having regular wages/salaries or business incomes must contribute through payroll taxes for health, perhaps something similar to the profession tax charged in some states. Other ways of generating revenues need to be considered, such as proportion of turnover of health degrading products like cigarettes, alcohol, guthka (tobacco), pan masalas etc.. as a health levy earmarked for the Ministry of Health. A health cess could be charged on items such as personal vehicles, air-conditioners, mobile phones and other luxury products, owned houses of a certain type/dimensions, on land revenues, on polluting industries etc..
- Summary and Conclusions To summarise the following issues of concern in the health sector emerge: ¨       Public Health Expenditures have been historically very low and in the last decade of the millennium we see a declining trend ¨       On the whole about three-fourths of these expenditures are spent on salaries (over 80% in primary care) leaving very little for other critical expenditures like drugs, capital investment, maintenance, equipment etc.. This lack of allocative efficiency is responsible for the waste, inefficiency and ineffectiveness of the public health system ¨       Investment expenditures (capital) have declined drastically in the nineties and this means the public health services have stopped growing ¨       The commitment to the health sector by the Centre is reducing but there is no evidence to show that the state governments are gearing up to take the additional burden ¨       The declining support by the State to the health sector, which impacts adversely on its quality of care, is pushing more and more people, including the poor, to use services of the rapidly growing private health sector ¨       The private health sector operates unregulated and the quality of care offered is questionable because not only non-allopaths but also unqualified persons in large numbers operate as private practitioners ¨       The health infrastructure, with the exception of production of doctors and medicines, is quite underdeveloped, especially in the rural areas ¨       The rural infrastructure apart from being grossly inadequate is also wasted because of the pressures to promote family planning, instead of providing comprehensive health care ¨       The overall health outcomes in the country are not very good â if we look at specific states the situation is quite alarming in the BIMARU region ¨       The large investment by the State in medical education is infact a subsidy for the growth of the private sector as over 80% of those who graduate from public medical schools work in the private sector, or worse still migrate abroad ¨       Overall there is a gross lack of accountability in both the public and private health sector â Establishing right to basic healthcare seems to be the only solution for an equitable and universal access healthcare system for both rural and urban areas