Millennium Post

Health a Fundamental Right, not a business

The Constitution of India upholds the ‘right to health’ as a Fundamental Right under Article 21. And Article 47 further places on the State the duty of raising the level of nutrition, standard of living and public health. However, the actual scenario is quite depressing.

The country’s aggregrate expenditure on health care taking public, private and household out-of-pocket (OoP) expenditure was 4.1 per cent of gross domestic product (GDP) in financial year 2008-2009. However, the public expenditure constituted only about 27 per cent of this total.

The availability of skilled human resources in terms of doctors, nurses and auxiliary nurse and midwifes (ANMs) remains a key constraint, with rural and tribal areas being poorly served. Against a global average physician density of 14.2 per 10,000 population, the figure for India stands at 6.5. The country’s nursing and midwifery density is 10 per 10,000 population against a world average of 28.1.

The worst indicator of health care in India comes with the density of hospital beds per 10,000 population which stands at nine against the international average of 30. The doctor-population ratio in rural areas is 3 per 10,000 while it is 13 per 10,000 in urban areas. Besides, just 26 per cent Indian doctors work in rural areas, serving 72 per cent of the population.

India’s public expenditure on core health (combined Plan and non-Plan taking the Centre and States together) was about 0.93 per cent of GDP in 2007-2008 and increased to about 1.04 per cent during 2011-2012.

Even Afghanistan spends 7.6 per cent of its GDP on healthcare, Bhutan 5.2 per cent, Haiti 6.9 per cent, Iraq 8.4 per cent, Nepal 5.5 per cent, Rwanda 10.5 per cent, Sudan 6.3 per cent. Among the developed nations, the USA spends 17.6 per cent, Canada 11.3 per cent, the UK 9.6 per cent and Australia 8.7 per cent.

According to the latest World Bank development indicators, only 15 countries outside sub-Saharan Africa had a gross national income per capita lower than India’s in 2011, including Afghanistan, Bangladesh, Burma, Pakistan, Nepal, Haiti, Yemen, Tajikistan and Uzbekistan. However, India’s rank even among these poor countries is an abysmal 10th for child mortality, 11th for female literacy & mean years of schooling, and 13th for access to improved sanitation & DPT immunisation.

In terms of the proportion of underweight children, our country shares the bottom rank with Yemen.
The Economic Survey for 2013 points to the fact that even though the country’s spending on health has increased by 13 per cent, it still has the lowest public health spending as a proportion of GDP.
There is clearly something amiss in India’s health sector.

While the country is doing spectacularly better than other South Asian countries in terms of per capita income, it is failing behind every other South Asian country (with the exception of Pakistan) in terms of key social indicators.

According to a report by the IMS Institute for Healthcare Informatics, about half the people in India and over three-fifths of those living in rural areas are forced to travel beyond 5 km to reach the nearest healthcare centre. Physical accessibility of public and private healthcare facilities is a major challenge in rural areas.

The availability of healthcare services is highly skewed towards urban centres with these residents, who make up only 28 per cent of the country’s population, enjoying access to 66 per cent of India’s available hospital beds. The remaining 72 per cent who live in rural areas have access to just a third of the beds.

Similarly, the distribution of healthcare workers, including doctors, nurses and pharmacists, is highly concentrated in urban areas and the private sector.

The country has undertaken several measures to promote a human rights-based approach to health and nutrition over its successive Five-Year Plans, policies and programmes. Notable among theses is the Integrated Child Development Services Scheme (ICDS), the Mid Day Meal Scheme (MDMS) and the expansive network of Sub-Centres, Primary Health Care Centres and Community Health Care Centres across the country.

The quality of health care services varies considerably in both the public and private sector, with many practitioners in the private sector not even being qualified doctors.  Regulatory standards for public and private hospitals too are not adequately defined and are, in any case,  ineffectively enforced.

The abysmal lack of extensive and adequately funded public health services pushes large numbers to incur heavy out-of-pocket expenditures on services availed in private sector hospitals. Despite efforts through the National Rural Health Mission (NRHM), India’s child sex ratio for the 0-6 age group has declined from 927 in 2001 to 914 in 2011. The country has neither been able to reduce its maternal mortality ratio (MMR) to 100 per 1,00,000 live births nor reduce its infant mortality rate (IMR) to 28 per 1,000 live births.

We have also not been able to reduce our total fertility rate to 2.1. The main reason for this is early marriage, close spacing of births and lack of quality contraceptive services.

Progress on goals relating to reduction in malnutrition among children in the 0-3 age group and anemia among women and girls cannot be assessed due to lack of updated data but localised surveys indicate that the status has not improved.

In order to take stock of the health situation in the country and to make meaningful intervention for an targeted improvements, the National Human Rights Commission (NHRC) is organising a two-day ‘National Conference on Health Care as a Human Right’ at New Delhi on 5 and 6 November.

The main aims of the conference will be to discuss ways in which the public health system can be strengthened from the perspective of human rights, especially with regard to accessibility, affordability and quality of health care, explore ways in which problems of health relating to women and children can be addressed, discuss issues relating to occupational health like silicosis etc and ways to ensure the rights of workers involved, and discuss measures for improving health care in terms of clean drinking water, hygiene and sanitation.

The conference will focus on four substantive issues, which would be followed by working group discussions. These sessions are:-

  • Availability, Accessibility, Quality and Affordability of Health Care Services in India: Need for Universal Health Care
  • Women and Child Health: Important Issues
  • Clean Drinking Water, Hygiene and Sanitation: A Step Towards Better Health Care
  • Occupational Health and Safety

For each of these sessions, NHRC has invited health professionals from diverse fields working in the country. Other than this, it has invited experts from Sri Lanka and Bangladesh. It has also requested State Secretaries of Himachal Pradesh, Kerala, Tamil Nadu, Bihar and Uttar Pradesh to make presentations on essential aspects of health care.

The participants to the conference are public health experts, policy makers and health scientists, legal experts, representatives of NGOs working in the health sector, representatives of civil society, including consumer groups, technical institutions, international organizations, representatives of Ministries/ Departments of Health and Family Welfare, Women & Child Development, Panchayati Raj Institutions, Consumer Affairs, Drinking Water & Sanitation and National and State Commissions.
What India needs today is the promotion of ‘good health at low cost’ along with focus on prevention by way of immunisation, sanitation, public hygiene, waste disposal, disease surveillance, health education, food safety regulation and so on. Expanded collective action in these areas is urgently required, taking into consideration India’s poor experience in fields like immunisation and sanitation.

There is a need not only for better health delivery through institutional change, but also for devoting much more resources, as a proportion of the GDP to public expenditure on health.
This has to go hand in hand with the cultivation of greater efficiency and accountability in public services, a subject on which there are many lessons already in India in states like Tamil Nadu, Kerala and Himachal Pradesh.
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