REPORI ON THE STATUS OF RIGHT TO HEALTH
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REPORI ON THE STATUS OF
RIGHT TO HEALTH - extracted text
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NATIONAL LAW SCHOOL OF INDIA UNIVERSITY
BANGALORE
PROJECT ON
ACCESS TO SOCIAL AND ECONOMIC RIGHTS
SUPPOR'FED BY NOVIB
REPORI ON THE STATUS OF
RIGHT TO HEALTH
w
By
Dr. N.R. MADHAVA MENON
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RIGHT TO HEALTH
CONTENTS
I.
Introduction
1
II.
Status of Health and Right to Health in Kerala
4
III
Right to Health : The Karnataka Scene
10
IV.
Right to Health in Andhra Pradesh
15
V.
Status of Health Rights in Tamil Nadu
19
0
HEALTH AS A BASIC RIGHT
I.
INTRODUCTION
Health is integral to life and right to life cannot be conceived without reference to health.
As such, it is common sense to sugue that everyone has a rigid to health. The problem is to
ascertain the content of the right, the conditions in which it stands violated, tire nature and scope
of obligations it imposes and the remedies one can claim if the right is violated.
Does rigid to health mean that every individual is to be guaranteed good health at all
times by the State?
Certainly, not.
This no State can ever guarantee as it is a condition
determined by a combination of factors like heredity, environment, timely health interventions,
model of development, personal hygiene etc. This is the reason why even the Covenant on
Social and Economic Rights speaks only of “the highest attainable state of health” as the object
of the right. 'The content of this rigid is thus relative, v^uying in time and place. Yet there is a
core content which is spelt out in public health and medical services law. By improving housing,
living conditions, level of nutrition, water supply, sanitation etc. Governments can protect health
of the people far more effectively than by opening more hospitals. That is why health rights are
emerging by way of specific standaids and procedures as found in the Court decisions on Blood
Banks, emergency medical services in accident cases, preventive health services in hazardous
occupations etc. In short, right to health, like other individual rights entitle citizens to demand
certain minimum standai ds and procedures in the maintenance of public health and to seek
remedies through Courts whenever such conditions are not maintained and as a result right to life
is endangered.
The World Health Organization, in its programme on Primary Health Care and Health for
All by the Year 2000 spelt out in 1978 what is called the Declaration of Alma Alta, certain
essential initiatives to achieve the “highest attainable standard of health” as stipulated in the
Covenant on ESC Rights.
These are :
(a)
Emphasis on preventive health measures (such as immunisation, family planning) more
than on curative measures;
-2(b)
Emphasis on participation of individuals and groups in the planning and implementation
of health care;
(c)
Emphasis on maternal and child health care;
(d)
Education concerning health problems;
(e)
Priority in health care to vulnerable and high risk groups;
(f)
Provision for equal access of individuals and families to health care at a cost the
community can afford.
One of the serious problems acknowledged by the Alma Alta Declaration is the gross
inequality in the allocation of health care and the health status of different groups in society like
women, tribals, slum dwellers.
Human rights are indivisible and inter-dependent. Hence the
right to health cannot be effectively protected without respect for other human rights like
equality and non-discrimination, participatory decision-making, education, housing etc.
Right to health has two basic components, (a) right to an environment involving the
minimum of health risks and (b) right to have access to health services that can prevent or
alleviate suffering and treat diseases. WHO has moved towards such a definition of the right. In
both aspects. States have positive and negative obligations which includes even preventing non
State actors from violating that right. Violation of minimum standards are violations of right to
health and, as such, enforceable if necessary tlirough court actions.
Other obligations are
promotional in natui e aimed towai ds achieving higher standai ds of health.
Medical ethics also are norms intended to protect health rights of patients and the society
at large. With growth of human rights standards, medical ethics evolved new norms of conduct
in medical care and delivery of health services and, as such, a lot of human rights violations can
be redressed tlirough enforcement of code of ethics.
The Indian Constitution devotes several Articles in directing the State to protect health
rights in a variety of situations. They are, of course, part of Directive Principles of State Policy
which are declared by the Constitution (Article 37) as fundamental in the governance of the
country. Among the relevant Articles are :
Article 38 -
State to secure a social order for the promotion of welfare of the people.
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Article 39 -
The State, in particular, to direct its policy towards securing : €<(e)
that the
health and strength of workers and the tender age of children are not abused and
that citizens are not forced by economic necessity to enter avocations unsuited to
their age and strength”.
Article 41 -
Right to
public assistance in cases of
old age, sickness and
disablement, and in other cases of undeserved want.
Article 47 -
Duty of the State to raise the level of nutrition and the standard of living and to
improve public health, and, in particular, the State shall endeavour to bring about
prohibition of the consumption except for medicinal purposes of intoxicating
drinks and of drugs which are injurious to health.
Article 48A- Duty of the State to protect the environment
Article 51A(g) - Duty of every citizen to protect and improve the natural environment -
etc.
It is interesting to note that in dealing with the subject of health, the Constitution makers
did use the language of both rights and duties (Articles 41,47 and 48-A) though they were
reluctant to put it as part ofjudicially enforceable fundamental rights. It is this reluctance which
was overcome by the Supreme Court when it interpreted Article 21 (Right to life and personal
liberty) to include right to health. In doing so they did seek support from international human
rights instruments as well the relevant provisions in the Directive Principles.
This study attempts to examine from the citizen’s perspective as to what is available to
him in practice in the field of health rights with a view to understand its status as basic human
rigid. What follows are brief reports on the findings of the survey in the four Southern States.
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IL
STATUS OF HEALTH AND RIGHT TO HEALTH IN KERALA
“Kerala is renowned as a State which has made success for years in the fields of health
and education. Kerala’s achievements in key areas of human development have been widely
appreciated. However, on deeper scmtiny it would appear that the progress is only in the
periphery and is not sustainable in the long run. There is food, but most of it is not produced
here. There is longevity, but it is tempered by morbidity. There is a semblance of cleanliness all
round, but this cleanliness does not stand the test of scrutiny.
People are concerned about
personal and household cleanliness; but indifTerent to public and environmental cleanliness’*.
lliis is how the 1998 report of the Task Force appointed by the Government of Kerala begins
about status of sanitation and health in Kerala.
1.
Sanitation
1.1
Tlie Report characterises environment sanitation in the State as dismal. Sanitation
coverage in Kerala is only 51%. According to the Report people living in the coastal belt, urban
slums and other problem areas live in extremely miserable conditions because of high density of
population and acute poverty and malnutrition. The situation of women is desperately pathetic
because they do not have access to toilet facilities and are deprived of the right to privacy. Many
years of experience in the water and sanitation sector has revealed that Kerala has completely
neglected the elements of community education, mobilisation and informed participation.
1.2
The report stated that 29 lakh families in the State, 32% of the poor households,
do not have proper toilet facilities! 1991 Census shows that the households with latrines is just
over 50 per cent (44% in rural areas and 72% in (he urban areas). Piped sewerage facility exists
only in 1 hiruvananthapuram and Cochin and that too covers only a small section of the
population (About 30 per cent in Trivandrum and 10 per cent in Cochin!).
1.3
Public investment in sanitation sector in the State has been very meagre and there
are no indications of it being any better in the future unless the Panchayat Raj institutions in
different areas take the initiative and mobilise opinion and resources.
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2.
Drinking Waiei
2.1
According to Government statistics 37^<> of the rural and 70% of the urban
population have access to piped water supply schemes.
However, National Family Health
Survey shows that only 19% of the rural households are consuming piped water. Open wells
from which bulk of rural people take their water supply are found to have a high degree of
bacteriological pollution. One survey showed that there were over 1800 habitations in the State
in 1994 which do not have even a single public source for potable water!
2.2
Hie State faces acute seal city of water during summer. In the Trivandrum District
nearly 60% of households faces severe scarcity of waler in summer months.
3.
NutriUon
3.1
According to National Sample Survey (1980, 83) Kerala ranks lowest in food
intake. The National Nutrition Monitoring Bureau and the Kerala Statistical Institute studies
report that the average per capita consumption of nutrients in Kerala is much below the
recommended consumption and remains the second lowest amongst eight States studied in 1990
while it was the lowest in 1979.
Food intake studies carried out on pregnant and lactating
women also reveal the same trends.
3.2
According to a more recent survey (1995) moderate to severe malnutrition is
widely prevalent in Kerala, among children under 4 years.
The NFHS survey revealed that
malnutrition is more common among nual children and among children of Scheduled Tribes.
3.3
Review of Hie birth weight of children over the last 30 years from the teaching
hospitals indicates (hat birth weight steadily increased during the 1960s, 1970s and early 1980s,
but has stalled to decline from the mid 1980s.
Low birth-weight babies ( less than 2.5 Kg)
comprised 21% of all births in 1989 (Nutrition and Keratites, C.R.Soman, 1998). The mean
weight is around 2810 grams.
3.4
Pre-School children in the urban environment suffer on an average, more than 100
days of illness while tlie number of disease free weeks is less than 26 for the whole year. About
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40 to 50 per cent of pre-school children sulfei from one or othei worm infection. Childhood
morbidity is fairly high in the State.
3.5
Childhood malnutrition still remains a problem in Kerala despite significant
reduction in child mortality. About 40% children live under the shadow of moderate to severe
malnutrition. Any adverse impact on food intake may result in the increase in the prevalence of
severe malnutrition. Food consumption being already below the recommended level, any further
decline in intake may lead to a serious deterioration of the nutritional situation.
4.
Health
4.1
As per (he conventional health indicators like birth and death rates, infant and
maternal mortality rates and life expectancy, Kerala claims to have achieved the “Health for All”
targets set for India for 2000 AD, even as early as by 1986? Though Keralites live longer (across
70 years) compai ed to other States, Keralite is dogged by more episodes of diseases. Many of
these diseases arise out of poverty and deprivation which calls for education, employment, better
sanitation, nutrition etc.
4.2
Presently 10% of the population is in the age group of 60P which is bound to
increase with mortality reduction and fertility regulation.
A third of health resources are
consumed by this group which may soon go up to 50%. The Health System has not adequately
addressed this phenomenon.
4.3
Compaied to (he rest of the counhy, diseases associated with circulatory and
respiratory systems, cancers of different kinds and nervous disorders an? much more in Kerala.
The brunt of psychosomatic illness (one that is caused or aggravat'd by mental stress) outweigh
that of physical illness in terms of numbers as well as in terms of the disability and loss of
mandays it engenders.
Nearly 20 persons in every 1000 reportedly suffer from
chronic
schizoplirenia, recunent affective disorders, severe psychomotor epilepsy, gross personality
disorders as well as profound mental retardation. The suicidal rate also is reportedly veiy high as high as 17 per lakh of population per year! In short, mental health is a very serious problem
inadequately addressed in the State. There are only 3 mental health centres under the
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Government with a bed strength of 1342. The manpower resources available is also totally
inadequate w ith just 78 M.D. degree holders and 164 Diploma holders registered in the State.
4.4
Another health problem in the State is said to be the high prevalence of dental
diseases. According to Kerala Dental Association study 33% of the teeth of an average Keralite
is out of gear marring not only the physical quality of life but the mental state and personality of
the individual. Government facilities for dental car e are limited to the dental OPs of the two
State Dental Colleges and some dental units attached to few district and other hospitals.
4.5
Tire threat from emerging diseases like IIIV/AIDS is said to be real and imminent
Io Kerala in view of the transmigration of the people of the Slate.
Mosquito borne viral
encephalitis and rat-borne leptospirosis are said to be other emerging tlneats for the State.
Rabies is ano ther significant source of danger in the State.
4.6
llie extent of fatal or serious accidents on roads and work places is increasing in
the State. There is very little preparedness for appropriate responses in times of natural disasters
and man-made calamities.
4.7
'Ihe health position of people with disabilities whose number may exceed 4 per
1000 is indeed pitiable. The available facilities are far too inadequate to the tasks in hand.
4.8
Finally, it is interesting to note that a large section of people in the State do not
invoke the health services available and manage their health themselves. Furthermore, 43% of
the poor seek private treatment at enormous cost while free public treatment facilities are open to
them in government hospitals. In fact, the government health services are being used only by
one-fourth of the population, tliree-fourths depending upon private health services.
5.
Health Infrastructure
5.1
Tire following table gives (lie general picture of the health facilities available
under government and private sectors in the Stale (Source : State Planning Board, 1995):
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HO-Ub Infraxtruttufc iia Kerala, £995
SYSTEM
PUBLIC/GOVT.
Facilities
Beds
ALLOPATHY
_1,249
42,438
AYURVEDA
686
2,309
HOMEOPATHY
405
950
PRIVATE
Doctors
Facilities
Beds
Doctors
1,846
49,030
6,335
621
1225
1,301
4,130
421
2,078
296
2,168
95
139
100
9,063
50,766
12,733
OTHERS
TOTAL
2,340
4,040
The Table conveys some interesting statistics such as
(a)
there is one Govt. Doctor for every 10,000 people (Allopathy).
(b)
titer e is 1.4 Govt. Hospital beds for every 1000 people and 3 per 1000 when combined
with private hospitals.
(c)
in hospitals, beds and doctors, the private sector is larger tlran that of the Government,
(d)
the non-allopalliic systems in private sector is five times bigger in terms of facilities though
they have the same number of doctors. They cater mostly to outpatients as their bed
strength is just 2% of the allopathic system.
(e)
the doctors working with Government ar e less than half of those working with private
hospitals.
5.2
Kerala’s problem is not so much in not having enough doctors but in not having
them where they are needed most, namely in rural locations. There is however, acute shortage of
nurses and tour-fold increase ot the existing number is recommended to match the norms set by the
Indian Nursing Council.
5.3
Daring 1998 a total of 11 lakhs in-patients and 2.3 crores out-patients were
reportedly treated in allopathic medical centres of the GoveniuneiiL hi the Ayurveda and Homeo
centres of the Govt, dur ing the same year a total of 50,000 in-patients and nearly 2 crores of out
patients were reportedly given ti eatnient.
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5.4
It is stated that though Kerala has only 3 per cent of India’s population, it
consumes 10 to 12 per cent of the drugs and medicines produced in the country. More than 20
per cent of the total Government expenditure for health programmes, is spent for purchasing
medicines.
Over 750 crores worth of medicines are sold out every year in the State.
Government alone spends 50 crores for purchasing medicines a year and still hospitals do not
have adequate supplies.
5.5
The S tate spends around 14-15 per cent of the total budget for health. More than
50 per cent of health car e needs of the people of Kerala are met by private sector hospitals,
'fhere is practically no control over tire private sector health system. With increasing flow of
patients to the private sector, the role of State medical institutions and the health policy itself
requires re-examination.
o
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HI.
RIGITT TO HEALTH : THE KARNATAKA SCENE
Introduction
The causes for poor health in India may be grouped under five diflerent heads :
(a)
Population increase and consequent pressures
(b)
Environmental sanitation problems
(c)
Communicable diseases
(d)
Nutritional problems
(e)
Inadequacies of medical care and health services
Added to these are the poverty, ignorance and illiteracy of the masses and the uneven
development of health care services.
Organization of Health Care Services
Medical care in urban centres is organized through District level hospitals of which there
are 176 in the 20 Districts of the Stale (16 District hospitals, 9 teaching hospitals, 8 major
hospitals, 16 specialised hospitals and 127 General/Matemity hospitals). In all these District
level hospitals combined there is provision for 22,000 beds. All these hospitals have specialised
units for a variety of diseases. They cater to patients referred to them from mofussil hospitals as
well as those who directly report to them for treatment.
Psychiatric clinics are in Shimoga,
Hassan, Bidar and Bangalore. The Emergency and Casualty Department work round the clock.
Blood Bank services are available in most of the District level hospitals.
In conformity with the Government of India guidelines in the implementation of the
Minimum Needs Programme (Rural Health), Karnataka has provided a three-tier health infra
structure; Sub-Centre, Primary Health Centre and Community Health Centres.
The Primary
Health Centre is to cater health services for every 30,000 population in plain areas and for every
20,000 population in hilly and tribal areas. Every PHC is supplied with drugs worth Rs.30,000
annually. Each PHC is intended to provide all the basic health services including curative,
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preventive and promotive health services,
Karnataka’s Primary Health Units liave been
upgraded into PHCs.
The Community Health Centre is to provide all national and State sponsored health
programmes for a lakh of population covering roughly four PHCs. It will have 30 bedded
hospitals located at sub-divisional headquarters having at least four specialities - General
Medicine, General Surgery, Obstetrics and Gynaecology and Dental Surgery.
Health Sub-Centres are intended to serve every 5,000 population in plain areas and 3,000
in hilly and tribal areas. One Junior Health Assistant (female) and one JHA (male) manage each
Sub-Centre and drugs worth Rs.2,000/- per annum are supplied for treatment of minor ailments.
The following rural health care centres reportedly functioned between 1990-’92 in
Karnataka:
1990-’91
1991’92
Community Health Centres
160
179
Primary Health Centres
1198
1236
Primary Health Units
626
621
Sub-Centres
7793
7793
Beds
9264
10192
o
Health Admin is tr a t io n
The health services administration is organized broadly at four levels - National, State,
District and local.
The Union Health Ministry has two Departments - Health and Family
Welfare. The functions assigned to it under the Constitution (Seventh Schedule, Union List and
Concurrent List) include
(a)
administration of port and inter-State quarantine;
(b)
administration of central health institutes; (c) drugs control; (d) prevention and spread of
communicable diseases; (e) prevention of food adulteration; (1) control of drugs and poisons;
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(g)
social planning, vital statistics and co-ordination;
and (h) medical education, medical
profession etc.
The Centra] Council of Health was set up in order to promote a co-ordinated effort
between the Centre and the States in the planning and implementation of health programmes.
There is a similar Council for Family Welfare.
The States are totally independent in matters pertaining to the provision of health services
and consequently there are variations in the pattern of health administration within each State.
Broadly speaking there is a Ministry of Health and Family Welfare under a Minister having
several Departments and Directorates to look after specific functions. Under them at the Sub-
divisional and District levels there are officers responsible for supervision and effective
implementation of various health-services in their assigned areas. The District Medical Officer
and Medical Officers in PHCs are people who actually deliver the services to people in need.
In Karnataka,
implementation.
there
are
several
externally-funded health projects now under
These include the World Bank and Germany assisted Karnataka Health
Systems Development Project, India Population Project and OPEC Project for strengthening
District hospitals in backward ai eas ofNorthem Karnataka
The schemesand programmes being implemented are many.
Leprosy Eradication Programme, National Tuberculosis
Control
These include National
Programme, National
Programme for Control of Blindness, National Malaria Eradication Programme, Health
Education and Training Programme, Nutrition Programme etc.
Health Status Indicators and Performance
The rate of population growth in the State has declined to 26% during 1971-81 to 21%
during 1981-’91. The crude birth rate is said to be 24 in 1995. In 1991, infant mortality rate was
77. About 12 lakh children are bom in Karnataka every year. Around one lakh of them die
before completing the first birth anniversary and 0.15 lakh die by the age of 5 years. Half of
these 1.15 lakhs of child deaths are said to be due to the six preventable childhood diseases.
Under the Universal Immunization Programme a substantial control of infant mortality is
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expected to be achieved.
Another scheme called Child Survival and Safe Motherhood
Programme is also launched since 1992-’93 under which reduction of infant mortality rate from
65 to 60 per thousand live births, reduction of child mortality from 41 to 10 and reduction of
maternal mortality from 4 to 2 per 1000 live births are expected to be achieved by 2000 AD.
Crash programmes of training of various types of medical and health personnel are also
under way.
about 56,000 cases.
The estimated leprosy cases in Karnataka in 1991 are
;
The
prevalence rate is 1.6 per thousand population. Eight Districts are endemic having prevalence
rate of 2.5 and above.
Another serious disease in the State is TB for the control of which Centre and State
Governments have a cost sharing on 50:50 basis; however, it was pointed out that State had
diverted its share of costs. Because of administrative corruption, the actual services available to
patients is very minimal. Nearly a lakh of people are victims of this disease.
The incidence of malaria has been on the increase since 1991. It rose from about 50,000
to nearly 3 lakhs in 1996.
Health Statistics are reported to be outrageously misleading. Statistics only reflect the
efficiency of the process of reporting and documentation system. It does not reflect the ground
reality.
In analyzing health situation one must have multiple approaches because of definition of
health can be a political - cultural statement conditioned by several parameters. As such the
analysis should at least have three approaches .
(a)
Health providers’ approach;
(h)
Welfare approach from the perspective of economic capacity and development
priorities of State; and
(c)
A basic right approach from the point of view of recipient of services.
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All the three approaches may not coincide though they do occupy common spaces. If
commitment is not there at the providers’ level, whatever be the inputs, health status cannot be
improved. Though the State has responsibilities, it is not always clear as to how in a system in
which health is the cumulative result of roles played by individual, community., Government and
the providers of services, riglit to health can be ensured. If the State is undermining the right by
shirking its responsibility, it can be restrained. Thus if the Government succumbs to the liquor or
tobacco lobby which engenders health. State and the industry can be made accountable. State
can be asked to standardize services and enforce quality control though punitive strategies are
not always effective. State can do promotional work by health education. State is to invest in
preventive health cai’e and public health services. The State can be asked to correct regional
imbalances and ensure equal accessibility of health care services.
If health care is to be
privatised. State can be asked to ensure access to poorer sections of the community tlirough
subsidy or special schemes (like public distribution system for essential commodities) to ensure
equity in health care.
o
Tims in assessing status of health as a basic riglit of all persons, there has to be agreement
on indicators of assessment and the role and responsibilities of the various players in the system.
For a population of 4.5 crores of people, Karnataka has a total bed strength (public and
private combined) oi a little over 52,000. This makes a ratio of one bed for about 1000 people.
It becomes still less when the rural sector alone is taken where 70% of the people live.
Health expenditure by the Stale is said to be declining over the years while it is increasing
for the citizens who are forced to seek services from the private sector. The annual per capita
expenditure is said to be as low as Rs. 103 in 1994-’95. The Health Budget has declined from
6.6% to 6.3% in 1994-’95.
There are serious problems in medical education in the State despite having the largest
number of teaching institutions of the country.
There are cases of unqualified medical
practitioners reported in the State causing untold suffering to ignorant village people.
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IV.
RIGHT TO HE ALTII IN ANDHRA PRADESH
Introduction
Right to health may be viewed from two angles - one, preventive which emphasises
reduction of risks in the physical and social environment tlirough public health measures, and
second, provision for easy access to medical services for treatment of diseases.
It is in this
context, the Indian Constitution discussed health both in terms ot rights and duties.
Though health is a subject in the State List, in actual practice, the policy, the priorities,
budgetary allocations are all influenced by the Central Government.
The status of health care administration is charcterised by emphasis on programme
management rather than identification and analysis of problems, integrating policy and
programmes, monitoring, evaluation and feed-back. Co-ordination and correction based on past
mistakes hardly take place in health admini strati on with the result the system consumes more
resources on establishment rather than on delivery of services. The medical personnel in the
Health Ministry are far removed fi om the ground realities which reflects on policy as well as on
implementation. With the appearance in the scene of Panchayat Raj institutions there is need for
greater fine-tuning of the system to make it not only accessible, but affordable.
About 8,000 corporates are producing over 30,000 drug formulations under different
brand names; yet there is shortage of life saving di ngs and profuse supply of avoidable mid nonessential medicines. The drug control enforcement is so soft and erratic that it is easy for anyone
to market some spurious drugs, make quick money and disappear from the market.
Doctors
prescribing drugs (a) have inadequate continuing education on the range of drugs and their
relative efficacy; (b) are influenced by the manufacturers and advertisement agencies and (c)
occasionally over-prescribe for various reasons.
Health-Care System in A.P.
The Primary Health Centres have not been quite successful in A.P. because of the
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absence of any supportive role from tertiary and secondary health care services. People have no
faith in PHCs. As a result there is a tendency to depend more on private sector and flock to the
tertiary hospitals even for minor ailments. This, in turn, results in unnecessary overburdening
and consequent dilution of the quality of tertiary facilities and services. Tertiary health care
facilities are not only expensive to establish and maintain but are not easily accessible to people
from rural areas. In addition, the providers at the tertiary level are often not familiar with the
cultural and social practices of tlie patients of remote areas. This results in a mismatch between
expectations of consumers and ajjproaches of providers.
Medicare in A.P. is characterised by high cost and low return. About 80 per cent of the
population in rural areas are catered by about 20 per cent of medical professionals. Only l/3,d of
professionals are in the service of Government and 2/3,d are in private practice who are relatively
untouched by public interest concerns of the medicare system. The public health institutions are
still in high demand; so much so, every doctor may have to examine about 600 patients every
day.
Recognising the need for an efficient secondary health care system, the Government set
up the Andhra Pradesh Vaidya Vidliana Parishad (APVVP) which did initiate lot of reforms to
improve the quality of services provided by hospitals.
In A.P. the tertiary health care facilities are co-ordinated by the Directorate of Medical
Education, while the primary health care and implementation of disease control programmes are
looked after by the Directorate of Health.
The Seventh Five Year Plan has proposed anorm of one bed for every 1000 population
of which 15% beds to be available at primary care institutions, 70% at secondary level and 15
o
per cent at tertiary level. Out of nearly 32,000 hospital beds now available in the public sector,
41% are in tertiary hospitals, 43% in secondary institutions and 16% in primary care institutions.
During recent years there has been a spurt in the growth of health service in the private
and voluntary sectors in the State. They together hold over 53,000 beds though the facilities are
not evenly spread and are concentrated in urban centres.
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The number of out-patients handled between 9 AM and 12 Noon by each district hospital
ranged between 600 and 1300 per day. Maintenance of hospital buildings and staff quarters was
poor. In summer most hospitals face acute water scarcity. Most hospitals do not have facilities
for scientific disposal of waste. Nurses spend more time on record keeping than on patient care.
Important diagnostic equipments often are out of order for weeks together.
The budget
allocation of Rs. 5/- per day for providing diet for in-patients is highly inadequate.
Utilisation of Treatment Facilities
The National Sample Survey data for the State on the use of medical care services
o
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a
revealed that in rural households the self-employed and casual labour constituted the bulk of
users, while in urban areas the salaried groups were predominant. An overwhelming majority of
households utilised the Allopathic system of medicine both for hospitalisation as well as for
other types of care. Preference for allopathy was universal and not influenced by household
characteristics such as income, social class or literacy.
Despite the presence of extensive health infra-structure in the public sector, there is a
distinct preference for private hospitals particularly in rural areas. This may be because of poor
access, non-availability of stafi and drugs, inhospitable attitudes and poor quality care of the
public hospitals. A high percentage of S.Cs and S.Ts used the public health care institutions.
Utilisation of free wards in public hospitals is very high and some of the users belonged to high
income groups. In both urban and rural areas, more than two-thirds of the medical expenditure
was on doctors’ fee and on drugs.
<
About a third of the sampled women in the National Family Health Survey in the State
had institutionalised delivery. Among those who had institutional deliveries, a higher proportion
preferred the private hospitals. Among home deliveries, about 17 per cent made use of the
services of health staff while the rest got assistance of relatives or neighbours. The utilisation of
institutional facilities for confinement was directly proportionate to the literacy status.
About a third of the children had immunization cards.
43% of all children had all
primary vaccinations before the completion of first year. The immunization coverage was better
among male children and residents of urban areas.
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There are some tribes and few others who still believe that illness is caused by
supernatural forces, sorcery and evil eye. They adopt violent and customary practices to cure
illness sometimes resulting in death of patients.
Tlie Health Budget of the State is in the range of 500 to 600 crores per year (6% of total
State Budget) with a per capita expenditure of roughly Rs.34/-. While expenditure on health did
increase, the quality of services declined. It is revealing to note that less than 3% of expenditure
was on water, sanitation and nutrition.
o
4
There is a move in A.P. to have the management of Primary Health Centres either
entrusted to NGOs or lor a partnership with them as well as with Panchayat Raj institutions.
A.P. has increasing incidence of snake-bites resulting in death,
Snake-bite venom is
available only in urban areas whereas the incidence are in rural areas.
Evaluation
In spite of impressive progress in several spheres, the demographic and health picture of
A.P. still raises several issues of concern.
Infant mortality is about 127 per 1000 live biiHis.
Malnutrition among children is exceptionally high. Only 31 per cent of the rural population has
access to potable water supply and less than one per cent enjoy basic sanitation facilities.
Communicable diseases still take a heavy toll of life.
The diseases oriented approach in
medicare has given benefits to the upper layers of society living in urban areas. The emphasis is
on curative approach almost to the near total exclusion of preventive strategies. The system of
medical education has built up a cultural gap between Doctors and patients. It is demonstrated
that more investment in primary health care can produce dramatic results. There is also need for
a reversal of the budget allocation between curative and preventive services and between the
peripheral services and the ever-growing urban hospitals.
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V.
STATUS OF HE ALTH RIGHTS EN TAMIL NADU
Introduction
In the context of modern life and patterns of consumption, the issue of Health cannot be
discussed in isolation. Environment, Education and Economy influence the status of health in
many ways, directly and indirectly. Economic growth leads to social and ecological disruption
including spread of diseases some of which unknown in the past. Unplanned urbanisation and
the resulting deterioration in basic services has increased respiratory and gastro-intestinal
ft
infections in urban areas. The plague-like epidemic in Sural and the dengue fever outbreak in
Delhi are examples of the outcome of urban neglect. Deforestation and dam building have been
shown to be related to a rise in malaria and different new types of fever. Poor water supply and
i
°
sanitation have promoted the resurgence of a whole range of gastro-intestinal syndromes.
Modem transport and communication systems and greater mobility of populations have spread
diseases more rapidly than before. Land degradation due to over use of chemicals and fertilizers
is a growing health hazard.
Tamil Nadu has an impressive record of progress on the health front with significant
reduction of maternal mortality, infant mortality, polio, malaria and malnutrition deaths.
Nonetheless the situation is far from satisfactory. Public health is the most dismal factor. There
are plenty of legislations intended to achieve sanitation of the environment, control of infections,
educating people on personal hygiene and provision of medical and nursing services. The Tamil
Nadu Public Health Act, 1939 is a comprehensive law enabling health officers the power to
*
secure the above goals. Local bodies working in co-operation of health officials can possibly
secure public health if there is political will and informed action.
Health Indicators and Performance
A serious distortion has taken place in policy formation process relating to the health
sector in Tamil Nadu and perhaps in other States as well. This is the displacement of medical
professionals by bureaucrats of the Administrative Services.
abdication of responsibility. Even heads of departments wIm)
There has been a near total
to be
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became ineffective against the combined strength of the bureaucracy headed by the Health
Secretary who is a passing bird in civil services.
At the same ^influential lobbies of the
pharmaceutical companies, private hospitals and associations ot competing professional groups
have hijacked the health administration to serve narrow sectarian ends. Doctors have found it
easy to toe the official line as they were to lose otherwise in terms of transfers, private practice,
foreign visits and attractive deputations outside.
For a population of 62 million, Tamil Nadu has 1420 primary health centres each
supposed to be serving a population exceeding 30,000. There are health workers whose numbers
may vai'y between 8 to 32 in each PHC. There ai’e over 200 dispensaries. Each PHC serves an
area between 2 to 15 KMs. Some of the PHCs are provided with ambulances which are used
more to transport doctors and health staffbetween their houses and hospitals rather than patients.
Tiie total number of doctors registered with the Medical Council in the State is over
42,000 of whom 2/3,(i may be in actual practice within (he State.
There are 48 teaching hospitals, 29 District headquarters hospitals and another 300 taluk
and other hospitals. The number of doctors serving the public sector hospitals may be about
10,000. There are ESI hospitals, railway hospital, hospitals of Madias Corporation which are
independently managed and are outside the Health System under State control. Public Sector
beds in these hospitals exceed 50,000. Private hospitals and nursing homes have increased in the
recent past. Their bed sh ength may exceed that oi Government. There are nearly 30,000 private
doctors in the State.
Health sector receives 8% of the Plan budget which is around 700 crores per year,
file
investment in drinking water and sanitation is outside this because it is under different
departments of the Government.
Status of Medicare Services
Admittedly health policy’ is not formulated keeping in mind the demands of human rights
of people in relation to health. As such evaluation of health care services in terms of human
riglits will be misleading. The concept is not clear either to medical personnel or Government
f
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officials. They do recognize (he duty of Government to provide medicare and public health
services to poor and needy people. Beyond that, the conception of health as a result of clean air,
water, nutrition, food and exercise is outside their calculations. Consequently people fail to see
the difference between health care and medicare. rIliey are used interchangeably.
From the point of view of health, the rigid should include clean air, clean potable water,
minimum staple food with minimum micro-nutrients and basic knowledge of health services.
The average infant mortality rate is 57 per thousand. It is more in rural areas than in
cities. Pre-natal deaths are 2 per 1000 live births. Nearly 100% of childr en born in the State do
get immunization services.
Communicable diseases affect 15% of the population of which T.B. alone affects 2 to 3%
of the people and one per cent each of malaria and hepatitis B. HIV is found among 0.5% to
0.8% people. 10% suffer from parasitic diseases.
More than 85% of available beds in public sector hospitals are occupied at any point of
time round the year which is an indicator of the prevalence of morbidity. T.B., malaria, asthma,
ischaemic heart diseases, pneumonia, diarrhoea, strokes, wonns in children, peptic ulcer,
anaemia and cancer are the common diseases of admission cases. The quality of care aid
treatment depends on the status and income levels of patients. Women get lesser attention than
men. Urban folks have better chances of attention then rural people. Over 90% of patients aregiven free treatment, food and drugs.
o
lire utilization of resources in the health sector is as follows.
About 55% of the
allocation is spent for administr ative expenses. About 80 crores per year (8 to 10%) is spent on
medicines. This is done tluough a fairly efficient arrangement managed by the Tamil Nadu
Medical Services Corporation, lire system ol accountability to patients in the whole system is
very weak.
Private sector in medicare is expanding fast with Government patronage. 65 to 70% of
services are now routed through the pr ivate sector. Each Government servant is entitled to
PH(2 ^30
!■«
- 22 Rs.75,000 worth of private medicare tiu ough contributory health fund of the State Government.
People prefer private hospitals and clinics.
Health rights of children get no priority. Mental patients do not get even the minimum
attention they deserve. Violation of health rights may be happening in many cases; but they do
not end up in litigation as yet. Drug control is not efficient. Frequently sub-standard drugs reach
the market and get distributed. Prohibited drugs are often sold.
Preventive health care is a low priority area. Smoking is prohibited in most public places
and transport. Alcoholism is widely prevalent. Health education is poor.
25% of children bom are those with less than 2.5 Kg of birth weight. Nearly 15% of
children die before they reach the age of five years in the State. Malnutrition of children is as
high as 56%.
Only 25% of people of Tamil Nadu have access to safe drinking water and sanitation.
10 to 15% of annual income of the average person in the State is spent on medical
treatment. It is said that if the health situation remains steady in 2000 AD it will be a big
achievement. Health for All by 2000 AD is a mere slogan and a far cry.
Tamil Nadu gives special importance to Indian systems of medicine of which the Siddha
system occupies the pride of place. There are Siddha units in majority of District/Taluk hospitals
and even in PHCs. Some of the PHCs are now being managed by local industries which is said
■
to be a welcome development for quality improvement and greater accountability in
administration.
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