RIGHT TO HEALTH CARE znooinyf'romrrn idea io reafiii/
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RIGHT TO HEALTH CARE
znooinyf'romrrn idea io reafiii/ - extracted text
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RIGHT TO HEALTH CARE
znooinyf'rom
rorn iidea io reafiii/
3rd and 4th January, 2003
ASF, Hyderabad
- a background reader -
organisecfby:
Centre for Enquiry into Health and Allied Themes
in coffaboration a/ii/i:
National Centre for Advocacy Studies anb
The Global Health Council
Operationalising Right to Healthcare in India
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.1 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.2 But this does not discount the special needs of disadvantaged
1 In the 18th 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.
2 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)
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.3 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
food4
• 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
3 Country specific thresholds should be developed by indicators measuring nutrition, infant mortality, disease
frequency, life expectancy, income, unemployment aqd 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)
4 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.
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 19th 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
sendees, 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.
0
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, budgetaiy, 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 nondiscriminatory basis, especially for vulnerable or marginalized groups;
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(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-a-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 return5 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.6
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.7 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.8 This
5 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.
6 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)
7 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
8 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
11
•
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
coercion9 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
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, UPS, Ministry of Health and Family Welfare, New Delhi, 2001)
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 lUCDs and were penalized for not fulfilling these
targets in different ways, like cuts and/or delays in salaries, punishment postings etc.
XT-
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 classes10, 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-a-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
10 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.
13
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.11 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.
11 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)
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.12 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)13, 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
12 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)
13 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.
15
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.14 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.15
• The medical councils must be made accountable to assure that only
licensed doctors are practicing what they are trained for.16 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
i4To 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)
15 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.
16 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.
•
•
•
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.17 (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 constraints18, 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 services19 should include at least the following:
17 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)
18 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.
19 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.
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 health20
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
20 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.
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
}CJ
25 per 1000 population per year or about 68,500
Deliveries/Births
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 System21
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.22 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
21 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
22 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
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 System23
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
23 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.
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?
> Family medical practitioners = 500,000
> Epidemiological stations = 35,000
> Health workers = 500,000
> Health supervisors = 125,000
> Public health nurses = 35,000
> Basic hospitals = 20,000
> Basic hospital beds = 1 million
> Basic hospital staff:
> general duty doctor = 120,000
> specialists = 100,000
> dentists = 20,000
> nurses = 360,000
> 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
> Capitation/salaries to FMPs
(@ Rs.300 per family per year
x 200 mi families) 50% of FMP services
60,000
36,000
> Overheads 30% of FMP services
24,000
> Fees for specific services 20% of FMP services
> Total FMP Services
120,000
> Pharmaceutical Services
(10% of FMP services)
12,000
> Total FMP Costs
132,000
> Epidemiological Stations
(@ Rs.3 mi per ES x 35,000)
105,000
> Basic Hospitals (@ Rs. 10 mi per
hospital x 20,000, including drugs,
i.e.Rs.200,000 per bed)
200,000
> Total Primary Care Cost
437,000
> Per capita = Rs. 437; 2.18% of GDP
> 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
> Total health services costs
512,000
> Medical Research (2%)
10,240
> Audit/Info.Mgt/Social Res. (2%)
10,240
> Administrative costs (2%)
10,240
> TOTAL RECURRING COST
542,720
> Add capital Costs (10% of recurring)
54,272
> ALL HEALTH CARE COSTS
596,992
> 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
^s~
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
Sources
Muncp. Sector
Govt.
3,000
7,000
70,000 25,000
1. Epidemiological services
5,000
45,000
5,000 65,000
2. FMP Services
1,000
5,500
5,500
3. Drugs (FMP)
15,000
85,000
4. Basic Hospitals
—
100,000i
5,000
20,000
30,000
5. Secondary/Teaching Hospitals 20,000
240
1,000
1,000
6. Medical Research
8,000
240
5,000
7. Audit/ Info. Mgt./ Soc.Research 5,000
240
7,000
3,000
8. Administrative Costs
272
4,000
25,000 25,000
9. Capital Costs
29,512
136,000 263,500 167,980
ALL COSTS
Rs.596,992 million
28
5
44
23
Percentages
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 rightsbased 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
1
Hospitals
2
Hospital &
dispensary beds
Total
% Rural
%Private
Total
% Rural
%Private
3
Dispensaries
% Rural
% Private
1951
2694
39
1971
1981
1991
1995
1996
1997
3862
6805 11174 15097 15170
15188
32 ___ 27
___ 31 34____ 34____
___ 43 ___ 57 ___ 68 68____ 68____
117000 229634 348655 504538 806409 849431 892738
896767
1961
3054
34
23
22
21
6600
79
9406
80
12180
78
__ 17_
__ 28 __ 32
16745 27431
__ 69
13
60
__ 20 23__
__ 36 37__
28225 25653
__ 43 41__
61 57
23__
37__
25670
40__
56
1998
2000
17,000
1,000000
£
5
PHCs
Sub-centres
6
Doctors
7
Nurses
8_
9
Medical colleges
Out turn
5568 22243 21693
51192 131098 131900
21917
134931
Allopaths 60840 83070 153000 266140 395600 459670
All Systems 156000 184606 450000 665340 920000
16550 35584 80620 150399 311235 562966
475780
725
Allopathy
Grads
P. Grads
30
1600
2695
5131
27929
60
3400
397
___98
10400
1396
111
12170
3833
128
13934
3139
492634
1080173
565700 607376
*
♦
22446
136379
165
23179
137006
24,000
140,000
503947 550,000"
1133470 1,250000
700,000
165
165
*
170
20,000
5,000
3656
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
1MR/000
CBR/000
CDR/000
years
Percent
134
41.7
22.8
32.08
146
41,2
138
37,2
___15
45.55
110
33.9
12.5
54.4
18.5
80
29.5
9.8
59.4
21.9
74/69
__ 29
___ 10
62
72
27
__ 9
62.4
28.5
71
27
8.9
63.5
72
27
9
64
42.3
70
26
8.7
65
126.27
113.13
101.65
50.78
82.17
12.86
3.35
1.08
0.22
Public
399.84
43.82 173.60 233.47
8.15
3.04
1.05
Private@
459.00
373.00
329.00
82.61 279.00
6.18 29.70
2.05
CSO estimate pvt.
0.81
0.88
0.91
0.92
0.95
1.05
0.84
0.71
0.25
Public
Health Expenditure
2.98
2.94
2.95
3.25
1.73
2.43
1.56
1.34
as percent of GDP ____ Private CSO
2.94
2.7
2.98
2.13
2.88
3.84
3.29
5.13
Public
2.69
Health Expenditure
as % to Govt. Total______________ ______ ______ ______ ______ ______ ______ ___________ ------------@ Data from - 1951:NSS 1st Round 1949-50; 1961: SC Seals All India District Surveys, 1958; 1971: NSS 28' Round
1973-74; 1981: NSS 42nd Round 1987; 1991 and 1995:NCAER- 1990; 1995: NSS 52nd Round 1995-96; 1997:
178.00
12
Life Expectancy |
Births attended by
trained practitioners
Health Expenditure
Rs. Billion
__ 19
41.22
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, UPS, 2000
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Ravi Duggal
raviduggal@vsnl.com
December 22, 2002
South African Health Care
A System in Transition
Greg Connolly 12/2/02
Global Health Council
Since the overthrow of Apartheid in 1994, the health care system
in South Africa has been under an ongoing revolution to erase inequities
in service and access, and to fund a higher level of health care. Their
approach is to decentralize the health care system into a District Health
System, and to assure that a standard Primary Health Care package is
available to all. This system in transition has made commendable
achievements, but there are still plenty of improvements to be made
before South Africa attains the system it has envisioned. The most
formidable adversary to their health care reform is the HIV/AIDS
epidemic.
The successes and shortcomings of this middle-income
developing country’s approach to improving health care provide valuable
lessons to other countries that face similar challenges to improving their
health care systems.
The South African Health Care System
South Africa, a middle income nation with a GDP per capita of
USD$7,555, and a population of 43,791,000, is a nation in transition.24
After four decades of minority apartheid rule, a democratic government
was established in 1994.25 This radical change in identity has called for
a great deal of policy adjustment. This change, coupled with the
emergence of the HIV/AIDS epidemic has cornered South Africa into a
national crisis; a crisis that is centered on health care. The keystone of
any government is tending to the well being of its people. The well being
of South Africans is teetering on the edge, and the people are depending
on the government to respond by putting the majority of its efforts into
improving national health.
Currently, the total health expenditure per capita in South Africa is
USD$530.00, and the total health expenditure as a percentage of the
GDP is 8.8%. These expenditures stand beside marginal quality health
indicators such as the life expectancy at birth of 47.7 years for men, and
50.3 years for women. Child mortality rates are 103 deaths per 1000
births for males, and 90 deaths per 1000 births for females.26
Unfortunately, these figures are worsening in a landslide caused by
24 “WHO Country Profile: South Africa.” http://www.who.int/country/zaf/en
25 McIntyre, D. and Gilson, L. “Putting Equity in Health Back onto the Social Policy Agenda-: Experience
from South Africa.” Soc Sci Med 2002 Jun; 54(11): 1637-56.
26 “WHO Country Profile: South Africa.” http://www.who.int/country/zaf/en
2^0
HIV/AIDS. But the government’s formidable approach to reforming
health care, by starting anew with a vision of health care equity, is on the
right track.
South Africa’s vision for health care is a decentralized system that offers
an equally accessible and free basic package of primary health care to all
of its citizens.27 These goals are presented in the National Health Bill of
2001, which establishes the structure for the implementation of a
national health care system based on Primary Health Care (PHC), and
operated by District Health Systems (DHS). For a description of the
government-funded services covered by the Primary Health Care package
in South Africa, visit this website (http://www.doh.gov.za/docs/reportsf.html).
The national Department of Health, headed by Minister
Mantombazana Edmie Tshabalala-Msimang, oversees the system of nine
provincial health departments.
Municipal boundaries for local
governments were demarcated in 2000.
Each provincial health
department has its own ministers and leaders. However, the youth of
this decentralized system is resulting in predictable management issues.
The impetus behind creating a decentralized health care delivery system
was that provincial governments would have the ability to customize the
health systems to their unique cultural groups, while the national
department of health would balance out inequities to assure that all
districts conform to the national health policy. In such a culturally
diverse nation, the state would be mistaken to mandate a one-size-fits-all
national health care policy. Meanwhile, the districts are presumably
small enough, and carry enough social solidarity that the District Health
Systems are centralized into one department. Eric Buch of the School of
Public Health of the University of Pretoria praises the model of
decentralization:
“Establishment of a District Health System with provinces and
local authorities starting to pool their resources and integrate care,
[offers] a more comprehensive service under one roof. This not
only improves economies of scale and efficiency, but means that
parents do not have to go to two or more venues and face duplicate
queues and examinations to get care for themselves and their
families.”28
He also explains that in order to meet the goals for elevating clinics to
fully functional levels, all clinics must have infrastructural services, such
27
Sait, Lynette. “Health Legislation: South African Health Review 2001.”
http: //www. hst. org. za/sahr/2001 /chapter 1. htm
28 Buch, Eric. “SAHR 2000: The Health Sector Strategic Framework: A Review.” The Health Systems
Trust, http://www.healthlink.org.za/sahr/2000/chapter2.htm.
as electricity, refrigeration, potable water, sanitation, and roads by
2004.29 Not only are clinics to be improved, but more clinics are to be
built. The goal is to provide equal accessibility to health care for all
South Africans. This primary objective of the South African health care
system is to ensure that all South Sfrican citizens are able to realize their
fundamental rights to health care as enshrined in Section 27 of the
Constitution. However, Dr. David McCoy, the Director of Research at the
Health Systems Trust in South Africa, explains why the South African
system is not yet a “universal” health care system:
“In order to define the nature of people’s rights to health care, the
national DoH has defined ‘package of Primary Health Care’ that is
expected to be available through the public sector. It lists the scope
of services to be provided in clinics and district hospitals. In
addition, we have a variety of clinical policies that define national
policy on standards of treatment and care in the country. For
example, we have official national HIV treatment guidelines.
However, while everyone essentially has unimpeded access to PHC,
in practice, many people have physical and financial barriers to
getting to health facilities, and when they do attend a health
facility, there is a significant gap between what is set out in the
policies with what is actually being delivered.”30
The definition of “universal” health care that is generally subscribed to is
a system in which the government covers the costs and administration of
the entire health sector, such as in the Canadian Health Care system.
But this kind of system is highly unlikely to be instituted in South Africa.
The obstacles are that the health system is already saturated with issues
demanding attention, there is an entrenched private health sector,
HIV/AIDS is churning up any continuity in health system development,
it is not an upper wealth nation, and there is not enough social
solidarity.
Dr. McCoy explains the funding mechanisms of the South African health
system:
“We don’t have a dedicated health insurance system. The public
sector is mainly funded from the general tax base and to a much
lesser degree from user fees. There are proposals for social health
insurance for the poor but employed, [leaving the poor and
unemployed unattended], which may segment the health care
29 Buch, Eric. “SAHR 2000: The Health Sector Strategic Framework: A Review.” The Health Systems
Trust, http://www.healthlink.org.za/sahr/2000/chapter2.htm.
30 McCoy, Dr. David. Director of Research at the Health Systems Trust. “Email to Greg Connolly - Nov.
25, 2002.”
'b^
system between the unemployed and the employed, as happens in
South America. While this offers opportunities for more people to
access the private sector, it could entrench a weak health care
system for the poor who are excluded from social health insurance.
Outside of the public sector, is a large private health care sector
which outstrips public health expenditure.”31
In the private sector, prepaid health plans accounted for 76.6% of the
private expenditure on health in 2000.32 Medical Schemes are the
dominant third-party intermediary with 73% of the private expenditure.33
And out-of-pocket expenditure on health as a percentage of the total
expenditure on health in 2000 was 12.6%.34 Antoinette Ntuli of the
Health Systems Trust proclaims: “The greatest health sector inequity
continues to be the imbalance of resources available to the public and
private sectors.”35 Such inequities are inherent in a young system that is
developing rapidly on a macro scale.
Eric Buch explains the
development pattern in South Africa:
“In other middle income countries the issues are more around
constant improvement off the baseline. In South Africa they are
around providing services for all that were previously available to a
few.”36
This approach has been necessary given South Africa’s impending health
crisis, yet it has left much room for improvement. The mission statement
of the Department of Health’s “1999-2004 Health Sector Strategic
Framework” is:
“While the first five years focussed on increasing access to health
care, especially for those who did not have access, ... the next five
years will focus on accelerating quality health service delivery.”37
This optimistic outlook passes over the need to improve on areas missed
in the initial surge of health sector reform. It inappropriately implies
that an end has been reached for achieving equal access to health care.
Let us now look at the issues that have challenged health sector reform,
address suggested improvements, and present the direction in which
31 Dr. David McCoy. Director of Research for the Health Systems Trust. “Email to Greg Connolly - Nov.
29, 2002.”
32 “WHO Country Profile: South Africa.” http://www.who.int/country/zaf/en
33 Goudge, Jane, et Al. “Private Sector Funding: South African Health Review 2001.”
http://www.hst.org.za/sahr/2001/chapter4.htm
34 “WHO Country Profile: South Africa.” http://www.who.int/country/zaf/en
35 Ntuli, Antoinette. “Listening to Voices: Preface to the South African Health Report 2001.”
http://www.hst.org.za/sahr/2001 /preface.htm
36 Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
37 Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
South Africa is moving toward achieving its envisioned socialized health
care system.
Challenges to the South African Health Care System
If the vitality of the health care services were related to water supply,
then the health care system would be the dam, and the reservoir would
be the resources that power the system. In South Africa, the reservoir is
running dry. There is inadequate funding, poor access to information, a
outward migration of medical professionals, and insufficient leadership
to sustain the system.
The most basic resource that the health care system relies on is funding.
In light of the HIV/AIDS crisis, it is promising that the government
spends 11.2% of its budget on public health.38 However, this will need to
increase. In the medical sector, it appears that even if all efficiency
measures are achieved, current public sector funding will not satisfy the
costs of providing the care desired.39 Eric Buch suggests:
"There are two places that significant additional funds could come
from. The first is a budget that grows significantly in real terms, v
and the second through raising more funds from users.”40
These are not dynamic solutions. But perhaps what is most needed is
more resources from the conduits built into the system. However, the
funding mechanisms built into the system are also problematic.
Antoinette Ntuli outlines the funding paradox:
"Current mechanisms for funding local government health services
are problematic. From the provincial perspective they do not allow
for adequate monitoring, while local governments are concerned
about the cash flow problems resulting from payments that5 are
paid quarterly in arrears.”41
In parallel, the private sector is also experiencing funding problems. Eric
Buch reports:
"The private sector model of guaranteed fee-for-service payment to
providers through for-profit medical administration companies,
together with other factors, kept private health inflation well above
that prevailing in the economy.”42
38 “WHO Country Profile: South Africa.” http://www.who.int/country/zaf/en
39 Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
40 Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
41 Ntuli, Antoinette. “Listening to Voices: Preface to the South African Health Report 2001.”
http://www.hst.org.za/sahr/2001 /preface.htm
42 Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
The above passage may imply that excessive expenditures are the results
of overproviding by health care professionals, however Buch clarifies that
this is not the primary cause of expense:
“Excessive expenditure on health care is not only driven by the
lack of constraints on members due to third party payer insurance,
but more importantly due to an asymmetry of information between
provider and patient on what interventions are required and
suitable.”43
Effective information dissemination is crucial to operating an efficient
health care system. In South Africa, information is in short supply.
Ninety-seven percent of provincial expenditures on health information
goes to hospitals, with the districts getting only three percent.44 In order
for inequities of access to be neutralized, this ratio must be reduced so
that rural clinics are given, and return enough information to enable
them to deliver care of acceptable quality. When asked if South Africa is
doing a good job of information dissemination, Dr. David McCoy
responded:
“I guess it’s all relative. The Department of Health does take the
need to disseminate information seriously. The Health Systems
Trust is one of the main sources of information [in South Africa] to
health care workers, and they are partially funded by the DoH. ”45
The other side of information dissemination is information gathering. Dr.
McCoy elaborates on this theme:
“Research is very important; but it can also be very distracting.
What is important is relevant research and research that targets
policy makers and managers as the consumers (not academic
journal editors). South Africa also needs to invest time in face-toface communication of research findings, and not rely on passive
paper-based dissemination.
The bureaucracy is reasonably
receptive to constructive criticism, but this culture needs to be,
carefully nurtured and protected.”46
One way any government bureaucracy can be culturally sensitive and
open to civil input is to empower nongovernmental organizations (NGO’s)
’43 Buch, Eric. “SAHR 2000: The Health Sector Strategic Framework: A Review.” The Health Systems
Trust, http://www.healthlink.org.za/sahr/2000/chapter2.htm.
44 Ntuli, Antoinette. “Listening to Voices: Preface to the South African Health Report 2001.”
http://www.hst.org.za/sahr/2001/preface.htm
45 McCoy, Dr. David. Director of Research at the Health Systems Trust. “Email to Greg Connolly - Nov.
29, 2002.”
46 McCoy, Dr. David. Director of Research at the Health Systems Trust. “Email to Greg Connolly - Nov.
29, 2002.”
3‘S~
to perform some of the work on the ground. Eric Buch makes a case for
NGO support in this passage:
“It is generally agreed that NGO’s working in, and with,
communities and those focussing on a health problem e.g. cancer,
tuberculosis, or a disability, have the ability to achieve results and
mobilize energy and volunteerism in a manner that is difficult for
formal health services to match.
This energy seems to be
dissipating in our society, with people waiting for government to do
things for them. The Health Department needs to intervene to
create an enabling environment for NGO’s, facilitate the emergence
of local NGO’s and provide seed funding in hitherto unserved
areas.”47
NGO’s tend to have an ability to feel the pulse of the people. They also
tend to access areas that would normally be overlooked by. government.
One of the major challenges to the South African health care system is
bringing health care to rural underserved populations. These people
often forego health services that would be deemed necessary by health
professionals because they don’t have access to services, or because they
lack the funds for services. There are also many traditional healers
throughout South Africa, who should not be dismissed in the new health
care system, but should be allowed their niche alongside modern health
care services.
NGO's are crucial to mediating sensitive issues like
traditional healing, and helping to facilitate new measures in
underserved areas.
Extending service to underserved areas is one of the most significant
challenges to the health care system. Not only must new clinics be built,
and basic utilities and resources provided, but also there need to be
health professionals to work in underserved areas. Doctors will need to
commit to working regularly in clinics. Moreover, supporting health
services staff such as nurses and assistants will need to be enticed into
working in underserved areas, and will require specific training for
working in these new environments. This will be a costly and demanding
measure. Eric Buch offers one suggestion for alleviating the financial
burden and pressing demand for sending health professionals to work in
underserved areas:
“Large numbers of rehabilitation, pharmacy, environmental and
other assistant categories (mid-level health workers), with one to
two years of tertiary education, need to be rapidly but effectively
trained and deployed...One conclusion drawn by the Human
47 Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000
Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
Resources planning process is that the current staffing model,
based on professionals alone, is unaffordable, and that extensive
use should be made of mid-level health workers.”48
This advice, while sensible, may sound grating to many South African
health analysts who are pressing for a more professional work force.
Amid the rapid, but necessary changes to the health sector, the health
work force is overburdened by changing values in the jobs, and
unreasonable work loads.49 Dr. Graham Bresick comments:
"Urgent attention needs to be paid to the low morale,
disillusionment, and high levels of stress and burnout among
health service staff. We can’t hope to build a reformed and
improved health sector on a spent work force.”50
Difficult working conditions, few incentives, and low morale are causing
health professionals to leave their jobs or seek work in other countries.
South Africa has an enormous problem with the colloquially termed
phenomenon of "Brain-Drain.” Many health care professionals, who
have received their training in South Africa, emigrate to countries with
more inviting health care systems. South African Department of Health
Minister Manto Tshabalala-Msimang states in her speech, "Health
Department’s Multi-Pronged Health Staffing Strategy”:
"We believe that if there is a major - and insidious - threat to our
overall health effort, it is the continued outward migration of key
health professionals, particularly professional nurses, with r a
consequent de-skilling of the professional base in both the public
and private sector.”51
Antoinette Ntuli illustrates the magnitude of this threat with the
following statistics:
"In 2001 there were 19.8 medical practitioners per 100,000
population as compared with 21.9 in 2000. For professional
nurses the ratio reduced from 120.3 in 2000 to 111.9 in 2001.”52
The Department of Health has taken a few measures to combat this
readily apparent threat. It developed a Code of Conduct for other
Commonwealth Nations in their recruitment of South African
professionals.
It created a new "Community Service” program to
48 Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
49 Bresick, Graham. “Email to Greg Connolly - Dec. 13, 2002.”
50 Bresick, Graham. “Email to Greg Connolly - Dec. 13, 2002”
51 Minister Manto Tshabalala-Msimang. “Health Department’s Multi-Pronged Health Staffing Strategy.”
http://www.doh.gov.za/(^ocs/pr/2002/pr 1023.html
52 Ntuli, Antoinette. “Listening to Voices: Preface to the South African Health Report 2001.”
http://www.hst.org.za/sahr/2001/preface.htm
encourage professionals to work in underserved areas. And it sent 254
students to Cuba to train to become physicians. These students have
committed to return to South Africa to offer four years of service to
underserved areas.53
Dr. David McCoy comments on these incentive programs:
"This is a major priority of the health system and we have been
talking about incentive schemes for the last six years. There has
been a recent resurgence of interest in policy-making circles, but
we await some positive outcomes. The only program that has been
put in place is a compulsory community service program for
medical graduates of one year, and a program to place Cuban
doctors in rural areas. Both initiatives have been partially
successful, but are insufficient to address the "brain drain” and
the inadequate levels of staffing in the rural areas.”54
It is not only the doctors and nurses who are strained by the needs of the
health care systems; it is also the administrators. In the early stages of
the new decentralized health care system, leadership was given to those
who may not have had proper training, avenues of decision making were
unclear, and the responsibilities of the leaders were too burdensome.
Antoinette Ntuli elaborates on these problems:
"Worryingly, many health services managers have a low sense of
personal accomplishment.
Huge demands, difficulties in
prioritizing, inadequate management skills, lack of rewards for
competence or sanctions for incompetence, and hierarchies that
are too rigid all impact upon their ability to deliver quality health
care. Other difficulties include inappropriate organograms, lack of
financial delegation, unsatisfactory communication between
provinces and districts and inconclusive appointments of staff,
(especially to strategic positions) many of whom are in acting
positions.”55
Dr. David McCoy echoes her concerns:
"There are inadequate management skills amongst managers and
policy makers who set the operational priorities for transforming
53 Minister Manto Tshabalala-Msimang. “Health Department’s Multi-Pronged Health Staffing Strategy.”
http://www.doh.gov.za/docs/pr/2002/prl023.html
54 McCoy, Dr. David. Director of Research at the Health Systems Trust. “Email to Greg Connolly - Nov.
25, 2002.”
55 Ntuli, Antoinette. “Listening to Voices: Preface to the South African Health Report 2001.”
http://www.hst.org.za/sahr/2001/preface.htm
yb
the health care system in a rational sequence of steps. One cannot
put the roof on before building the walls. This is technical work.”56
Building a national health system is not easy, and South Africa has only
had eight years in which to do it. The nation has certainly made a
commendable effort at health care reform. The problems that arose are
all problems that can be solved, and were virtually inherent in developing
a new health care system. South Africa provides an example of a nation
doing fairly well in transforming their health care system under pressure.
However, that pressure is immense and must be confronted. When
asked if South Africa was doing a good job with its health care reform,
David McCoy gave this response:
“Is the glass half empty or half full? Relative to many developing
countries we are doing okay. Given the history of the country and
the relative inexperience of the government, we are also doing
okay. However, relative to our health needs and the emergency
that is AIDS, we are doing poorly. AIDS threatens to wipe out all
gains made since 1994. We have to run fast to keep still.”57
The HIV/AIDS Crisis
“South Africa has more HIV positive people than any other country in the
world.”58 Two years ago the South African government reported that 4.7
million, which is one in nine, South Africans was HIV positive. Today
that number is expected to be far higher. The South African government
is starting to acknowledge its massive HIV/AIDS crisis. “This year the
government almost tripled its anti-AIDS budget to USD$108 million, and
plans to up to $194 million in the next financial year.”59 “Tony Leon,
leader of the main opposition Democratic Alliance said, ‘South Africa’s
fight against AIDS has been massively hampered and harmed by
government’s dithering, denial and dissent from the orthodoxies
associated with the disease.” He also pointed out that women’s life
56 McCoy, Dr. David. Director of Research at the Health Systems Trust. “Email to Greg Connolly - Nov.
29, 2002.”
57 McCoy, Dr. David. Director of Research at the Health Systems Trust. “Email to Greg Connolly - Nov.
29, 2002.”
58 Cohen, Mike. “World AIDS Day rallies focus on global awareness.” Associated
Press. The Burlington Free Press. December 2, 2002.
59
Cohen, Mike. “World AIDS Day rallies focus on global awareness.” Associated
Press. The Burlington Free Press. December 2, 2002.
expectancy will fall from 54 to 38 in the next decade, and more than 2
million children will be orphaned by AIDS in this time.60
Not only are children being orphaned, but also:
“Each year, more than 600,000 infants [worldwide] become
infected with HIV, mainly through mother-to-child transmission.
WHO and the UNAIDS Secretariat recommend that the prevention
of mother-to-child transmission of HIV, including antiretroviral
regimens such as nevirapine, should be included in the minimum
standard package of care for HIV-positive women and their
children.”61
The article by WHO and UNAIDS also explains: “The simplest regimen [of
PMTCT drug therapy] requires a single dose of nevirapine to the mother
at delivery and a single dose to the newborn within 72 hours of birth.”62
Yet despite the World Health Organization and UNAIDS endorsements of
nevirapine therapy, the South African government was reluctant to
distribute the drug to health providers. Instead the Department of
Health set up an eighteen-site test of the effectiveness and risks of
Intrapartum Nevirapine treatment, because as Minister Manto
Tshabalala-Msimang explained:
“The public sector cannot afford to provide the drugs, while
nevirapine did not guarantee the virus could not be passed from
mother to child.”63
This is a clear example of the Department of Health’s reluctance to give
HIV/AIDS the attention it has warranted. It is this kind of negligence
that prompted Dr. Peter Berman of the Harvard School of Public Health
to say; “South Africa could be an example of what to avoid in AIDS
policy.”64
Dr. David McCoy issued the following statement on what other countries
can learn from South Africa’s HIV/AIDS policy:
60 Cohen, Mike.
“World AIDS Day rallies focus on global awareness.” Associated
Press. The Burlington Free Press. December 2,2002.
61 “WHO and UNAIDS continue to support use of nevirapine for prevention of mother-to-child HIV
transmission.” http://www.who.int/mediacentre/statements/unaids/en/print.html
62 “WHO and UNAIDS continue to support use of nevirapine for prevention of mother-to-child HIV
transmission.” http://www.who.int/mediacentre/statements/unaids/en/print.html
63 Sait, Lynette. “Health Legislation: South African Health Review 2001.”
http ://www.hst. org. za/sahr/2001/chapter 1 .htm
64 Berman, Peter and Bossert, Tom. “Interview with the Global Health Council.” Harvard School of
Public Health.
“Political leadership is critical [to an effective HIV/AIDS policy].
Openness is critical, as is making the problem a national priority
at the early stages of the epidemic.
Ensuring that the basic primary health care infrastructure is
capable of providing correct treatment of sexually transmitted
infections (STI’s), condoms, family planning, and TB control...in
other words, getting the basics in place. This then provides a
foundation for the implementation of more complex treatment
programs.
Human resource training is critical - especially of community lay
workers who can act as agents of community mobilization.
Prevention intervention is not just a health care system
responsibility, but needs to be planned and implemented from a
broad base of government and non-governmental institutions.
Understanding local culture and beliefs is very important. Social
science research must be employed from the beginning to inform
prevention interventions in particular.
The western model of
individual-based counseling is inappropriate and has been a
millstone around our neck.”65
These words of advice are poignant especially to countries that are now
just starting to be infiltrated by HIV/AIDS. India, China and other
countries in Asia, where the .virus is spreading most rapidly should learn
from South Africa’s shortcomings in HIV/AIDS policy.
Implications
The South African health care system has many implications for
developing countries. The model of social equity in health care that
South Africa envisions is appropriate to the needs of its people, and can
be achieved given the nation’s wealth, infrastructure, and relative social
solidarity.
Decentralization beneath a governing body seems to be the
most effective design in a socialized health care system. Public provision
of primary health care services without interfering with privatized
secondary and tertiary health care services achieves a balance of
government control while allowing for the private market to drive
progress. South Africa’s approach to reform was on the macro scale.
This may not be possible for more diverse and impoverished nations, and
65 McCoy, Dr. David. Director of Research at the Health Systems Trust. “Email to Greg Connolly - Nov.
25, 2002.”
Hr)
as seen here, can leave holes, w“=hJ»9hire rcpairinfr
thorough approach to healt ca
government and
pilot program format, and through the work of bog^
non-governmental organizations bu.ld up to a
>
attending to the “mphcahons that arrive^ g^
significantly, developing
, learning, while it is important to
H1V/A1DS policy. As South Mnca m learn 8
be
if
Works Cited
Barron, Peter, and Asia, Bennett. “The District Health System: South African Health
Review 2001 - Chapter 2.” http://www.hst.org.za/sahr/2001/chapter2.htm.
Berman, Peter and Bossert, Tom. “Interview with the Global Health Council.” Harvard
School ofPublic Health.
Bresick, Graham. “Email to Greg Connolly - Dec. 13, 2002.”
Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health
Review 2000 - Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
Cohen, Mike. “World AIDS Day rallies focus on global awareness.” Associated Press.
The Burlington Free Press. December 2, 2002.
Goudge, Jane, et Al. “Private Sector Funding: South African Health Review 2001.”
http://www.hst.org.za/sahr/2001 /chapter4.htm
Mbatsha, Sandi, and McIntyre, Di. “Financing Local Government Health Services:
South
African
Health
Review
2001
Chapter
3.”
http://www.hst.org.za/sahr/2001/chapter3.htm.
McCoy, Dr. David. Director of Research at the Health Systems Trust. “Email to Greg
Connolly-Nov. 25, 2002.”
McCoy, Dr. David.' Director of Research at the Health Systems Trust. “Email to Greg
Connolly - Nov. 29, 2002.”
McIntyre, D. and Gilson, L. “Putting Equity in Health Back onto the Social Policy
Agenda: Experience from South Africa.” Soc Sci Med 2002 Jun; 54(11): 163756.
Minister Manto Tshabalala-Msimang. “Health Department’s Multi-Pronged Health
Staffing Strategy.” http://www.doh.gov.za/docs/pr/2002/prl023.html
Ntuli, Antoinette. “Listening to Voices: Preface to the South African Health Report
2001.” http://www.hst.org.za/sahr/2001 /preface.htm
Pillay, Yogan. “Voices of Health Policy Makers and Public Health Managers: South
African
Health
Review
2001
Chapter
16.”
http://www.hst.org.za/salir/2001/chapterl6.htm .
Sait,
Lynette.
“Health Legislation: South African
http://www.hst.org.za/sahr/2001/chapterl.htm
Health
Review
2001.”
“South African Health
http://www.hst.org.
Reviews
The
1995-2001.”
“South
African
Minister
http://www.doh.gov.za/ministry/minister.html
of
Health
Systems
Health
Trust.
Profile.”
“WHO and UNAIDS continue to support use of nevirapine for prevention of mother-tochild
HIV
transmission.”
http://www.who.int/mediacentre/statements/unaids/en/print.html
“WHO Country Profile: South Africa.” http://www.who.int/country/zaf/en
Canadian Health Care
The Universal Model Evolving
Greg Connolly 11/18/02
Global Health Council
For over thirty years Canada has taken pride in its universal health care program,
Medicare. This experiment in health care systems is founded on the principal that every citizen
should have equal access to high quality health care. But what was the nation’s pride has become
nation’s most controversial program.
Skyrocketing costs and plummeting satisfaction levels
forecast a dire future for Canadian Medicare. Public consensus calls for fundamental changes to
the system. An eighteen-month study ending in Roy Romanow’s report, Building on Values: The
Future of Health Care in Canada, attempts to answer the calls for reform by making a
comprehensive series of suggestions for the renewal of the Medicare system. A group of medical
economists are advising that Canada should introduce a Catastrophe Insurance/Medical Savings
Account model into the health care system. This dynamic time in the Canadian health care
system is yielding important lessons for the other nations of the world, who for many years have
looked to the Canadian model for health care.
The Canadian Medicare System
“Our proudest achievement in the well-being of Canadians has been in asserting that illness is
burden enough in itself. Financial ruin must not compound it. That is why Medicare has been
called a sacred trust and we must not allow that trust to be betrayed.”
--Canadian Justice Emmett Hall
In Canada, health is viewed as a human right. Using this philosophy as their guide, the Canadian
government has developed a socialized health care system that evolved from a small experiment
in Saskatchewan in the 30’s and 40’s, to the current Medicare system.66 This system provides
almost 32 million people spread out over 10 million square kilometers with equal access to
government-funded health services.67
66 Blouin, Chantal. “Canadians’ Health Care Concerns Cannot Stop at Our Borders.” The North-South
Institute. http://www.straightgoods.ca/ViewFeature.cfm?REF=724. Nov. 10,02.
IDB Summary Demographic Data for Canada.
http://devdata.worldbank.org/extemal/dgprofile.asp?RMDK=82656&SMDK=l&W=0.
^5
The policy of a universal health care system was solidified in the 1960’s with the passage of two
key acts. “The Hospital Insurance and Diagnostic Services Act (1957)” and the “Medical Care
Act (1968)” dictated the terms for the Medicare system. However, due to low compensation and
a lack of incentives, medical service providers, such as doctors and nurses, manipulated loopholes
in the legislation to increase their salaries. Some providers introduced extra-billing, which was
the direct charging of extra fees to patients for insured services. User charges were another
exploitation of the system. These were fees charged to the patients, which were not covered by
insurance. For example, a patient could have been charged a user fee before being given access
to care by a. doctor. The problems of extra-billing and user charges were addressed by the
“Canada Health Act (1984).” This legislation penalized such behaviors by allowing the national
government to withhold payments to provincial health departments equal to the amounts
predicted that were charged in extra billing and user charges. Once the providers paid the
provincial health ministers back the extra charges, then the Government would release the
withheld funds. This alleviated the problems of extra-billing and user-fees.
The hierarchy of the Canadian Medicare System cascades as such: House and Senate,
Governor in Council, Minister of Health, Provincial Health Ministers, Provincial Health
Insurance Nonprofit, Provider, Consumer.
As a means of understanding this mechanism,
consider the following profile:
Philip Brodeur, of Quebec, breaks his arm. He reports to the ER, which, unfortunately is
crowded.
Eventually he is treated, his paperwork is filed, and he goes home.
His
paperwork is then processed by the hospital, and sent to the public provincial nonprofit
health insurance agency, called the Ministere de la Sante et des Services Sociaux
(Ministry of Health and Social Services). The insurance agency then sends a payment to
the doctor, and a payment to the hospital. The amount payable to the doctor is based on
the service provided, and the hospital is reimbursed for the materials used. At the end of
the year, the public insurance agency reports the annual provincial health costs to the
national Ministry of Health.
The Ministry of Health then sponsors an audit of the
provincial health insurance nonprofit. If all information reported is accurate, then the
Minister of Health, under the authority of the Governor in Council, reimburses the
provincial health nonprofit for all of the publicly insured health care expenses incurred in
the province that year.
The Governor in Council then reports the national annual
L\ C
spending on health care to the House of Parliament and the Senate, which determines the
national budget for the Medicare system and the tax rate for health care. The system’s
greatest achievement is that Philip LaFayette would have ideally received the same high
level of medical care if he were a businessman in Toronto, or a commercial fisherman in
British Columbia.
The treatment of health care as a basic right is responsible for the high standard of health in
Canada, as shown by the following indicators from 1999: The life expectancy at birth was 78.2
years; the fertility rate was 1.6 births per woman, the infant mortality rate was 6.1 per 1,000 live
births, and there was negligible malnutrition for children under 5 years.68 But despite these signs
of a healthy population, the health care system is ailing.
Challenges to the Medicare System
“The fundamental flaw of the [Canadian] Medicare system is that patients bear no direct costs for
the medical services they receive.”
--David Gratzer
The state of the Canadian Medicare system has become the nation’s foremost political issue.
Despite the successes of the system complaints, flaws, and suggestions are procuring the most
attention. The system is founded on humanistic principals, but is plagued by a flaw of human
nature: in a free-care system, there is virtually no personal accountability.
The increasing level of national dissatisfaction in the Canadian Medicare system is alarming to
health care professionals and policy makers. In 2001, only one in five Canadians thought the
Medicare system was working well. In 1998, 80% of Canadians thought the system needed at
least fundamental changes; and three years later, 18% believed the system required complete
rebuilding.
Also in 2001, 26% of Canadians claimed that their access to health care had
deteriorated over the previous two years.69
68 IDB Summary Demographic Data for Canada.
http://devdata.worldbank.org/external/dgprofile.asp?RMDK=82656&SMDK=l&W=0 .
69
Blendon, Robert, et. Al. “Canadian Adults’ Health Care System Views and Experiences, 2001.”
http://www.cmwf.org/programs/international/can_sb_552.pdf The Commonwealth Fund. New York, NY:
2001.
The primary cause for dissatisfaction is the pattern of extensive queuing in the health care system.
Long waits for medical attention result from overuse of the health care system. Consider the
following queuing estimates to see the source of dissatisfaction:
“It takes nearly 25 weeks to get an appointment with an ophthalmologist in Canada,
almost 21 weeks to receive orthopedic care, more than 18 weeks to get a heart by-pass,
over 16 weeks to see a neurosurgeon, and nearly 12 weeks for a gynecological exam.
,■>10
Another source of dissatisfaction is the apparent breach of one of the Canada Health Act’s five
principals; universality. Studies have shown the existence of class disparities in the provision of
health care in Canada. One study, conducted by the Commonwealth Foundation in 2001, found
that 23% of Canadians with below national average income thought the health care system
needed to be rebuilt, whereas only 13% of those with above national average income thought the
system needed to be rebuilt.71 Likewise, 47% of those earning under $25,000 wanted a private
health insurance option for Medicare, whereas only 39% of those earning over $75,000 wanted
such an option.72 These results show that the lower socioeconomic groups are not as satisfied
with their access to services as are the upper socioeconomic groups. The lower classes reported
more difficulty accessing insured care; especially off-hours and specialty care.
This could
possibly be attributed to the upper class members’ greater abilities to advocate for themselves.
73
The lower classes also had trouble obtaining uninsured elective health services, such as dental,
optometry, medical equipment, and prescription drug services because they would have to pay for
these services from their own funds. Many in the upper classes now have private insurance to
cover these expenses, but the poor usually cannot afford supplemental insurance.74
The cost of health care is climbing rapidly, not only for consumers, but also for the entire system.
The national cost of health care in 1998 was 55.6 billion dollars, which is 6.32% of the Gross
70 Weber, Joseph. “Canada’s Health Care System Isn’t a Model Anymore.” Business Week. August 31,
1998.
71 Blendon, Robert, et. Al. “Canadian Adults’ Health Care System Views and Experiences, 2001.”
http://www.cmwf.org/programs/intemational/can_sb_552.pdf. The Commonwealth Fund. New York, NY:
2001.
72 Crowley, Brian Lee, et. Al. “Operating in the Dark: The Gathering Crisis in Canada’s Public Health
Care System.” Atlantic Institute for Market Studies.
73 Crowley, Brian Lee, et. Al. “Operating in the Dark: The Gathering Crisis in Canada’s Public Health
Care System.” Atlantic Institute for Market Studies.
74 Blendon, Robert, et. Al. “Canadian Adults’ Health Care System Views and Experiences, 2001.”
http://www.cmwf.org/programs/intemational/can_sb_552.pdf. The Commonwealth Fund. New York, NY:
2001.
Domestic Product/755 This is a smaller fraction of the GDP than the US system spends on their
health care system; however, the Canadian system has hidden costs, such as the loss of
productivity due to queuing.76
A study by Foot and Stoffman found that, “Canada’s health
spending nearly doubled between the mid-1980’s and mid-1990’s, but there was no evidence that
people were healthier as a result.”77 These findings imply that the extra spending has gone to
ineffective administration of the system.
In individual provinces, where most of the
administering is done, 30% of the annual provincial budgets are portioned to health care.
Unfortunately, these discouraging figures are on the early slope of a gathering wave.
Canada’s birth rate is low, and its mortality rate is also low. This recipe will yield a glut of
seniors when the baby-boomers reach those years, accompanied by a small work force to support
them. By 2030 the population of seniors will be equivalent to 40% of the working population,
which must cover their health costs. Canadians over 65 currently use about half of all health care
expenditures.78 Foot and Stoffman observe:
“By the time you are in your late 70s, you will use hospitals five times more than your
life-time average rate of use. If you survive until your late 80’s, you will use hospitals 12
times more than your lifetime average.”7
The amount of usage of the health care system is exactly the problem. There is not one group in
the system to blame; they all contribute to its inefficiency. Beginning with the first-tier of the
system, we can see that consumers are overconsuming. In a free-care system, expense is not a
consideration; only convenience matters.
For example, when given the option to receive
immediate attention in the ER, or wait for a less expensive appointment with a physician, the
tendency is to choose the ER because it is more convenient. “In 1997, the Regina Health District
found that from 43-49% of the ER patients in its three hospitals were nonurgent cases.”80 In the
1973 New England Journal of Medicine article, “Distribution,” by Enterline et al., it was found
73 Crowley, Brian Lee, et. Al. “Operating in the Dark: The Gathering Crisis in Canada’s Public Health
Care System.” Atlantic Institute for Market Studies.
Health
76 Danzon, Patricia, M. “Hidden Overhead Costs: Is Canada’s System Really Less Expensive?”
Affairs. Spring 1992.
77 Gratzer, David. “Code Blue: Reviving Canada’s Health Care System.” ECW Press. Toronto: 1999.
78 Crowley, Brian Lee, et. Al. “Operating in the Dark: The Gathering Crisis in Canada’s Public Health
Care System.” Atlantic Institute for Market Studies.
79 Gratzer, David. “Code Blue: Reviving Canada’s Health Care System.” ECW Press. Toronto: 1999.
80 Gratzer, David. “Code Blue: Reviving Canada’s Health Care System.” ECW Press. Toronto: 1999.
that before Medicare, patients called their doctors for free consultation on minor problems, but
immediately after Medicare was introduced, phone calls dropped, and personal free visits
increased by the same percentage. In another New England Journal of Medicine article titled,
“Effects,” also by Enterline, et al., it was found that physicians in Quebec believed that since the
introduction of Medicare, frivolous patient complaints rose by 75%.81 Also in Quebec, in the first
two years after Medicare was introduced, the amount of time physicians spent with each patient
dropped by 16%, and the number of patients seen per day increased by 32%.82 This shows that
the number of patients increased dramatically, but also, doctors’ behaviors changed.
In the Medicare system, doctors are paid on a fee-for-service basis. Due to the high national cost
of health care, each service is assigned a relatively low rate of compensation. Low compensation,
and overwhelming demand for services, are disincentives for providers. As a result, there are few
Canadian medical students; and of the ones who become doctors, many leave Canada for the
greener pastures of the American health care system. Canadian doctors have one primary way to
raise their incomes; raise the number of patients they see.
A major trend in physician overprovision is requiring multiple patient visits, when fewer visits
would suffice. Not only is the doctor/patient relationship strained by the shorter, incomplete
visits, but also the patient is removed from the work force and made to suffer from his or her
ailments longer by having to make multiple visits. Here is an example of overprovision:
“In Ontario, it was reported that over 200 family physicians had billed the government
for more than $400,000 each in 1994-95 (Bohuslawsky, “Patient Overdose”). These
high-billing doctors had pushed through an average of 67 patients a day, or one every
eight minutes.”83
The RAND Health Insurance Experiment, conducted on 2,000 families in the U.S., between
1974-1982 tested for overprovision as a result of health systems. One group of patients with free-
care coverage paid on a fee-for-service basis, like the Canadian model. The other group of
patients with free-care coverage had HMO plans, in which the providers got paid a capitated (flat)
81 Gratzer, David. “Code Blue: Reviving Canada’s Health Care System.” ECW Press. Toronto: 1999.
82 Danzon, Patricia, M. “Hidden Overhead Costs: Is Canada’s System Really Less Expensive?” Health
Affairs. Spring 1992.
8* Gratzer, David. “Code Blue: Reviving Canada’s Health Care System.” ECW Press. Toronto: 1999.
fee. Expenditures in the fee-for-service group were 28% higher, and hospital admissions and
days spent in the hospital were 40% higher than for the HMO coverage group.84 The only
difference was that doctors had an incentive to overprovide for the fee-for-service group. A more
disquieting version of this experiment was conducted by Blomqvist. He found that in California,
when surgeons were paid on a fee-for-service basis, the number of hysterectomies (removal of the
uterus) was five times higher than when surgeons were paid a flat salary.83 Although these
experiments were conducted outside of Canada, and now have some years behind them, they still
reveal the negative trends of overprovision, which are applicable to the Canadian system.
Overprovision and overconsumption are manifestations of a system that needs fixing. Hospital
administrators, and politicians are also responsible for the problems in Canadian health care.
Hospital expenses account for 40% of provincial health costs. For this reason, hospital reform
has been the focus of health officials for almost a decade.86 Other attempted repairs such as
reducing medical payments, and limiting the time doctors can spend performing surgery, have
come up short.87 Politicians tend to point out obvious faults, and pour money into fixing them.
This looks good to the public, whereas addressing the messy roots of problems looks bad.
Perhaps this is partly responsible for why attempted solutions are treating the symptoms, and not
the system.
Reform
In April 2001, the Canadian Prime Minister appointed former Saskatchewan Premier Roy
Romanow to head a Commission on the Future of Health Care in Canada. The ensuing 18 month,
$10 million investigation, which gathered information and public input from tens of thousands of
Canadians, culminated on November 28, 2002 with the release of Romanow’s final report.
Building on Values: The Future of Health Care in Canada.
The question addressed was the almost frantic question reverberating throughout Canada, “What
shall we do to sustain our health care system?”
The most striking recommendation that
Romanow made was a drastic input of national funds into the Canadian Medicare system. The
84 Gratzer, David. “Code Blue: Reviving Canada’sHealth Care System.” ECW Press. Toronto: 1999.
85 Gratzer, David. “Code Blue: Reviving Canada’sHealth Care System.” ECW Press. Toronto: 1999.
86 Gratzer, David. “Code Blue: Reviving Canada’sHealth Care System.” ECW Press. Toronto: 1999.
87
Weber, Joseph. “Canada’s Health Care System Isn’t a Model Anymore.” Business Week. August 31,
1998.
report was a profound message that Canada should not regress from the accomplishments of the
Medicare system toward a hybrid privatized system; Canada should commit to restoring its
national health care system to meet the ideals that it set out to achieve many years ago.
Romanow’s report makes the recommendations that he feels Canadians would agree with for
restoring the medicare system.88 Each recommendation is thoroughly explained, given a timeline,
and given an estimated cost.
But it is the cost that has alarmed Canadians.
Romanow
recommends that the government cover a minimum of 25% of the cost of insured health services
by 2005/2006 and it should sustain this funding floor in the future. In addition to this, Romanow
has called for an initial surge of funds to get Canada back on a track for sustainability. The
additional funding should be above forecasted federal funding by $3.5 billion in 2003/2004, $5
billion in 2004/2005, and $6.5 billion in 2005/2006, which is a surge of $15 billion.89 In his
statement to the nation about his final report, he emphasizes this passage:
“But I want to make one thing absolutely clear. The new money that 1 propose investing
in health care is to stabilize the system over the short-term, and to buy enduring change
over the long-term. I cannot say often enough: that the status quo IS NOT AN OPTION!
If the only result of these past 18 months of collective effort by Canadians is simply more
dollars for health care, our time will have been wasted.”90
These renewal funds will go to the following five new programs to regenerate the sustainability
of the Medicare system:
•
A Rural and Remote Access Fund ($1.5B total over 2 years): to improve timely access to
care in rural and remote areas.
•
A Diagnostic Services Fund ($1.5B total over 2 years): to improve wait times for
diagnostic services.
•
A Primary Health Care Transfer ($2.5B over 2 years): to support efforts to remove
obstacles to renewing primary care delivery.
88 Romanow, Roy J. “Statement on the release of the Final Report of the Commission on the Future of
Health Care in Canada.” Nov. 28, 2002. http://fmalreport.healthcarecommission.ca.
89 “Romanow Report Proposes Sweeping Changes to Medicare.” Commission on the Future of Health Care
in Canada, http://finalreport.healthcarecommission.ca.
90 Romanow, Roy J. “Statement on the release of the Final Report of the Commission on the Future of
Health Care in Canada.” Nov. 28, 2002. http://finalreport.healthcarecommission.ca.
|
O
pc
•
A Home Care Transfer ($2B over 2 years): to provide a foundation for an eventual
national homecare strategy.
.
A Catastrophic Drug Transfer ($1B beginning in FY 2004/5): to protect Canadians in
instances where they require expensive drug therapies to remain healthy.
Romanow expands on some of these recommendations in his speech.
He makes several
recommendations for improving access and quality of care. One suggestion is an improved data
collection system to help provinces collect health outcomes information, and to report regularly to
other provinces so that the nation acts together to improve. A national personal electronic health
record will improve efficiency, accuracy, and security in keeping patient records. A coordinated
wait list management system between health care centers will provide more reliable wait time
estimates and reduce wait times. Attention to long-term human resources strategies will attune
administrators to the evolving needs of supply and demand in the health sector.
To address the challenges posed by the rapidly advancing pharmaceutical industry and rising drug
costs, Romanow makes three suggestions: There should be a catastrophic drug transfer to help
provinces provide funding for prescriptions in cases where drugs become crucial to a consumer’s
health. Currently many Canadians have no drug coverage, and the majority of those without
coverage are poor.
The establishment of a national drug agency could monitor the
pharmaceutical industry to improve costs, safety, and knowledge about drugs. And the drug
patent legislation should be refined to allow for purchasing of generic versions of drugs
immediately after new drug patents run out.93
One of the thematic grievances about modernized health systems is the loss of home care
services. In Canada, where doctors are paid on a fee-for-service basis, home care is especially
neglected. But research has found the obvious, that home care is very valuable to improving
health for many people.
In particular, home mental health care, post-acute home care, and
91 “Romanow Report Proposes Sweeping Changes to Medicare.” Commission on the Future of Health Care
in Canada, http://finalreport.healthcarecommission.ca.
92 Romanow, Roy J. “Statement on the release of the Final Report of the Commission on the Future of
Health Care in Canada.” Nov. 28, 2002. http://fmalreport.healthcarecommission.ca.
93 Romanow, Roy J. “Statement on the release of the Final Report of the Commission on the Future of
Health Care in Canada.” Nov. 28,2002. http://finalreport.healthcarecommission.ca.
palliative home care demand attention. Romanow suggests the establishment of a national home
care system.94 This will become increasingly important as the population ages.
Romanow makes many smaller recommendations; forty-seven of them in total. In addition to
recommendations, he issues observations, warnings and requests, which make his final report an
approachable, sensible, and sensitive document.
He warns politicians that inter-provincial
bickering over health care is deleterious and he requests cooperation. This request has already
been denied, especially by Quebec. Quebec traditionally prefers to be more autonomous than
other provinces, and is upset by the centrality of Romanow’s recommendations. The province
would very much like the extra funding Romanow proposes, but would like it with no strings
attached so that it can use the funds in its own way. Alberta is also unhappy with Romanow’s
request that all provinces report the precise usage of its federal funds.95 These provinces feel that
they can better attend to its peoples’ health care needs with less patriarchal central monitoring.
Another warning that Romanow issues is that if Canada does not renew the sustainability of
Medicare, then the system will succumb to the privatized sector. He states:
“The grave risk we will face is pressure for access to private, parallel services - one set of
services for the well off, another for those who are not. Canadians do not want this.”96
Romarrow holds strongly to the ideals of the Canadian system; universality, equity, and quality.
His commission’s nationally engaging, comprehensive, transparently presented investigation, and
its clearly written, persuasive final report present to Canadians what is nearly the most accessible
evaluation of the medicare system possible. While there have been many other suggestions for
improving the Canadian health care system, Romanow’s recommendations seem to construct a
track toward sustainability.
Implications
At the end of his statement to the nation, Roy Romanow issues this pointed counsel:
94 Romanow, Roy J. “Statement on the release of the Final Report of the Commission on the Future of
Health Care in Canada.” Nov. 28, 2002. http://fmalreport.healthcarecommission.ca .
95 “Health minister promises help on national reform.” The Burlington Free Press. Wire Reports. Dec. 8,
2002. Pg. 4B.
96 Romanow, Roy J. “Statement on the release of the Final Report of the Commission on the Future of
Health Care in Canada.” Nov. 28, 2002. http://fmalreport.healthcarecommission.ca .
“Many of the so-called “new solutions” being proposed for health care - pay-as-you-go,
user and facility fees, fast-track treatment for the lucky few, and wait-lists for everyone
else - are not new at all. We’ve been there. They are old solutions that didn’t work then,
and were discarded for that reason. And the preponderance of evidence is that they will
not work today.”97
Romanow clearly has his biases. Although his recommendations are supported by evidence, it
would be unfortunate to dismiss other “new solutions.” One new solution that is gradually
garnering support from medical economists, is what Romanow would perhaps refer to as a payas-you-go model. A new Catastrophe Insurance/Medical Savings Account model of health care
coverage could have profound implications for Canada. And even if this model is not eventually
utilized to rebuild Canada’s health care system, exploring it will surely hold lessons.
The
Catastrophe/MSA model has also been looked at in the US as a way to reduce health care costs in
a completely privatized system. For this reason, it will be valuable for other countries, such as
India, which has a highly privatized system, to consider the Catastrophe/MSA model.
The Catastrophe Insurance/Medical Savings Account Model
“We generally rely on insurance to protect us against events that are highly unlikely to occur but
involve large losses if they do occur—major catastrophes, not minor regularly occurring
expenses. We insure our houses against loss from fire, not against the cost of having to cut the
lawn.”98
-Milton Friedman
Health insurance around the world has become an integral part of health care systems. Yet, it has
evolved its own definition of insurance. Health insurance policies that cover everything from
family planning to geriatrics are costly, and may not be the best means to paying for health care.
From the U.S.’s privatized health care system, to Canada’s universal health care system, to
97 Romanow, Roy J. “Statement on the release of the Final Report of the Commission on the Future of
Health Care in Canada.” Nov. 28, 2002. http://finalreport.healthcarecommission.ca.
98 Friedman, Milton. “How to Cure Health Care.” The Public Interest. Winter 2001.
http://www.thepublicinterest.com/archives/2001 winter/article 1 .html.
systems in developing nations, a new model is emerging to challenge the current health insurance
paradigm.
Many health economists are recommending a restoration of health insurance to its original
purpose. It is far more cost-effective for an employer, or country, to purchase a high-deductible
catastrophe medical plan for its dependents, rather than purchasing a comprehensive plan, which
covers a lot of services not used. The money saved from switching to a catastrophe medical plan,
would be deposited into a Medical Savings Account (MSA). An MSA is a tax-exempt account
that can be used to pay for approved medical services of the holder’s choice. The result is,
instead of putting money into a comprehensive insurance plan, where unused money goes to the
insurance company, the account holder pays for his own services and keeps the unused money.
This new catastrophe insurance/MSA model has promising implications backed by empirical
evidence.
The previously mentioned RAND Health Insurance Experiment also tested consumer paying
models. One group received free care, like in the Canadian system. The other group was given
money, and had to pay for their medical services (user fee group). It was found that the free care
group was 28% more likely to use medical services, 67% more likely to see a doctor, and 30%
more likely to be admitted to the hospital, with 20% more days per year of restricted activity than
those who were in the user fee group. It costs 45% more to have a free care system. And there
was no difference found in the overall health of either group"
Similarly, Lohr et al. (1996) found that a cost-sharing scheme, like the catastrophe/MSA model,
reduced the use of both necessary and unnecessary medical services. Yet there was no decrease
in the health of the individuals surveyed. Their hypothesis is that unnecessary medical visits can
be adverse to your health, resulting in necessary visits. When you eliminate both, there is no net
change in health.100
The natural conclusion to draw from these studies is that when consumers must spend their own
money on health care, they spend it more prudently than when they are spending the
government’s or insurance company’s money.
99 Gratzer, David. “Code Blue: Reviving Canada’s Health Care System.” ECW Press. Toronto: 1999.
100 Ramsay, Cynthia. “Medical Savings Accounts: Universal, Accessible, Portable, and Comprehensive
Health Care for Canadians.” The Frasier Institute - Critical Issues Bulletin. May 1998.
The Canadian government could introduce a catastrophe insurance/MSA health care system, in
which it pays for catastrophe insurance for each citizen, and gives each citizen an MSA stipend
based on his or her health, age, and socio-economic class. The catastrophe insurance would
relieve the anxiety-producing risk of major medical expenses. And the MSA’s would reintroduce
a competitive market to the health care system.
A competitive market drives progress through efficiency and incentives. Consumers would
benefit most because the affects of change are amplified most at the end of a cascade. They
would likely spend less on health care because they would be accountable for their own expenses.
These expenses could include currently uninsured services, such as dental, home care, and
medical supplies. This freedom would be beneficial to the sick and the poor who currently have
trouble paying for prescriptions and other uninsured services.101 Fewer visits to the doctor would
allow consumers more time to participate in the work force. At the end of each year they could
withdraw the money in their MSA’s as taxable income, or they could roll it over into their
accounts for the next year. Less spending would mean lower national health costs, leading to
lower taxes for consumers. Less consumption would resolve the queuing problem and raise
consumer satisfaction by giving them faster access to medical services. They would also likely
be more discerning over who provides their medical services.
The catastrophe insurance/MSA model would restore doctor/patient relationships. Patients would
choose their providers carefully and know about their doctors before they went in for
appointments. Lower demand on services would give doctors more time to spend with their
patients. This would give them time to develop relationships with their patients, educate their
patients, and address medical complaints that in the current system would require multiple patient
visits. Increased patient selectivity would bolster competition between physicians to provide
better care to attract more patients. This incentive would raise provider salaries, which in turn
would make medicine a more attractive career field. Medical school admissions would likely
rise, and the resultant doctor to patient ratio would improve, thus potentially leading to better
national health.
Several nations are already using catastrophe insurance/MSA options to optimize their national
health. The private sector in the U.S. is gradually implementing such plans, to high reported
101 Gratzer, David. “Code Blue: Reviving Canada’s Health Care System.” ECW Press. Toronto: 1999.
S 7-
levels of success.
Singapore and China have catastrophe insurance/MSA options.
Shaunn
Matisonn of the National Center for Policy Analysis discusses South Africa’s experience with
such plans:
“For most of the last decade [the nineties]... South Africa enjoyed what was probably the
freest market for health insurance anywhere in the world...In just five years, MSA plans
captured half the [private insurance] market... attractfing] individuals of all different ages
and different degrees of health.”102
Success in other nations, empirical evidence, and advising from medical economists strongly
support the new health care systems model of catastrophe insurance with MSA’s. The dust storm
of politics over the current state of Medicare, makes such a change difficult to see in the near
future for Canada. However, this model could emerge as a solution for other countries.
Conclusion
The Canadian Medicare system has been a grand experiment in health care systems. It has
succeeded for many years, and it has set an example for the rest of the world, both in its successes
and its failings. Current trends allude to its eventual collapse. In order for Canada to regain the
sustainability of its touted health care system, there will need to be fundamental changes to its
structure. Roy Romanow’s very thorough report, Building on Values: The Future of Health Care
in Canada, makes a complete collection of recommendations for refurbishing the health care
system that was once Canada’s jewel. If the recommendations are followed closely with minimal
political interruption, then it seems that they could lead Canada back onto the track for
sustainability in its health care system. The forthcoming, honest, comprehensive methodology
used by the Commission on the Future of Health Care in Canada during its study should provide a
model to other countries for how to properly evaluate and confront national health care issues.
Meanwhile, a growing group of health economists are adhering to the catastrophe insurance/MSA
model. Other nations can learn a great deal from the ideas and methodologies that are emerging
in this period of transition for the Canadian health care system.
102 Friedman, Milton. “How to Cure Health Care.” The Public Interest. Winter 2001.
http://www.thepublicinterest.com/archives/2001 winter/article 1 .html.
Works Cited
Blendon, Robert, et. Al. “Canadian Adults’ Health Care System Views and Experiences,
2001http://www.cmwf.org/programs/intemational/can_sb_552.pdf . The
Commonwealth Fund. New York, NY: 2001.
Blouin, Chantal. “Canadians’ Health Care Concerns Cannot Stop at Our Borders.” The
North-South Institute. http://www.straightgoods.ca/ViewFeature.cfm?REF=724 .
Nov. 10, 02.
Crowley, Brian Lee, et. Al. “Operating in the Dark: The Gathering Crisis in Canada’s
Public Health Care System.” Atlantic Institute for Market Studies.
Danzon, Patricia, M. “Hidden Overhead Costs: Is Canada’s System Really Less
Expensive?” Health Affairs. Spring 1992.
Friedman, Milton. “How to Cure Health Care.” The Public Interest. Winter 2001.
http://www.thepublicinterest.com/archives/2001winter/articlel.html.
Gratzer, David. “Code Blue: Reviving Canada’s Health Care System.” ECW Press.
Toronto: 1999.
“Health minister promises help on national reform.” The Burlington Free Press. Wire
Reports. Dec. 8, 2002. Pg. 4B.
“Huge health care upgrade proposed in Canada.” The Burlington Free Press. Wire
Reports. Nov. 29, 2002. Pg. 13A.
IDB Summary Demographic Data for Canada.
http://devdata.worldbank.org/extemal/dgprofile.asp?RMDK=82656&SMDK=l&
W=0.
Ramsay, Cynthia. “Medical Savings Accounts: Universal, Accessible, Portable, and
Comprehensive Health Care for Canadians.” The Frasier Institute - Critical
Issues Bulletin. May 1998.
“Romanow Report Proposes Sweeping Changes to Medicare.” Commission on the Future
of Health Care in Canada, http://fmalreport.healthcarecommission.ca .
Romanow, Roy J. “Statement on the release of the Final Report of the Commission on
the Future of Health Care in Canada.” Nov. 28, 2002.
http://fmalreport.healthcarecommission.ca .
“The Canada Health Act.” Government of Canada. http://laws.justice.gc.ca/en/C-
6/text.html.
Weber, Joseph. “Canada’s Health Care System Isn’t a Model Anymore.” Business
Week. August 31, 1998.
Costa Rican Health Care
A Maturing Comprehensive System
Greg Connolly 12/8/02
Global Health Council
A history of commitment to health and social reform has yielded
for Costa Rica the best health outcomes of any country in Latin America.
These outcomes are the result of a well-developed publicly funded
comprehensive health care system built on the principals of universal
coverage and equity.
While the fundamentals of this system were
becoming entrenched, several predictable challenges arose. Costa Rica is
confronting those problems with outside aid in a period of reform, which
began in 1994. Now, the World Bank has decided to support Costa Rica
with its Second Health Sector Strengthening and Modernization Project,
which will build off of existing initiatives and trends toward improvement
of the health care system. While Costa Rica occupies a tight niche as a
small country of middle wealth and high social solidarity, the
development of its health care system still holds lessons for some of the
most complex nations of the world.
The Costa Rican Health Care System
Framed by Nicaragua to the north, Panama to the south, and the Pacific
Ocean and Caribbean Sea, the small country of Costa Rica (area 51,100
sq. km)103 stands out from its neighbors with a deep history of
commitment to social reform and a thriving economy. With a population
of only 3,810,179, 59% of which live in urban areas,104 the nation is not
only small, but also it has been able to hold social solidarity. This
solidarity arose from the nation’s agricultural history in which the upper
and lower classes were dependent upon each other.105 In the past
decade the ratio between the income of the upper 20% and the lower
20% held stable.106 The democratic government composed of executive,
legislative, and judicial branches, and a four-year rotating presidency,
has also shown remarkable stability. Sustained economic growth has
built a GDP per capita of USD$8,500 in 2001 with the primary industries
being services, industry, and agriculture.
The development model,
“Based on promoting exports and tourism and modernizing state
103 Pan American Health Organization - Country Profile: Costa Rica.
http://www.paho.org/English/SHA/prflCOR.htm . Pg. 1.
104 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 1.
105 Roemer, Milton. National Health Systems of the World - Volume I. Oxford
University Press. New York, NY: 1991.
106 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 4.
n
CONTENTS
l.The Right to Health Care-Moving from idea to reality - Aftesmiv^v
1
2. Operating Right to Healthcare in India
Ravi Duggal
5
Greg Connolly
29
3. South African Health Care
4. Canadian Health Care the Universal Model Evolving - Greg Connolly
44
5. Costa Rican Health Care
6. Draft Note-Legal Position Paper on Right to Health
■ Greg Connolly
60
NCAS
73
•\
The Right to Health Care - moving from idea to reality
"Should medicine everfulfil its great ends, it must enter into the larger political and social
life ofour time; it must indicate the barriers which obstruct the normal completion of the life
cycle and remove them. Should it ever come to pass, Medicine, whatever it may then be, will
become the common good ofall."
- Rudolf Virchow, c. 1850
Background: Inequity in health and access to health care
India is known to have poor health indicators in the global context, even in comparison with
many other developing countries. However, we also bear the dubious distinction of being
among the more inequitous countries of the world, as far as health status of the poor
compared to the rich is concerned. This underscores the fact that there is a tremendous burden
of unnecessary morbidity and mortality, which is borne almost entirely by the poor. Some
striking facts in this regard are • Infant mortality among the economically lowest 20% of the population is 109, which is
2.5 times the IMR among the top 20% population of the country.
• Under-five mortality among the economic bottom 20% of the population (bottom
quintile) is 155, which is not only unacceptably high but is also 2.8 times the U5MR of
the top 20% (top quintile).
• Child mortality (l-5yrs age) among children from the ’Low standard of living index'
group is 3.9 times that for those from the 'High standard of living index' group according
to recent NFHS data (UPS, 2002). Every year, 2 million children under the age of five
years die in India, of largely preventable causes and mostly among the poor. If the entire
country were to achieve a better level of child health, for example the child mortality
levels of Kerala, then 16 lakh deaths of under-five children would be avoided every year.
This amounts to 4380 avoidable deaths every day, which translates into three avoidable
child deaths every minute.
• Tribals, who account for only 8% of India's population, bear the burden of 60% of
malarial deaths in the country.
Such gross inequalities are of course morally unacceptable and are a serious social and
economic issue. In addition, such a situation may also be considered a gross violation of the
rights of the deprived sections of society. This becomes even more serious when viewed in
the context of grass disparities in access to health care • The richest quintile of the population, despite overall better health status, is six times
more likely to access hospitalisation than the poorest quintile. This actually means that the
poor are unable to afford and access hospitalisation in a large proportion of illness
episodes, even when it is required
• The richest quintile have three times higher level of coverage for measles immunization
compared to the poorest quintile. Similarly, a mother from the richest 20% of the
population is 3.6 times more likely to receive antenatal care from a medically trained
person, compared to a mother from the poorest 20%. The delivery of the richer mother is
over six times more likely to be attended by a medically trained person than the delivery
of the poor mother.
• As high of 82% of outpatient care is accessed from the private sector, met almost entirely
by out-of-pocket expenses, which is again often unaffordable for the poor.
• About three-fourths of spending on health is made by households and only one-fourth by
the government. 1 his often pushes the already vulnerable poor into indebtedness, and in
•
over 40% of hospitalisation episodes, the costs are met by either sale of assets or taking
loans.
&
The per capita public health expenditure in India is abysmally low at Rs. 21 per person,
among the lowest in the world. India has one of the most privatized health systems in the
world (only five countries on the globe are worse off in this respect), effectively denying
the poor access to even basic health care.
1 he gist of these sample facts is that the existing system of‘leave it to the market’ effectively
means ‘leave health carefor the rich and leave the poor to fendfor themselves
One implication that emerges from the above discussion is that the problem of large-scale ill
health in India should not be seen as primarily a technical-medical issue. The key
requirement is not newer medical technologies, more sophisticated vaccines or diagnostic
The ?Ct ‘u31
prosPerous sections of the Population enjoy a reasonably good
health status implies that the technical means to achieve good health do broadly exist in our
country today (though there is definitely a need to better adapt these to our country’s
cond.tions and traditions, and certain improved techniques might help in specific contexts)
n fact, for the vast majority, the key barriers to good health are not the lack of technology
but poverty and health system inequity. Poverty, a manifestation of social inequity leads to
samtat
hnSOf
p0pulat,0n bein8 denied adequate nutrition, clean drinking water and
all nrereo.
g°°d quallty housing and a healthy local environment, which are
which deni
rt h hu
Same tlme’ WC haVe a highly inetluitable health system
which denies quality health care to all those who cannot afford it (the fact that even those
.s ue'i’lith0 11
nOta'WayS g6t rati°nal Care iS an°ther important’ but somewhat separate
issue J. In this paper, which is primarily addressed to those working in the health sector we
will focus on the critical health system issues, with a rights-based approach. Let us see how
we can view this entire situation from a rights based perspective.
The Right to Health Care as a component of the Right to Health
Looking at the issue of health under the equity lens, it becomes obvious that the massive
burden of morbidity and mortality suffered by the deprived majority is not just an unfortunate
accdent. It constitutes the daily denial of a healthy life, to croreslfpeop^bTcauseof^p
‘ “Abased T6’
I and ^yond the health sector. This denial needs to be addressed in
rights based framework, by systematically establishing the right of every citizen of this
eoun^
a heaI,h
More specifca||yi hea|th
technical issue lo be leg to the experts and bureaucrats, an issue of charity to be dealt with be
benevo ent service delivering institutions, or a commodity to be sold by private doctors and
hospitals. Tbs cole of .11 these actors needs to be redefined and recast in’ Ze»“”whe"e
ry person, including the most marginalized, is assured of basic health care and can
demand and access this as a right.
adequate'IXd'o/ShTWhiCh WOuld en“
reZ f““ “o ooS)!
T° PrOm°'e
Rl81"
““b" ^“bes action on tceo
Similarly in the cases Bandhua Mukti Morcha v. Union of India and others, 1982
concerning bonded workers, the Supreme Court gave orders interpreting Article 21 as
mandating the right to medical facilities for the workers.
Basic social services are now being recognised as fundamental rights with the 93
amendment in the constitution accepting Education as a fundamental right. Despite the
controversy and problems regarding the actual provisions of the Bill, it is now being accepted
that essential social services like education can be enshrined in the fundamental rights of the
Constitution. This forms an appropriate context to establish the right to health care as a
constitutionally recognised fundamental right.
The social and economic justification
It is now widely recognised that besides being a basic human right, provision of adequate
health care to a population is one of the essential preconditions for sustained and equitable
economic growth. The proponents of 'economic growth above all' may do well to heed the
words of the Nobel Laureate economist Amartya Sen:
'Among the different forms of intervention that can contribute to the provision of social
security, the role of health care deserves forceful emphasis ... A well developed system of
public health is an essential contribution to the fulfilment of social security objectives.
...we have every reason to pay full attention to the importance of human capabilities also as
instruments for economic and social performance. ... Basic education, good health and other
human attainments are not only directly valuable ... these capabilities can also help in
generating economic success of a more standard kind ... (from India: Economic
Development and Social Opportunity by Jean Dreze and Amartya Sen)
The human rights justification
" ' as a human right and India is a
The right to basic health care is recognised internationally
Economic,
Social
and Cultural Rights which states
signatory to the International Covenant on L
in its Article 12 The States Parties to the present Covenant recognise the right of everyone to the enjoyment
of the highest attainable standard of physical and mental health... The steps to be
taken...shall include those necessary for ...The creation of conditions which would assure
to all medical service and medical attention in the event of sickness.
Reference can be made to other similar international conventions, wherein the Government of
India has committed itself to providing various services and conditions related to the right to
health, e.g. the Alma Ata declaration of ‘Health for all by 2000’. The National Human Rights
Commission has also concerned itself with the issue of ’Public health and human rights with
one of the areas of discussion being 'Access to health care'. The time has come to begin
asking as to how these human rights related commitments and concerns will be translated into
action in a realistic, time-bound and accountable framework.
The core content of the Right to Health Care in the first phase
Moving towards establishing the Right to Health Care is likely to be a process with various
phases. First let us see what could be the core content of this right in the first phase, which
could be achieved in the short to medium term.
Promoting the Right to underlying determinants of health
This involves working for the right 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’ (WHO, 2002).
Agencies engaged in the health sector cannot deal with most of these issues on their own,
though they need to highlight the need for better services and conditions, and can advocate
for improvements in these areas in a rights based framework. Organisations working in the
health sector can support other agencies working directly in these areas, to help bring about
relevant improvements.
Promoting the Right to Health Care
Given the gross inequities in access to health care and inadequate state of health services
today, one important component of promoting the Right to Health would be to ensure access
to appropriate and good quality health care for all. This would involve reorganisation,
reorientation and redistribution of health care resources on a societal scale. The responsibility
of taking forward this issue lies primarily with agencies working in the health sector, though
efforts in this direction would surely be supported by a broad spectrum of society.
In the remaining portion of this paper, we will focus on the process of establishing the Right
to health care as a imminent task, to be taken up by organisations in the health sector in the
broader context of Right to Health outlined above.
The justification for establishing the Right to Health Care
We may view the justification for this right at three levels - constitutional-legal, socialeconomic and as a human right issue.
The constitutional and legaljustification
The right to life is recognised as a fundamental right in the constitution (Article 21) and this
right has been quoted in various judgements as a basis for preventing avoidable disease
producing conditions and to protect health and life. The directive principles of the Indian
constitution include article 47, which specifies the duty of the state in this regard:
47. Duty of the state to raise the level of nutrition and the standard of living and to improve
health:- The state shall regard the raising of the level of nutrition and the standard of living
of its people and the improvement of public health as among its primary duties ...
In an important judgement (Paschim Banga Khet Mazdoor Samity and others v. State of
West Bengal and another, 1996), the Supreme Court of India ruled that -
In a welfare state the primary duty of the Government is to secure the welfare of the people.
Providing adequate medical facilities for the people is an essential part of the obligations
undertaken by the Government in a welfare state. ... Article 21 imposes an obligation on the
State to safeguard the right to life of every person. ... The Government hospitals run by the
State and the medical officers employed therein are duty bound to extend medical assistance for
preserving human life. Failure on the part of a Government hospital to provide timely medical
treatment to a person in need of such treatment results in a violation of his right to life
guaranteed under Article 21. (emphasis added)
Right to a set of basic public health services
In the context of the goal of'Health for AH' and various Health Policy documents, an entire
range of health care services are supposed to be provided to all from village level to tertiary
hospital level. As of today these services are hardly being provided adequately, regularly or
of the required quality. Components of the public health system to be ensured in a rights
based framework include:
1. Adequate physical infrastructure at various levels
2. Adequate skilled humanpower in all health care facilities
3. Availability of the complete range of specific services appropriate to the level
4. Availability of all basic medications (also see below)
The expected infrastructure and services need to be clearly identified and displayed at various
levels and converted into an enforceable right, with appropriate mechanisms to functionalise
this. For example, in a justiciable framework, basic medical services especially at Primary
and Secondary levels cannot be refused to anyone - for example a PHC cannot express
inability to perform a normal delivery or a Rural hospital cannot refuse to perform an
emergency caesarean section. In case the requisite service is not provided by the facility when
required, the patient would be entitled to approach a private hospital and receive care, for
which the hospital would receive time-bound reimbursement of costs incurred, at standard
rates. This would firstly constitute a strong pressure on the public health system to perform
and deliver all services, and secondly, would ensure that the patient receives the requisite care
when required, without incurring personal expenses. This forms the one of the first steps
towards accessing the right to health care.
Similarly the state has an explicit obligation to maintain public health through a set of
preventive and promotive services and measures. These of course include coverage by
immunisation, antenatal care, and prevention, detection and treatment of various
communicable diseases. However, it should also encompass the operation of epidemiological
stations for each defined population unit (say a block), organizing multi-level surveillance
and providing a set of integrated preventive services to all communities and individuals.
Right to emergency medical care and care based on minimum standards from
private medical services
Although the right to health care is not a fundamental right in India today, the right to lite
is. In keeping with this ‘Emergency Medical Care’ in situations where it is lifesaving, is the
right of every citizen. No doctor or hospital, including those in the private sector, can refuse
minimum essential first aid and medical care to a citizen in times of emergency, irrespective
of the person’s ability to pay for it. The Supreme Court judgement quoted above (Paschim
Banga Khet Mazdoor Samity and others v. State of West Bengal and another, 1996), directly
relates to this right and clear norms for emergency care need to be laid down if this right is to
be effectively implemented. As a parallel, we can look at the constitutional amendments
enacted in South Africa, wherein the Right to Emergency Medical care has been made a
fundamental right.
At the same time there is an urgent need for a comprehensive legislation to regulate
qualification of doctors, required infrastructure, investigation and treatment procedures
especially in the private medical sector. Standard guidelines for investigations, therapy and
surgical decision making need to be adopted and followed, combined with legal lestrictions
on^common medical malpractices. Maintaining complete patient records, notification of
specific diseases and observing a ceiling on fees also needs to be observed by the private
medical sector. The Govt, of Maharashtra is in the process of enacting a modified act to
address many of these issues, and the National Health Policy 2002 shpulates the enactment of
suitable regulations for regulation of minimum standards in the private medical sector in the
entire country by the year 2003. This would include statutory guidelines for the conduct ot
clinical practice and delivery of medical services. There is a need to shape such socia
regulation of this large medical sector within the larger, integrated framework of Right to
health care.
Right to essential drugs at affordable cost
Attaining this right would consist of two components:
1. Availability of certain basic medications free of cost through the public health system
2. A National Essential Drug Policy ensuring the production and availability of an entire
range ofessential drugs at affordable prices
The Union as well as state Governments need to publish comprehensive lists of essential
drugs for their areas. A ceiling on the prices of these drugs must be decided and scrupulously
adhered to, with production quotas and a strict ban on irrational combinations and
unnecessary additives to these drugs.
Right to patient information and redressal
The entire range of treatment and diagnosis related information should be made available
to every patient in either private or public medical facility. Every patient has a right to
information regarding staff qualifications, fees and facilities for any medical centre even
before they decide to take treatment from the centre. Information about the likely risks and
side effects of all major procedures can be made available in a standard format to patients.
Information regarding various public health services which people have a right to demand at
all levels should be displayed and disseminated. This should include information about
complaint mechanisms and for redressal of illegal charging by public health personnel.
Superseding the CPA, a much more patient-friendly grievance redressal mechanism needs
to be made functional, with technical guidance and legal support being made available to all
those who approach this system. This would provide an effective check on various forms of
malpractice. In case the services mandated under this right are not given by a particular
facility, the complainant need not take recourse to lengthy legal procedures. Rather, the
grievance redressal mechanism with participation of consumer and community
representatives should be empowered to take prompt, effective and exemplary action.
Right to monitoring and accountability mechanisms
Keeping in mind the devolution of powers to the Panchayati Raj system, we need to
propose an effective system of people's monitoring of public health services which would be
organised at the village, block and district levels. Community monitoring of health services
would significantly increase the accountability of these services and will lead to greater
people's involvement in the process of implementing them. The Union Ministry of Health and
Family Welfare, with support from WHO, has been successfully implementing an innovative
pilot project for 'Empowering the rural poor for better health' in six talukas of the country.
Taking this and various other experiments into account, a basic framework for such
monitoring needs to be developed.
The broader objective - a system for universal health care and
basic health care as a fundamental constitutional right
While trying to achieve these specific rights in the first phase, our overall goal should
be to move towards a system where every citizen has assured access to basic health care,
irrespective of capacity to pay. A number of countries in the world have made provisions in
this direction, ranging from the Canadian system of Universal health care and NHS in Britain
to the Cuban system of health care for every citizen. In the Indian context, the right to health
care needs to be enshrined in the Constitution as a fundamental right. One conception of the
minimum content of the fundamental right to health care is outlined in the accompanying
box.
Proposed minimum content of the fundamental right to health care
i 1. Making the right to health care a legally enforceable entitlement by legal enactment
2. A national health policy with a detailed plan and timetable for realization of the core right
to health care
3. Developing essential public health infrastructure required for health care; investing
sufficient resources in health and allocating these funds in a cost-effective andfair manner
4. Providing basic health services to all communities and persons; focusing on equity so as to
improve the health status ofpoor and neglected communities and regions
5. Adopting a comprehensive strategy based on a gender perspective so as to overcome
inequalities in women’s access to health facilities
6. Adopting measures to identify, monitor, control and prevent the transmission of major
epidemic and endemic diseases
7. Making reproductive health and family planning information and services available to all
persons and couples without anyform ofcoercion
8. Implementing an essential drug policy
(Adaptedfrom Audrey R. Chapman, The Minimum Core Content of the Right to Health)
One realistic scenario to make this right functional could be a system of universal
social health insurance. The services could be given by a combination of a strengthened and
community-monitored public health system along with publicly regulated and financed
private providers, under a single umbrella. The entire system would be based on public
subsidisation and cross-subsidy, with free services to the majority population of rural and
urban working people including vulnerable sections, and affordable premium amounts (which
could be integrated with the taxation system) for higher income groups. One key aspect
would be that this should be a Universal system (not targeted), which would ensure coverage
of the entire population and also retain a strong internal demand for good quality services.
(Of course, certain very affluent sections may choose to pay their share of taxation / premium
and yet opt out and access private providers.) Another issue is that there would be no fees or
nominal fees at the time of actual giving ofservices. Finally, the patient would be assured of a
range of services with minimum standards, whether given from the public health system or
publicly financed and regulated private providers. The entire system could be managed in a
decentralised manner, with consumer’s monitoring of quality and accessibility of services.
This entire model would of course imply a significantly higher public expenditure on
health services. However, with decentralised management and a focus on rational therapy, it
has been estimated that it should be possible to organise the basic elements of such a system
by devoting about 3% of the GNP towards public health care to start with. This should then
be progressively raised to the level of 5% of GNP to give a full range of services to all. This
level of funds could be partly raised by appropriate taxation of unhealthy industries,
reallocations within the health sector (including reorganising existing schemes like ESI) and
ending all subsidisation of the private medical sector. This of course needs to be combined
with changed budgetary priorities and higher overall allocation for the health sector.
Incidentally, the new National Health Policy claims on paper the intention to more than
double the financial allocation for the public health system and bring it io the level of 2% of
the GDP, and to increase utilisation of public health facilities to above 75% by the end of this
decade. This admirable yet vague intention needs to be converted into concrete action by
means of strong and sustained pressure from various sections of civil society, coupled with
concrete proposals to functionalise universal access to health care.
In this context, ensuring Health care for all is not an unrealistic scenario, but both a
practical possibility and an imperative for a nation, which as the 'world’s largest democracy'
claims to accord certain basic rights to its citizens, including the right to life in its broadest
sense.
Ways ahead - creating a consensus on the right to health care
Some of the possible areas of activity of a potential broad coalition which could support a
campaign on the issue of Right to Health Care are suggested below.
Involving diverse social sectors in a dialogue on the Right to Health Care
While some health activists and groups have mooted the concept of the Right to Health Care,
it is an idea which is yet to be widely discussed and accepted in our country. One of the key
tasks in the immediate future is to generate discussion at the broadest possible level about this
right. Groups to be involved in such a debate include health policy makers, medical and
public health academics, private medical professionals, various segments of the NGO sector
including both health related and non-health NGOs, trade unions of health care personnel and
people's organisations. It is obvious that the viewpoints of various social groups and actors
may be greatly divergent on this issue. However, the very process of discussing and debating
the issue gives it a primary legitimacy, which then needs to be built upon. This becomes a
basis for generating a continuously widening consensus about the basic justification, content
and implementation model for the Right to Health Care.
Collating international experience on the Right to Health Care
There is valuable international experience available about mandating the Right to Health or
Health Care. These experiences need to be collated, and analysed with the Indian context in
mind. Especially legislation and provisions made in developing countries are of value in this
respect.
Twelve different countries of Latin America, which have Civil law provisions, include the
right to health or State duties to protect health in their constitutions. While Chile was the first
such country to make such a provision, Argentina, Brazil, and Mexico are also included
among these. Cuba with a socialist constitution accords the right to health to its citizens,
according it a status equivalent to civil and political rights.
South Africa, after the overthrow of apartheid, in Article 27 of its constitution has specified
certain provisions relevant to this right. This includes mandating the right to access to health
care services, specifying that the state must take reasonable legislative measures to achieve
realisation of this right, and declaring that no one may be refused emergency medical
treatment. From another end, we have a new system of Universal health care access in
Thailand whose features need to be studied and discussed as relevant to the Indian context.
Similarly, there has been an entire process of developing the concept of right to health and
health care in the international human rights discourse. Various United Nations health rights
instruments refer to health related rights. The UN International Covenant on Economic,
Social and Cultural Rights (ICESCR), UN Convention on Rights of the Child (CRC) and the
UN Convention on the Elimination of All Forms of Discrimination Against Women
(CEDAW) are some such significant conventions, in which India is a signatory.
Given this background, one of the critical tasks ahead of us is to make an in-depth study of
these experiences and utilise this for developing the judicial form and .mplementation-relate
content of the Right to Health Care in the Indian situation.
Oraanizina state and national conventions on the Right to Health Care
On? way of developing such a consensus is to organise a series of conventions on he issue
of Righ^t to Health Care, first at state level and ultimately at the national level. Each
convention could bring together representatives of key stakeholders outlined above and
could result in a clearer conceptualisation of the core content and processes related to making
this right functional. The national convention could also culminate in a dialogue with the
Health Minister, promoting the idea of recognising and implementing this rig t.
Discussing detailed proposals to implement the Right to Health Care
One of the crucial issues in furthering this campaign is the development of a model for
implementing this Right. This needs to be done keeping in mindthe' sPe^Cltl®S °f th
Indian health care system, judicial framework (including the fact that Health is a state
subject), socio-economic situation including major class, caste and gender disparities and
recent processes such as the 93rd Constitutional amendment. Considerable groundwork and
consultation is required to develop a model, which would take into account the positions
various stakeholders and form the basis for practical implementation of this right.
Forming a multi-sector independent body to monitor implementation of the
Mwmere is^th^need for a multi-sectoral body with representation from various social
sectors to monitor the processes of establishment and implementation of the Right to Health
Care. Such a body would have the social legitimacy, diverse experience and capacity to
continuously assess the movement towards realisation of this right, and help usher in a new
phase in the development of the health system and establishment of social-economic rights in
this country.
(This note has been prepared by Dr. Abhay Shukla ofCEHAT, with inputs of various health
experts including Dr. Ravi Narayan, of Community Health Cell. Several actions of this
article are adapted from Abhay’s article 'Right to health care'published in Health Action,
May 2001)
6)
institutions in the 1990’s,”107 has landed Costa Rica in 41st position in a
1999 development survey of 162 of the world’s wealthiest countries.108
A primary contributor to Costa Rica’s success has been its focus on the
well being of its people. For Costa Rica, health and education are
priorities for the success of their nation. The World Bank highlights this
priority:
“The Government of Costa Rica sees the health sector as an
essential determinant of the country’s economic and social
development, giving it a priority that is manifested in sustained
high levels of spending and active policy attention at the highest
levels.”109
The attention to health has brought this middle-wealth country’s health
indicators in line with those of OECD countries.110 In 2001 the average
life expectancy at birth in Costa Rica was 76.6 years.111 In 2000, 97% of
births were attended by skilled professionals, 89% of the pregnant
women were given prenatal care, and 93% of children under 1 had health
insurance.112 From 1990 to 2000 life expectancy increased by 0.8 years,
the fertility rate dropped, and the population grew due to an influx of
Nicaraguan immigrants.113 In 2000 there were 16 physicians and 3.2
nurses per 10,000 population.114 In 1999 there were 12,000 people
living with HIV/AIDS, giving an adult prevalence rate of 0.54%.115
However, Costa is the only Central American country to provide
antiretroviral treatment to all patients through its social security
system.116 The leading causes of death were cardiovascular disease and
neoplasms, which is comparable to many OECD countries.117 Spending
on health care has increased steadily over recent years, and in 2000 it
composed 9% of the national GDP.118
107 Pan American Health Organization - Country Profile: Costa Rica.
http://www.paho.org/English/SHA/prflCOR.htm. Pg. 3.
108 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 1.
109 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/ . Pg. 5.
110 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/ . Pg. 1.
111 Pan American Health Organization - Country Profile: Costa Rica.
http://www.paho.org/English/SHA/prflCOR.htm. Pg. 1.
112 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 2.
113 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 2.
1.4 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 7.
1.5 UNAIDS. “National Response Brief - Costa Rica.” http://www.unaids.org/nationalresponse/result.asp
116 UNAIDS. “National Response Brief- Costa Rica.” http://www.unaids.org/nationalresponse/result.asp
117 Pan American Health Organization - Country Profile: Costa Rica.
http://www.paho.org/English/SHA/prflCOR.htm. Pg. 4.
118 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/ . Pg. 2.
6^
These outcomes are the result of one of the world’s most successful
“universal” health care systems.
“Universality” in the Costa Rican
system means that 100% of the population is given equal comprehensive
public health insurance with equal access to services. The success of the
system is built upon a history of stalwart determination by the national
government to ensure high quality health care for its entire people. In
1941 social security legislation was passed in Costa Rica, establishing
the Costa Rican Bureau of Social Security (CCSS). This legislation set
the provisions for medical insurance that through the gradual expansion
of the CCSS would eventually become a universal health insurance
system.
Costa Rica wrote a new constitution in 1949. The most
significant component of the Constitution was the abolishment of a
national army. This opened funding and allowed more attention to go
toward social programs, such as education and health. Gradual health
sector improvement ensued until 1973, when the health sector was given
a dramatic boost. The General Health Law of 1973 placed all health
treatment services, including all health care areas and hospitals, under
the control of the national social security program. In the next decade
public health care coverage extended to reach 78% of the population in
1982.
By this point, all those employed, regardless of their
socioeconomic status, received health care.119 The Ministry of Health
(MOH), which was established in 1907120, at this time was responsible
for public health programs such as prevention and promotion, and
provided primary care for the uninsured. The MOH and the CCSS,
working together to provide national health care, continued to refine
their roles. In the early 1990’s the MOH turned over primary health care
provision responsibilities to the CCSS.121 The MOH has since been in
charge of all public health programs, and the CCSS has been in charge of
all health provision programs.
The public sector is the predominant health care sector in Costa Rica. It
is composed of the following branches:
“The Costa Rican Social Security Fund (CCSS), which provides
health insurance, including comprehensive health care and
financial and social benefits; the National Insurance Institute (INS),
which covers occupational and automobile accidents; the Costa
119 Roemer, Milton. National Health Systems of the World - Volume I. Oxford
University Press. New York, NY: 1991.
120
IHCAI
Foundation.
“Costa
Rican
Health
Care
System
Profile.”
http: / / www.ihcai.org/Heal th%20System%20of%20Costa%20Rica_Learn%20Spanish%2
Pin%20 tropics%20. htm.
121 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World Bank. 2001.
http://www-wds.worldbank.org/. Pg. 1.
Rican Institute of Water Supply and Sewerage Systems (AyA),
which regulates the supply of water for human consumption and
wastewater disposal; and the Ministry of Health (MOH), which
monitors the performance of essential public health functions and
exercises the steering role in the sector.” 122
The CCSS provides universal health care insurance to employed Costa
Ricans. Workers contribute 15% of their salaries to health insurance,
broken down in this manor: 9.25% from the employers, 0.25% from the
total national wages, and 5.5% from actual worker wages.123 Universal
coverage means that even those who are unemployed are able to obtain
public funding for all health services, including prescription drugs. By
law, the CCSS must cover 100% of the population, and it achieves this
with the following strategy:
“The CCSS is aware that only 80% of the population is insured
either through the compulsory or voluntary system, or as
pensioners or their dependents. Of the remaining 20%, 10% are
insured through state subsidies, given that this population group
is under the poverty line. The other 10% can request public
services when necessary and pay for them directly.”124
Not only is the insurance coverage universal, but also the access to ■
comprehensive health care is nearly equal throughout the countiy:
“A 1998 study showed that...access was practically the same in
rural and urban areas (average distances to the nearest facility of
1.28 km and 1.10 km, respectively).”125
A large reason why the quality of coverage and access to care are so
strong is that the CCSS employs a large number of mid-level health
workers:
“[There is] a relatively modest supply of doctors, which apparently
serves the country’s needs quite well because of extensive use of
auxiliary nurses and health assistants; these personnel work in
the rural health posts, health centers, and hospitals.”126
122
Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 5.
“Profile of the Health Services System of Costa Rica.” PAHO. May27, 2002. Pg. 2.
124 (l|Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 6.
125 Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 24.
123
126
Roemer, Milton. National Health Systems of the World - Volume I. Oxford
University Press. New York, NY: 1991.
Mid-level health workers with little training are very effective at extending
access to rural areas. The relatively small amount of training necessary
makes it easier for people from villages to become medically certified and
contribute to the health care provision in their villages. The usage of
mid-level health workers also reduces the overall cost of the health care
system because the government doesn’t have to pay for expensive
medical educations, and it doesn’t have to pay high doctors’ salaries.
South Africa is looking to use more mid-level health workers for just this
reason.
The CCSS has a very innovative way of organizing its health care
professionals. It provides five comprehensive care programs for children
adolescents, women, adults, and the elderly.127 It operates through 93
health areas and 783 Basic Comprehensive Health Care Teams
(EBAIS).128 Each EBAIS is composed of a physician, a nurse, and one or
more primary care technical assistants (ATAP’s). Currently each EBAIS
serves an average of 3,500 people.129 Teamwork is an overarching theme
in the health care system. The branches of the centralized public health
sector must work together, the states must cooperate with national
mandates, and the health care providers work in teams. Working in
teams allows each EBAIS to develop comraderie and refine its skills as a
unit to provide better health care than if the members were working in
inconsistent groups. These teams serve set groups of people. In the
Costa Rican system, a person is assigned to providers and a medical
center based on place of residence.130 Lack of choice may be perceived
as a problem, but consistency gives each patient the best care he can
receive in a centralized publicly funded system.
Consistency also
nurtures Costa Rica’s highly developed information collection system.
There is a very extensive amount of information available in the public
health sector. However, the private sector lacks an efficient information
collection system. This is a significant problem because of the increasing
importance of the private sector in health care.131
Thirty percent of the population used the private sector in 2001, and
24% of doctors worked at least partly in the private sector.132 The CCSS
does not cover the costs of private sector usage. Mixed Medicine, in
which a patient will pay for a private consultation with the physician of
his choice, and the CCSS will pay for the diagnostic services and drugs,
127 Pan American Health Organization - Country Profile: Costa Rica.
http://www.paho.org/English/SHA/prflCOR.htm . Pg. 12.
128 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 15.
129 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg.6.
130 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg.26.
131 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/. Pg. 3.
132 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 6.
is playing an increasing role.133 Another new trend is the usage of
Corporate Medical Officers. In this type of program a company will hire a
private physician to care for its workers and their families, and the CCSS
pays for diagnostic and drug services.134 A more direct form of PublicPrivate Partnership (PPP) arose in 1998 when the CCSS began
purchasing services from private providers called health cooperatives.
“In 2001, four cooperatives and a foundation at the University of Costa
Rica were already contracted, serving a total population of 400,000.”135
11% of the population now gets coverage from PPP’s.136 Incorporating
the private sector has alleviated some of the strain on the public system.
The private sector does not threaten the public sector because people are
happy with the public insurance they already pay for, the quality of
public health care is very high, and publicly employed providers are well
compensated.137 A major problem that is arising with the incorporation
of the private sector is the difficulty of regulating it. It has been
suggested that:
“There are opportunities for the CCSS to use its purchasing power
to require minimum performance as it contracts more with private
providers.”138
Strengthening the CCSS’s central power will make it more effective. In a
country where interests are do not deviate far from general consensus,
centralizing power is the most effective way to guide social programs to
achieve equity and public satisfaction and monitor outcomes. The CCSS
has wielded its power throughout its existence to effect change. The
CCSS uses its central purchasing power to maximize cost-effectiveness of
drug purchases by making mass orders to international pharmaceutical
companies for all the nation’s pharmaceutical needs. Another example of
how the CCSS has been able to affect a positive change is the recent
implementation of management contracts.
In 2001, all health areas signed management contracts, which set
outcome-based goals for performance to be evaluated at the end of each
year.139
This is a significant step toward giving health sector
133 „“Profile of the Health Services
System of Costa Rica.” PAHO.May 27,2002. Pg. 20.
Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 21.
135 u|Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 6.
136 ...
Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 2.
134
137
Bossert, Thomas, PhD. “Phone Interview - December 5, 2002.” Harvard School of
Public Health.
138 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/. Pg. 4.
i3’ “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/. Pg. 2.
<
1
administration more of a business-like approach. Hospital and clinic
directors are now getting managerial education.140 This will hopefully
increase efficiency in medical facilities. Management contracts are the
primary new tool to guide the reallocation of public funds on a
performance-based system, where case mix, adjusted production, and
quality outcomes will determine hospital revenues.141
This gives
incentives to hospitals and providers to be more efficient and have better
patient outcomes. The result is that finally, half of the accountability for
health sector performance is now taken off of the CCSS and put onto the
hospitals and clinics.142 The evaluation of management contracts will be
aided by a Diagnostic Related Groups (DRG) system, which is set up in
Costa Rica but has not yet been used.143 The DRG system is a way of
monitoring the services rendered by each hospital or clinic monthly. It is
a helpful guide, but it only gives quantitative measures. Therefore
qualitative evaluation will have to be made separately when evaluating
each hospital’s annual performance. There will need to be a large
amount of new support for the CCSS to successfully monitor this
program and link pay to performance.144
In parallel, the MOH has recently developed a regulation program for the
accreditation of hospitals based on quality assurance. The program is
currently a pilot project, which requires all maternity hospitals to adhere
to standards set by the MOH in order to earn accreditation.145 However,
“The ministry’s ability to enforce sector regulation is weak,”146 and will
need support to make this program effective on a national scale.
The Ministry of Health has recently maintained a low profile. With the
transfer of many of its programs to the COSS in the 1990’s, the MOH lost
power. However, throughout the history of the Costa Rican health care
system, the Ministry of Health’s public health programs have been
crucial to the success of the system. Milton Roemer praises the MOH’s
prevention programs:
140 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 21.
141 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.Org/.Pg.5.
142 Bossert, Thomas, PhD. “Phone Interview - December 5, 2002.” Harvard School of
Public Health.
143 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/ . Pg. 5.
144 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/ . Pg. 2.
145 Pan American Health Organization - Country Profile: Costa Rica.
http://www.paho.org/English/SHA/prflCOR.htm . Pg. 13
146 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/ . Pg. 3.
“The benefits of prevention were dramatically demonstrated. Their
strength and effectiveness probably contributed to the harmonious
relationships that the MOH developed later with the social security
program.”147
Indeed, the MOH’s prevention and promotion programs have contributed
greatly’ to Costa Rica’s overall health outcomes.
The following two
departments give examples of what the MOH contributes.
“Sanitary controls for and registration of drugs, food, and
hazardous toxic substances are the responsibility of the
Department of Drugs and Narcotics Controls and Registries of the
MOH. Health regulation and surveillance, which includes the
monitoring of air and soil quality, housing, chemical safety, and
hazardous waste are the responsibility of the Environmental
Sanitation Division of the MOH.”148
There are several other programs that contribute to Costa Rica’s health
sector success. By 1995 the National Institute of Aqueducts and Sewers
(AyA), had provided potable drinking water to 99.6% of the population,
and had given 95.7% of the population a sewerage system. Electricity
was available to 93% of the population at that time.149 The Costa Rican
Demographic Association does extensive work in sex education and
family planning.150 Roemer states, “Health-related research, to produce
new knowledge in fields of special importance, is exceptionally welldeveloped in Costa Rica.”151
The specialization of duties created by dividing the MOH and the CCSS
and their collaboration has lead to a very successful health care system.
Milton Roemer says, “According to conventional measurements of health
status, the results [of the Costa Rican health care system] have been
phenomenal.”152 However, nothing makes a more decisive statement
about the success of a health care system than the satisfaction levels of
147 Roemer, Milton. National Health Systems of the World - Volume I. Oxford
University Press. New York, NY: 1991.
148 Pan American Health Organization - Country Profile: Costa Rica.
http://www.paho.org/English/SHA/prflCOR.htm. Pg. 13.
149 Pan American Health Organization - Country Profile: Costa Rica.
http://www.paho.org/English/SHA/prflCOR.htm. Pg. 3.
'’G Roemer, Milton. National Health Systems of the World - Volume I. Oxford
University Press. New York, NY: 1991.
151 Roemer, Milton. National Health Systems of the World - Volume I. Oxford
University Press. New York, NY: 1991.
152 Roemer, Milton. National Health Systems of the World - Volume I. Oxford
University Press. New York, NY: 1991. Pg. 420
6S
its users. A 2000 SUGESS survey found that 88% of health system
users reported receiving proper medical treatment and 81% said the
physicians educated them properly.153 And a national survey in 2000
showed that over 70% of health system users were satisfied with their
care.154
Reform
The Costa Rican health care system has matured through several waves
of challenge and reform. Despite its impressive health outcomes, Costa
Rica is now in a period of reform intended to refine its successful
programs, and improve efficiency by building off of trends that have been
developing for years. A period of reform starting in 1994 was successful,
and now the World Bank will provide an extra surge to finish
implementing positive reforms.
The reform period from 1994-2001 was funded by the Inter-American
Development Bank (USD$4.3 million), and the World Bank (USD$22
million). Technical support was also given by the Pan-American Health
Organization/World Health Organization.155 This
’ reform
"
’had- a four -part
- agenda:
“A steering role for the Ministry of Health and its strengthening;
institutional strengthening of the CCSS; a new system for the
reallocation of financial resources; and adaptation of the health
care model.”156
The new World Bank reform project is entitled, “Costa Rica - Second
Health Sector Strengthening and Modernization Project.” This project
will allocate nearly USD$33 million to: “Improve health system
performance and financial sustainability by supporting the ongoing
policy changes in the health sector in Costa Rica.
Rica. ”157 The Costa Rican
government’s reform priorities are to: “Develop high levels of regulatory
capacity and to implement the most important regulations during the
next five years.”158
153 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg.27.
154 “Profile of the Health Services System of Costa Rica.” PAHO. May 21,2002. Pg. 17.
155 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 2.
156 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 2.
is? “Costa Rica - Second Health Sector Strengthening and Modernization Project. ” World
Bank. 2001. http://www-wds.worldbank.org/. Pg. 6.
iss “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/. Pg. 6.
67
Many of the problems with the health care system can be better
addressed by first strengthening the centralized power of the MOH and
the CCSS. PAHO states:
“Steering role functions [in the MOH] need to be further
strengthened, and it is necessary to improve the performance of
certain essential public health functions, the management of
services [by the CCSS], the quality of care, and equity in the
allocation of resources.”159
Once the MOH and the CCSS have been strengthened, then the CCSS
will be better enabled to fulfill its responsibility of facilitating the reform
projects. A major objective is to improve the financial state of the health
care system by enacting efficiencies and reallocating funds.
We have already reviewed the reform mechanisms for reallocating funds;
namely, using management contracts to create performance-based
allocation of funds. Another movement to save money is to reduce the
amount of inpatient care by transferring more patients to ambulatory
care. Inpatient care is far more expensive than ambulatoiy care. But
ambulatory care requires higher quality health service initially, and
better mechanisms for providing home care. The World Bank makes this
statement about increasing ambulatoiy care:
“In 1999, fewer than 5 percent of all hospital discharges were
resolved in an ambulatory setting. With minor investments in
training, equipment and infrastructure (remodeling), the CCSS
could increase ambulatory interventions to nearly 20 percent of all
discharges. Benefits would include cost savings of more than
USD$12 million per year, improved quality, and greater patient
satisfaction.”160
Another area where financial improvements can be made is in
purchasing pharmaceuticals. “Pharmaceuticals represent 12% of CCSS
health expenditure (nearly 1% of the GDP).”161 There needs to be
improved monitoring of drug usage through improved communication
between health centers and the central purchasing power of the CCSS,
so that the correct amounts and types of drugs are purchased.
159 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 2.
160 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/. Pg. 4.
161 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/. Pg. 4.
The need for better communication calls for an improvement in health
care information systems. For reasons referred to above:
“Implementation of an integrated [information] management
system for health care providers, hospitals and health areas is a
continuing obstacle to improved efficiency.”162
Better access to information will be needed to monitor health outcomes,
which is especially important to the new performance-based funding
allocation system. The natural counterpart to improving communication
is improving technology. In the past ten years technology has made
astronomical advances. However:
“The CCSS has not built a new hospital in the past 30 years, and
during the 1990’s investment [in hospital infrastructure] was
reduced to less than 3 percent of total expenditure.”163
More money will clearly have to be invested into hospitals and technology
if Costa Rica is to achieve the high potential for health care that its
excellent system has set it up for. While Costa Rica has impressive
outcomes for its region and its economy, it still lags behind the best
systems in the world in terms of performance. But it may work its way
up in the pattern of gradual improvement that it has traditionally
followed.
A major problem with health care access is that there are long waiting
lines for specialty care such as orthopedics, surgery, and gynecology.
PAHO reports:
“[At the start of 2001 the waiting list for surgical hospitalization
numbered nearly 14,000 patients]164...75% of hospitals have one or
more specialties with...waiting lists longer than three months.”165
Another area where access can be improved is in rural areas. Although
Costa Rica does an excellent job of extending services to all, there is still
room for improvement toward equity.166 As the demographics change,
approaches toward equity will have to follow suit. There is an increasing
elderly population, which will benefit from establishing better home care
162 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/. Pg. 4.
163 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.Org/.Pg.4.
164 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 6.
165 “Profile of the Health Services System of Costa Rica.” PAHO. May 27, 2002. Pg. 26.
166 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/. Pg. 4.
and hospice care mechanisms.167 Likewise, the leading causes of death
have changed in Costa Rica, and the MOH needs to adjust its prevention
and promotion programs to address non-communicable diseases and
healthy lifestyles.168
Medical education also needs to adjust to the changes of the times. In
particular the medical education curriculum needs to better address the
most advanced technologies, pharmaceutical advances, and the new
primary health care model. At the same time, continuing medical
education needs to be enforced and the same topics need to be taught to
keep the current physicians up to date.169
These reforms are being made to Costa Rica’s strong comprehensive
health care system to help it achieve its potential for reaching and
sustaining goals of universality, quality, and affordability.
Implications
One of the World Bank’s statements of purpose for funding the second
health sector reform in Costa Rica is:
“Provision of assistance to expand knowledge of international
experiences in similar topics, emphasizing and facilitating the
dissemination of the Costa Rican experience to other countries.”170
Costa Rica’s health care system will serve as an example to other
countries. There are very few countries that match Costa Rica’s profile of
small size, small population, social and political solidarity, and gradually
growing middle-wealth economy. But it was not these factors that led to
Costa Rica’s excellent health care system. It was how Costa Rica used
these factors that has aligned it for success. When one looks at Costa
Rica in the Latin American context, the nation’s achievements become
very impressive. The factors listed above did not come with the land, but
were arrived at through social development. It becomes apparent that
steadfast commitment to social reform with priorities on education and
health may lead a nation to social success.
167 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.Org/.Pg.4 .
168 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/. Pg. 5.
169 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/ . Pg. 4.
170 “Costa Rica - Second Health Sector Strengthening and Modernization Project.” World
Bank. 2001. http://www-wds.worldbank.org/. Pg. 7.
Costa Rica can be looked at as a pilot project for Latin America. This is
analogous to looking at the health care system in one state of India as
compared to the entire nation. When segmented down to a manageable
region, a centralized health care system works best if one agrees with the
Costa Rican model. Centralization allows for decisive management, and
power to effect the changes necessary to building a successful health
care system. However, when dealing with a larger region, the South
African and Canadian systems point to centralization within states, and
a decentralized national approach under the control of a central
authority.
There are several components of the Costa Rican health care system,
which should be of special notice to India. Primarily, management
contracts are an excellent way to share accountability, promote the
monitoring of information and health outcomes, promote improved
quality of care through incentives, and reduce costs by leading to more
efficiency. Mid-level health workers are very valuable for extending care
to underserved regions and for reducing overall medical costs. Costa
Rica’s use of Public-Private Partnerships may carry some lessons about
how to better incorporate India’s 80% private sector into a national
health care system. And Costa Rica’s ability to harness and utilize
external aid could be a good example to India, which will rely heavily on
external funding to alleviate its problems with HIV/AIDS, and to build its
national health care system.
Draft Note
LEGAL POSITION PAPER ON RIGHT TO HEALTH
It is a well-accepted fact that majority of the people in the world today are living at
appallingly low levels of nutrition and health. Health and nutrition are becoming issues
that non-governmental agencies are increasingly being asked to tackle during the course
of their work. Governmental agencies are spending lesser amounts on public health care,
leading to a situation where the populations are accessing private health care services,
which can be unaffordable.
A person’s health is related to several other aspects of her/ his life, and good health
becomes a pre condition to the enjoyment of other rights as well as the individual
participation in social, political, economic life. A World Health Organization Report on
Health and Economics from 1989, states that, globally government spending on health
averaged less than 10 dollars per person per year. Most developing countries have large
populations that live in endemic poverty. Health care systems in these countries do not
serve these populations. Infrastructure investment in health is not a priority spending area
for governments.
There are many factors that influence health and are integral to it. These include access to
nutritious food, clean environments- air and water, source of livelihood that is constant,
etc.
In this context it becomes imperative to closely examine what the burden of the State in
providing health is care and will making right of health care a fundamental right act as a
pressure on the State to provide quality health care services.
The concept of the State being responsible to provide health care facilities, has its origins
in the Charter of the United Nations and has been held in several individual constitutions.
United Nations Charter hold that “.. .the United Nations shall promote
a. higher standards of living, full employment, and conditions of economic and social
progress and development; and
b. solutions of international economic, social, health, and related problems; and
international cultural and educational cooperation; ...”
Article 25 further outlines the protection of health and also details the protection of health
of vulnerable populations, such as women and children should be specially protected.
Article 25.
(1) Everyone has the right to a standard of living adequate for the health and well-being
of himself and of his family, including food, clothing, housing and medical care and
necessary social services, and the right to security in the event of unemployment,
sickness, disability, widowhood, old age or other lack of livelihood in circumstances
beyond his control.
1 Universal Declaration of Human Rights Articles 23 (1)
(2) Motherhood and childhood are entitled to special care and assistance. All children,
whether born in or out of wedlock, shall enjoy the same social protection”"
The World Health Organisation, in its Constitution, states clearly, “The enjoyment of the
highest attainable standard of health is one of the fundamental rights of every human
being without distinction of race, religion, political belief, economic or social
condition.”3
However it is only in the International Covenant on Economic, Social and Cultural Rights
that one explicitly sees that health is recognized as a fundamental right of every human
being.
International Covenant on Economic, Social and Cultural Rights:4
Article 7 (b)
“ Safe and healthy working conditions;”
Article 10 (2)
“ Special protection should be accorded to mothers during a reasonable period before and
after childbirth. During such period working mothers should be accorded paid leave or
leave with adequate social security benefits.”
Article 11 (1)
“...recognize the right of everyone to an adequate standard of living for himself and his
family, including adequate food, clothing and housing, and to the continuous
improvement of living conditions...”
Article 12
“1. ...recognize the right of everyone to the enjoyment of the highest attainable standard
of physical and mental health.
2. The steps to be taken by the States Parties to the present Covenant to achieve the full
realization of this right shall include those necessary for:
(a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the
healthy development of the child;
(b) The improvement of all aspects of environmental and industrial hygiene;
(c) The prevention, treatment and control of epidemic, endemic, occupational and other
diseases;
(d) The creation of conditions which would assure to all medical service and medical
attention in the event of sickness.”
This is the most comprehensive and direct statement on the right to health at the
international level. Article 12 (2) outlines the specific goals that must be attained with
regard to the enforcement of this right.
2 ibid. Article 25
3 Constitution of the World Health Organization, opened for signature July 22, 1946
4 International Covenant on Economic, Social and Cultural Rights
Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI)
of 16 December 1966; entry into force3 January 1976, in accordance with article 27
Several countries, in their constitutions, have held the right to health in varying degrees.
Perhaps the most comprehensive of these is the South African Constitution that takes into
account several rights that are necessary for healthy living apart from access to health
care services. It also clearly states the right to access reproductive health care.
Chapter 2, The Bill of Rights in the South African Constitution states as follows-
“Section 24 Environment
Everyone has the right (a) to an environment that is not harmful to their health or well
being; and...
Section 27 Health care, food, water and social security
(1) Everyone has the right to have access to (a) health care services, including reproductive health care;
(b) sufficient food and water; and
(c) social security, including, if they are unable to support themselves and their
dependants, appropriate social assistance.
(2) The state must take reasonable legislative and other measures, within its available
resources, to achieve the progressive realisation of each of these rights.
(3) No one may be refused emergency medical treatment”5
Similarly, the Constitution of Uzbekistan, holds the right of citizens to skilled medical
care, social security in the case of old age and disability. It also guarantees the access to
skilled medical care.
Constitution of the
Republic of Vietnam:
Socialist
Chapter V: Fundamental Rights and
Duties of the Citizen
Article 61
“The citizen is entitled to a regime
of health protection.
The State shall establish a system
of hospital fees, together with one
of exemption from and reduction of
such fees.
The citizen has the duty to observe
all
regulations
on
disease
prevention and public hygiene...”
Constitution of Mongolia
Chapter Two: Human Rights and
Freedoms Article 16 “2) The right
to healthy and safe environment,
and to be protected against
environmental
pollution
and
ecological imbalance....
5) The right to material and
financial assistance in old age,
disability, childbirth and childcare
and in other cases as provided by
law.
6) The right to the protection of
health and medical care. The
procedure and conditions of free
medical aid shall be determined by
law.”'
5 Constitution of the Republic of South Africa Adopted on: 8 May 1996} {Amended on: 11 Oct 1996}
{In Force since: 7 Feb 1997}
The Constitution of India also has provisions regarding the right to health. They are
outlined the Directive Principles of State Policy- Articles 42 and 47, outlined in Chapter
IV, and are therefore non-justiciable.
Article 42
“Provision for just and humane conditions of work and maternity relief- The State
shall make provision for securing just and humane conditions of work and for maternity
relief’
Article 47
“Duty of the State to raise the level of nutrition and the standard of living and to
improve public health- The State shall regard the raising of he level of nutrition and the
standard of living of its people and the improvement of public health as among its
primary duties 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”1
The above articles act as guidelines that the State must pursue towards achieving certain
standards of living for its citizens’. It also shows clearly the understanding of the State
that nutrition, conditions of work and maternity benefit as being integral to health.
Although the DPSP quoted above are a compelling argument for the right to health, this
alone is not a guarantee. There must be a clearly defined right to health so that
individuals can have this right enforced and violations can be redressed.
The Indian judiciary has interpreted the right to health in many ways. Through public
interest litigation as well as litigation arising out of claims that individuals have made on
the State, with respect to health services etc. As a result-there is substantial case law in
India, which shows the gamut of issues that are related to health.
The Fundamental Right to Life, as stated in Article 21 of the Indian Constitution,
guaranties to the individual her/his life which or personal liberty except by a procedure
established by law. The Supreme Court has widely interpreted this fundamental right and
has included in Article 21 the right to live with dignity and “all the necessities of life such
as adequate nutrition, clothing....”. It has also held that act which affects the dignity of an
individual will also violate her/his right to life.2. Similarly in Bandhua Mukti Morcha Vs
Union of India, the Supreme Court has held that the Right to life includes the right to live
with dignity.
The recognition that the right to health is essential for human existence and is, therefore,
an integral part of the Right to Life, is laid out clearly in Consumer Education and
Resource Centre Vs Union of India3. It also held in the same judgment that humane
1 Part IV, Constitution of India adopted on 26tl‘ November 1949
2 Mullin Vs Union Teritory of Delhi
3 AIR 1995 SC 636
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working conditions and health services and medical care are an essential part of Article
21.
Further in, State of Punjab and Others v. Mohinder Singh4 “It is now a settled law that
right to health is integral to right to life. Government has a constitutional obligation
to provide health facilities.”
Apart from recognizing the fundamental right to health as an integral part of the Right to
Life, there is sufficient case law both from the Supreme and High Courts that lays down
the obligation of the State to provide medical health services.
This has been explicitly held with regard to the provision of emergency medical
treatment in Parmanand Katara Vs Union of India 5. It was held that “Every doctor
whether at a government hospital or otherwise has the professional obligation to
extend his services with due expertise for protecting life”.
The issue of adequacy of medical helath services was also addressed in Paschim Baga
Khet Mazoor Samiti Vs State of West Bengal.6 The question before the court was
whether the non-availability of services in the government health centres amount to a
violation of Article 21? It was held that that Article 21 imposes an obligation on the State
to safeguard the right to life of every person. Preservation of human life is thus of
paramount importance. The government hospitals run by the State and the medical
officers employed therein are duty-bound to extend medical assistance for
preserving human life. Failure on the part of a government hospital to provide
timely medical treatment to a person in need of such treatment results in violation of
his right to life guaranteed under Article 21. Therefore, the failure of a government run
health centre to provide timely treatment, is violative of a person’s right to life. Further,
the Court ordered that Primary health care centres be equipped to deal with medical
emergencies. It has also been held in this judgement that the lack of financial resources
cannot be a reason for the State to shy away from its constitutional obligation.
In Mahendra Pratap Singh v. State of Orissa7, a case pertaining to the failure of the
govrnment in opening a primary health care centre ina village, the court had held “In a
country like ours, it may not be possible to have sophisticated hospitals but definitely
villagers within their limitations can aspire to have a Primary Health Centre. The
government is required to assist people get treatment and lead a healthy life. Healthy
society is a collective gain and no Government should make any effort to smother it.
Primary concern should be the primary health centre and technical fetters cannot be
introduced as subterfuges to cause hindrances in the establishment of health centre.” It
also stated that, “ great achievements and accomplishments in life are possible if one is
permitted to lead an acceptably healthy life”. Thereby, there is an implication that the
enforcing of the right to life is a duty of the state and that this duty covers the
providing of right to primary health care, This would then imply that the right to life
includes the right to primary health care.
4 AIR 1997 SC 1225
5 AIR 1989 SC 2039
6 AIR 1996 SC 2426
7 AIR 1997 Ori 37
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8
The instrument of Public Interest Litigation used by Common Cause, addresses the issue
of the working of commercial blood banks. The court while recognizing that blood
donation is considered as a great life saving service to humanity, it must be ensured that
the blood that is available with the blood banks for use is healthy and free from infection.
The Supreme Court in this case laid down a system of licensing of blood banks. It may
be inferred from the above reasoning that the State is entrusted with the
responsibility in matters of health, to ensure efficient functioning all centres relating
to health care.
More recently the Supreme Court has addressed the epidemic of HIV/ AIDS. In a case
where the court had to decide whether an HIV positive man should disclose his condition
to the woman he was to marry, the court has held that “the woman’s right to good health
to precedence over the man’s right to privacy”? It found that the hospital did not error in
disclosing his status to his fiance. In MX VS ZY10, the Bombay High Court found that if
a person were fired from his employment solely because of his HIV positive condition, it
would be condemning a person to "certain economic death".
While the provision of health services is essential to ensure good health, there are several
others factors that influence a person’s health. The Supreme Court has recognized this in
a number of ways. This was first addressed in Bandhua Mukti Morcha V Union of
India,11 a case concerning the living and working conditions of stone quarry workers and
whether these conditions deprived them of their right to life. The court held that humane
working conditions are essential to the pursuit of the right life. It laid down that workers
should be provided with medical facilities, clean drinking water and sanitation facilities
so that they may live with human dignity.
In Citizens and Inhabitants of Municipal Ward v. Municipal Corporation, Gwalior the
court deliberated on the question- Is the State machinery bound to assure adequate
conditions necessary for health? The case involved the maintaining of sanitation and
drainage facilities by municipal corporartions. It was held that the State and its
machineries (in the instant case, the Muncipal Corporation) are bound to assure
hygienic conditions of living and therefore, health.
The Karnataka High Court has deliberated on the right of an individual to have access to
drinking water. In Puttappa Honnappa Talavar v. Deputy Commissioner, Dharwad I2, the
High Court has held that the right to dig bore wells therefore can be restricted or
regulated only by an Act of legislature and that the right to life includes the right to have
access to clean drinking water.
8 AIR 1996 SC 83
9 AIR 1999 SC 495
10 MX v. ZY, A.I.R. 1997 Bom. 406
11 A.I.R. 1984 S.C. 802, 808
12 AIR 1998 Kar 10
The High Court of Rajasthan has held that stray animals in urban areas pose a danger to
people and also cause nuisance to the public.13 The question before the court was, does
the negligence of restraining the number of these animals violate Art 21 of the public at
large? The court found that stray animals on the road interfere with transportation,
polluted the city and therefore posed a health risk to people. It was held that public
nuisance caused by these stray animals was a violation of Art. 21,of the public at
large.
With regard to maintaining a clean environment, which is critical to a person’s health,
there are many questions that Courts have deliberated on. For example in Municipal
Council, Ratnam v Shri Vardichan 14, where the Court had been called upon to decide
whether municipalities are obligated to maintain certain conditions to ensure public
health. It was held by the court that a public body constituted for the principal statutory
duty of ensuring sanitation and health is not entitled to an immunity on breach of this
duty. Further, “pollutants being discharged by big factories... are a challenge to the social
justice component of the rule of law”.
Also in Santosh Kumar Gupta v Secretary, Ministry of Environment, New Delhi15,
contended that the policy, controls/regulations and their implementations are inadequate
thereby causing health hazards. In its judgements, the High Court of Madhya Pradesh has
laid down that pollution from cars poses a helath hazard to people and that the State must
ensure that emission standards are implemented maintained.
In the land mark MC Mehta v Union of India16, the Supreme Court has held that
environmental pollution causes several health hazards, and therefore violates right to life.
Specifically, the case dealt with the pollution discharged by industries into the Ganges. It
was held that victims, affected by the pollution caused, were liable to be compensated.
There is sufficient case law on the issue of health in State run institutions such as remand
homes for children and “care homes”. In Sheela Barse v Union of India and Another 17, a
case pertaining to the admitting of non-criminal mentally ill persons to prisons in West
Bengal, the Supreme Court has held that “(1) Admission of non-criminal mentally ill
persons to jails is illegal and unconstitutional.... The Judicial Magistrate will, upon a
mentally ill person being produced, have him or her examined by a Mental Helath
Professional/Psychiatrist and if advised by such MHP/Psychiatrist send the mentally ill
person to the nearest place of treatment and care.” It has further directed the state to
improve mental health institutions and integrate mental health into primary health care,
among others.
13 Sanjay Phophaliya v. State of Rajasthan, AIR 1998 Raj 96
,4_ 1980 (4) SCC 162
15 AIR 1998 MP 43
16 A.I.R. 1987 S.C. 1086
17 1993-(004)-SCC -0204 -SC
ge
Further in Sheela Barse v Union of India and others18, the Supreme Court has entrusted to
High Courts the duty to monitor the conditions of “mentally ill and insane” women and
children in prisons and pass appropriate orders from time to time.
In the most recent case involving the death of 25 inmates of a mental helath institution in
Erawadi, Ramnathapuram District19 as they were chained to poles or beds and could not
escape from a fire that broke out, the Supreme Court has directed the state to implement
the provisions of the mental health act as well s undertake a survey of all institutions that
provide mental health facilities and ensure that they are maintaining standards of care.
From the above discussion of cases it is evident that the judiciary has clearly read into
Article 21, Right to Life, the right to health. It in fact has gone deepr into the meaning of
. health and has substantiated the meaning of the the right to life.
The question that must be discussued more thoroughly is whether an amendment to the
Constitution, which will state the fundamental right to helath, is desirable. Enumerated
rights have an edge over wider interpretations of existing rights, as States can be held
accountable for violations. However, with the extensive case law that is available is it not
possible to use what is available to ensure that health care, facilities and condition
ensuring health are fundamental rights of every citizen? If the case law reflects the ability
of the courts to read the meaning of ‘health’ in very wide sense (everything from the
responsibility of the municipal corporation to provide sanitation facilities down to access
to emergency medical treatment has been interpreted in the right to health) then why not
use the instrument of case law to confer rights? It is this question that must be examine in
the light of the recent amendment guaranteeing primary education for all. Th process that
led upto the amendment njist be looked at crtically as well as how the implementation of
it is currently taking place.
Also, closely associated with helath are the issues of nutrition and clean drinking water,
which must be available through out the year. The judiciary has read into Article21, the
right to food. These are complementary rights, the guaranteeing of the right to health, will
have no meaning without the others.
Any amendment guaranteeing the right to health should have a focus on primary health
care, which is preventive and curative. It should also have specific focus on the health of
women- more specifically reproductive health, children, and the disabled- both physically
and mentally.
Keeping this in mind there must be more detailed examination of an amendment to the
Constitution, guaranteeing the right to helath.
18 1995-(005)-SCC-0654 -SC
19 2002-(003)-SCC -0031 -SC
A Draft paper by NCAS, Pune
Paper under preparation, kindly do not quote anything from this paper.
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