The Right to Health Care is a Basic Human Right
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- Title
- The Right to Health Care is a Basic Human Right
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RF_L_7_SUDHA
The Right to Health Care is a Basic Human Right!
Towards attaining the Right to health care...
I he Government of India has been unable to fulfill it’s commitment of* Health for All by 2000
A.D. till now. In fact, primary health care services are becoming more and more difficult to obtain
for people living ^specially in urban slums, villages or remote tribal regions. The condition of
government hospitals is worsening day by day. Nowadays, in most of the Government hospitals there
is inadequate staff, the supply of medicines is insufficient and the infrastructure is also inadequate.
w
■
There are very inadequate facilities for safe deliveries or abortions in1 Govt, hospitals. Given the fact
that women do not even get adequate treatment for minor illnesses such as anaemia, services for
problems such as the health effects of domestic violence remain almost completely unavailable. At the
village level, there is no resident health care provider to treat illnesses or implement preventive
measures. All hospitals are located in big cities, and here too public hospitals are increasingly starved
of funds and facilities. Thus there is lack of availability of government health care services on one
hand and the exorbitant cost of private health services on the other. This often leaves common people
in rural areas with no other option but to resort to treatment from quack doctors who often practice
irrationally. Thus most of the population is being deprived of the basic right to health care, which is
essential for healthy living.
The Indian Constitution has granted the ‘Right to Life’ as a basic human right to every citizen of
India under article 21. In article 47 of the Directive Principles of the Indian Constitution, the
Government’s responsibility concerning public health has also been laid down. Yet the Government is
backtracking from fulfilling this responsibility. This is obvious from the fact that the Governments
proportion of expenditure on public health services has been declining in successive years.
What can be done in the near future to establish the Right to Health Care?
The year 2003 is the silver jubilee year of the ‘ Health for all* declaration. On this occasion, Jan
Swasthya Abhiyan is launching a nationwide campaign to establish the Right to health care as a basic
human right. Some of the following activities are being taken up as part of this campaign-
•
We can document case .studies of ‘denial of health care* in our areas. This process has
already started in Maharashtra. Information is being collected in a specific format with the
help of a questionnaire. The cases where denial of health services has led to the loss of life,
physical damage or severe financial loss of the patient are being emphasised. These case
studies would be presented to the National Human Rights Commission. These case studies
would help us to depict the real status of provision of the primary health services by the
government, would strengthen our demand for improving public health services and would
help us in dialoguing with the public health system.
1
w
s
•
On the occasion of completing 25 years of the Alma Ata Declaration, a National
Workshop is being organised by JSA on 5lh September 2003 in Mumbai, for JSA activists
from all over the country. During this workshop, the perspective, issues and campaign
strategy regarding Right to Health care would be discussed in detail, and the cases that have
been documented would be shared. This would be followed by a National Public
Consultation on “Right to Health Care'" on 6th September in Mumbai. The Chairman of
NIIRC, the Chairperson and Secretary of the Health committee of NHRC and the Health
Sccretaiy, Central Ministry of Health and Family Welfare are being invited to this programme
which will be in the nature of a public hearing. Various public health experts and legal experts
will also speak during this program about the Right to Health Care. Selected case studies of
denial of right to health care will be presented to the NHRC, and an attempt would be made to
build a social consensus on this issue, so that this can be established as a legal right.
•
A report on “ Status of Health Care in India” is under preparation, which would give an idea
about the availability of health care services, differentials in accessibility to these services,
state of health care financing and issues related to health care services for specific sections of
the population. Well-known public health experts arc authoring various chapters of this
report. This report could be released in various State capitals, along with case studies and
other information related to the state. This could be done during the ‘People’s Health
Assembly anniversary’ from 1* to 8,h December 2003 (anniversary of the Kolkata and Dhaka
Health Assemblies) and would also be an occasion to highlight the situation of health services
in each state and the need to establish the Right to Health Care.
•
Filing of a Public Interest Litigation (PIL) to establish the constitutional right to health care
is also under consideration.
These are some of the steps being planned to move towards establishing the Right to health care.
Let us join this campaign and strengthen the movement to achieve health care and health for all!
Jan Swasthya Abhiyan
Let’s al! join the fight,
_______________________________ For health as a basic right!
For further details contact: Dr. Ekbal (National Convenor) -ckbal@vsnl.com
Amil Sengupta (Jt. Convenor) - ctddgf@vsnl,C9m
T. Sundararaman (Jt. Convenor) - sundar2@123india.com
lheima Narayan (Jt. Convenor) — sochara@vsnl.com
Amitava Guha (Jt. Convenor) - finrai@vsnl.net
Abhay Shukla (Jt. Convenor and National Secretariat) - cchatpun@vsnl com
Vandana Prasad (Member, National Secretariat) - chaukhat@yahoo.com
N.B. Sarojini (Member, National Secretariat) - sam3aro@nda,vsnl.nct.in
2
I
I
o
Protocol to document cases of
Denial of Right to Health Care
I he purpose ol these case studies is to demonstrate how specific persons have been denied
basic health care that is expected from Public health services. The idea is to capture events where
obvious and major violations have taken place, leading to loss of life, disability, serious health or
economic consequences. We should focus on availability of those services, regarding which the public
health system cannot deny its responsibility. The idea is to document structural deficiencies and not
cases of negligence by individual doctors or staff. However, lack of availability of required medical
stall when required, because of significant understaffing should be documented. The objective is not
to target individual public health care providers, but rather to document the serious structural
deficiencies that exist, which need to be corrected by major strengthening of the public health system.
Some of the major types of cases of this kind are outlined below, however any other similar
cases, which come to the attention of activists, can be documented.
Sonic types of cases of denial of Right to Health Care
(Ibis is not an exhaustive list but rather outlines certain broad categories with examples)
A. General Emergencies: Cases where a patient with a serious medical problem has been taken to a
Govt, health centre or hospital (PIIC / Rural / Cottage / Sub-divisional / District Hospital) and has
been denied the life-saving or stabilising services expected at that facility. The patient may have
unnecessarily been referred to a higher facility, leading to delay in treatment and serious adverse
consequences, including death. Examples may include non-availability of:
•
In a PIIC - Non-availability of treatment for snakebite or Anti-rabies vaccine; Non-availability
of treatment for a child with pneumonia or severe dehydration due to diarrhea resulting in death
•
In a Rural hospital: Above or Lack of blood transfusion for a bleeding patient due to accident or
bleeding related to pregnancy; Non-availability of emergency drugs leading to serious delay in
treatment and death or disability of the patient
•
In a Cottage / Sub-divisional / District Hospital: Above or Non - availability of emergency
surgery leading to death or disability of the patient; non-availability of essential or emergency drugs
B. Women’s health care: Women should receive certain basic health care related to both
reproductive and non-reproductive health problems. Denial may include for example:
•
Maternal Health Care: Lack of facility or performance of a normal delivery in a PHC or higher
facility; lack of facilities for necessary cesarean operation in Rural hospital or higher facility;
unavailability of blood transfusion service to a woman before, during or after delivery; lack of
abortion facility leading to septic abortion or other adverse consequences
•
Care for burns: A woman reporting with bums in a Rural hospital or higher facility and not
receiving care for bums
C. Major chronic illnesses: Any facility, PHC or above not regularly giving full range of
medication to patients with T.B. Ie<iding to deterioration of the patients condition including death;
Sub-divisional hospital or higher facility not treating/admitting a case of AIDS
D. Outbreak of immunisable or other major preventable illness such as measles, cholera, epidemic
hepatitis or malaria - due to failure of basic preventive or public health measures.
E. Mental Illnesses - Patients who have been denied health care for mental illness in a CHC or
higher facility
I
1
Some guidelines for activists documenting the case studies.
•
At least two case studies should be collected from each district / by each organisation. The
attempt should be to document cases where denial of health care has resulted in significant loss to
the patient, either in physical or financial terms, to strengthen the case for a human rights
violation. Document only those case studies where incidence of denial has taken place in the last 6
months. Collect at least half of the case studies concerning women who have been denied health
care. Any case papers / prescriptions or other relevant documents should be collected as supportive
documents.
•
Take oral consent of the person from whom the information will be elicited. Give that person
information about the campaign. Tell him / her that the case study may be presented to NHRC, and
in such case would have relevant implications. Fill the questionnaire only after taking oral consent
from the person.
1
Primary Health Center/ Govt. Hospital Services — Survey Questionnaire
Name of patientAgeSexc
Ad dress-
Details of care received at PHC / Hospital
♦
Location ol the PIIC / Location and type of Hospital —
i
♦
Illness / complaints lor which PI IC / Hospital was visited —
4
f Otal Number of visits to PI IC / Hospital for this illness
4
Date of last visit —
1. History of last visit in the patients / attendants words (I lere we want to collect information regarding the main symptoms of the patient, who gave
care and what kinds of examination, investigation and treatment were given)
1
•
What were the perceived shortcomings or deficiencies in care? (As perceived by the
patient or attendants)
♦ According to patient was there any adverse outcome because of deficient care? (Death,
disability, continued or chronic health problem, severe financial loss e.g. major loan or
sale of assets)
I
2. Medical attention received:
♦ Name of the doctor who attended le-you -
If the doctor was not available at that time, then who attended te-you 1. Nurse / ANM
2. MPW
3. Pharmacist
4. Any other person, specify
♦
I low long after you reached the Pl 1C / I lospital did the Medical Officer / Doctor attend to-
♦
Was examination / treatment / operation delayed or denied because of non-availability of
a nurse, doctor or specialist?
2
♦
In case of an emergency did the doctor immediately attend
to the patient? During hospital
stay, regarding conditions (hat required immediate care, was the doctor available to
immediately attend to the patient?
♦
Were nurses or hospital stafl'available to attend to the patient
as and when required?
c
o
♦
_
Do you think that non-availability of any crucial equipment or supply (oxygen,
incubator, anaesthetic equipment, blood, emergency drugs etc.) adversely afTcctcd the
quality of care?
o
♦
Were all the equipments required for the examination and treatment of the patient
available in working condition in the hospital?
-
Diagnosis- (as told by the doctor)
3. Medicines:
♦
Did you get all the required medicines at the PI IC / I lospital?
o
♦
Did you have to go to any private medical shop to buy some medicines?
♦
If so, which medicines you had to buy from private medical shop?
♦
How much did it cost?
♦
Do you have the prescription?
4. Expenditure:
♦
Case paper / card made - yes/no
♦
Case paper fee / indoor fees charged
3
♦
Did you receive a receipt tor the payment made?
♦
Were you charged excess money at the PHC /1 iospital (more than specified rates)?
♦
If yes. how much excess was charged?
♦
Did your family have to sell assets (land, cattle, jewelry etc.) or take loans to pay for
treatment in the Govt, hospital?
5. Referral:
♦
Was the patient refused admission or referred to another hospital without giving (list aid
.i
care?
♦
If the patient was referred, was ambulance or other vehicle made available for the same?
♦
Did the Govt, doctor ask you to avail of any private services (e.g. laboratory services,
Sonography / X ray) while you were admitted in the Govt, hospital?
♦
in case you had to take the patient to a private hospital, which hospital? (name and
address of the hospital)
♦
What was the total expenditure on care at the private hospital / private lab or imaging
centre?
♦
Did your family have to sell any assets (land, cattle, jewelry etc.) or take loans to pay for
the private hospital charges?
I
4
I he Right to Health Care is a Basic Human Right!
l owards attaining (he Right to health care...
I he Government of India has been unable to fulfill it's commitment of ‘ I icalth for All by 2000
A.D.’ till now. In fact, primary health care services are becoming more and more difficult to obtain
for people living especially in urban slums, villages or remote tribal regions. The condition of
government hospitals is worsening day by day. Nowadays, in most of the Government hospitals there
is inadequate staff', the supply of medicines is insufficient and the infrastructure is also inadequate.
I here are very inadequate facilities for safe deliveries or abortions in Govt, hospitals. Given the fact
that women do not even get adequate treatment for minor illnesses such as anaemia, services for
problems such as the health effects of domestic violence remain almost completely unavailable. At the
village level, there is no resident health care provider to treat illnesses or implement preventive
measures. All hospitals are located in big cities, and here too public hospitals are increasingly starved
of funds and facilities. I bus there is lack of availability of government health care services on one
hand and the exorbitant cost of private health services on the other. I his oflen leaves common people
in rural areas with no other option but to resort to treatment from quack doctors who oflen practice
irrationally. Thus most of the population is being deprived of the basic right to health care, which is
essential for healthy living.
fhe Indian Constitution has granted the ‘Right to Life’ as a basic human right to every citizen of
India under article 21. In article 47 of the Directive Principles of the Indian Constitution, the
Government’s responsibility concerning public health has also been laid down. Yet the Government is
backtracking from fulfilling this responsibility. This is obvious from the fact that the Governments
proportion of expenditure on public health services has been declining in successive years.
What can be done in the near future to establish the Right to Health Care?
rhe year 2003 is the silver jubilee year of the ‘ Health for all’ declaration. On this occasion, Jan
Swasthya Abhiyan is launching a nationwide campaign to establish the Right to health care as a basic
human right. Some of the following activities are being taken up as part of this campaign•
We can document case .studies of ‘denial of health care’ in our areas. This process has
already started in Maharashtra. Information is being collected in a specific format with the
help of a questionnaire. The cases where denial of health services has led to the loss of life,
physical damage or severe financial loss of the patient are being emphasised. These case
studies would be presented to the National Human Rights Commission. These case studies
would help us to depict the real status of provision of the primary health services by the
government, would strengthen our demand for improving public health services and would
help us in dialoguing with the public health system.
1
•
On the occasion of completing 25 years of the Alma Ata Declaration, a National
W'orkshop is bein^ organised by JSA on 5,h September 2003 in Mumbai, for JSA activists
from all over the country. During this workshop, the perspective, issues and campaign
strategy regarding Right to Health care would be discussed in detail, and the cases that have
been documented would be shared. This would be followed by a National Public
Consultation on “Right to Health Care” on 6/h September in Mumbai. The Chairman of
NHRC, the Chairperson and Secretary of the Health committee of NHRC and the Health
Secretary, Central Ministry of Health and Family Welfare are being invited to this programme
which will be in the nature of a public hearing. Various public health experts and legal experts
will also speak during this program about the Right to Health Care. Selected case studies of
denial of right to health care will be presented to the NHRC, and an attempt would be made to
build a social consensus on this issue, so that this can be established as a legal right.
■
•
A report on “ Status of Health Care in India” is under preparation, which would give an idea
about the availability of health care services, difTcrentials in accessibility to these services,
state of health care financing and issues related to health care services for specific sections of
the population. Well-known public health experts are authoring various chapters of this
report. This report could be released in various State capitals, along with case studies and
other information related to the state. This could be done during the ‘People’s Health
Assembly anniversary’ from 1st to 8,h December 2003 (anniversary of the Kolkata and Dhaka
Health Assemblies) and would also be an occasion to highlight the situation of health services
in each state and the need to establish the Right to Health Care.
•
Filing of a Public Interest Litigation (PIL) to establish the constitutional right to health care
is also under consideration.
These are some of the steps being planned to move towards establishing the Right to health care.
Let us join this campaign and strengthen the movement to achieve health care and health for all!
Jan Swasthya Abhiyan
Let’s al!join the fight,
_____________________________ For health as a basic right!
For further details contact: Dr. Ekbal (National Convenor) - ekbal@vsnl.com
Amit Scngupta (Jt. Convenor) - ctddgf@vsrd,com
T. Sundararaman (JI. Convenor) - sundar2@123india.coin
Thelma Narayan (Jt. Convenor) - sochara@vsnl.com
Amitava Guha (Jt. Convenor) - finrai@vsnl.ngt
Abhay Shukla (Jt. Convenor and National Secretariat) -cchatpun@vsnl.com
Vandana Prasad (Member, National Secretariat) -chaukhat@vahoo.com
N.B. Sarojini (Member, National Secretariat) -samsaro@nda.vsnl.net.in
2
c
Protocol to document cases of
Denial of Right to Health Care
I
The purpose of these case studies is to demonstrate how specific persons have been denied
basic health care that is expected from Public health services. The idea is to capture events where
obvious and major violations have taken place, leading to loss of life, disability, serious health or
economic consequences. We should focus on availability of those services, regarding which the public
health system cannot deny its responsibility. The idea is to document structural deficiencies and not
cases of negligence by individual doctors or stall'. However, lack of availability of required medical
stall'when required, because of significant understaffing should be documented. The objective is not
to target individual public health cure providers, but rather to document the serious structural
deficiencies that exist, which need to be corrected by major strengthening of (he public health system.
Some of the major types of cases of this kind are outlined below, however any other similar
cases, which come to the attention of activists, can be documented.
Some types of cases of denial of Right to Health Care
(I his is not an exhaustive list but rather outlines certain broad categories with examples)
/y General Emergencies: Cases where a patient with a serious medical problem has been taken to a
Govt, health centre or hospital (PIIC / Rural / Cottage / Sub-divisional / District Hospital) and has
been denied the life-saving or stabilising services expected at that facility, fhe patient may have
unnecessarily been referred to a higher facility, leading to delay in treatment and serious adverse
consequences, including death. Examples may include non-availability of:
•
In a PIIC - Non-availability of treatment for snakebite or Anti-rabies vaccine; Non-availability
of treatment for a child with pneumonia or severe dehydration due to diarrhea resulting in death
•
In a Rural hospital-. Above or Lack of blood transfusion for a bleeding patient due to accident or
bleeding related to pregnancy; Non-availability of emergency drugs leading to serious delay in
treatment and death or disability of the patient
•
In a Cottage / Sub-divisiona! / District Hospital: Above or Non - availability of emergency
surgery leading to death or disability of the patient; non-availability of essential or emergency drugs
B. Women’s health care: Women should receive certain basic health care related to both
reproductive and non-reproductive health problems. Denial may include for example:
•
Maternal Health Care-. Lack of facility or performance of a normal delivery in a PHC or higher
facility; lack of facilities for necessary cesarean operation in Rural hospital or higher facility;
unavailability of blood transfusion service to a woman before, during or alter delivery; lack of
abortion facility leading to septic abortion or other adverse consequences
•
Care for burns: A woman reporting with bums in a Rural hospital or higher facility and not
receiving care for bums
C. Major chronic illnesses: Any facility, PHC or above not regularly giving full range of
medication to patients with T.B. leading to deterioration of the patients condition including death;
Sub-divisional hospital or higher facility not treating/admitting a case of AIDS
D. Outbreak of immunisable or other major preventable illness such as measles, cholera, epidemic
hepatitis or malaria - due to failure of basic preventive or public health measures.
E. Mental Illnesses - Patients who have been denied health care for mental illness in a CHC or
higher facility
Some guidelines for activists documenting the case studies.
•
At least two case studies should be collected from each district / by each organisation. The
attempt should be to document cases where denial of health care has resulted in significant loss to
the patient, either in physical or financial terms, to strengthen the case for a human rights
violation. Document only those case studies where incidence of denial has taken place in the last 6
months. Collect at least half of the case studies concerning women who have been denied health
care. Any case papers / prescriptions or other relevant documents should be collected as supportive
documents.
•
Take oral consent of the person from whom the information will be elicited. Give that person
information about the campaign. Tell him / her that the case study may be presented to NHRC, and
in such case would have relevant implications. I'ill the questionnaire only after taking oral consent
from the person.
1
Primary Heahli Center/ Govt. Hospital Services - Survey Questionnaire
Name of patient-
AgeSexc
Address-
Details of care received at PHC / Hospital
♦
Location ol the PHC / Location and type of Hospital i
♦
Illness / complaints for which PHC / Hospital was visited —
♦ Total Number of visits to PI IC / I lospital for this illness -
4 Date of last visit -
1. History of last visit in the patients / attendants words (Here we want to collect information regarding the main symptoms of the patient, who gave
care and what kinds of examination, investigation and treatment were given)
I
•
What were the perceived shortcomings or deficiencies in care? (As perceived by the
patient or attendants)
♦ According to patient, was there any adverse outcome because of deficient care? (Death,
disability, continued or chronic health problem, severe financial loss c.g. major loan or
sale of assets)
2. Medical attention received:
♦ Name of the doctor who attended ky-you -
If the doctor was not available at that time, then who attended to-yoo 1. Nurse / ANM
2. MPW
3. Pharmacist
4. Any other person, specify
♦
How long after you reached the Pl IC / Hospital did the Medical Officer / Doctor attend fo^ew?
♦
Was examination / treatment / operation delayed or denied because of non-availability of
a nurse, doctor or specialist?
2
♦
In case ol an emergency did the doctor immediately attend to the patient? During hospital
stay, regarding conditions that required immediate care, was the doctor available to
immediately attend to the patient?
♦
Were nurses or hospital stafTavailable to attend to the patient
as and when required?
o
♦
.
c
Do you think that non-availability of any crucial equipment or supply (oxygen,
incubator, anaesthetic equipment, blood, emergency drugs etc.) adversely affected the
quality of care?
o
♦
Were all the equipments required for the examination and treatment of the patient
available in working condition in the hospital?
Diagnosis- (as told by the doctor)
3. Medicines:
♦
Did you get all the required medicines at the PI 1C / I lospital?
o
♦
Did you have to go to any private medical shop to buy some medicines?
♦
If so, which medicines you had to buy from private medical shop?
♦
I low much did it cost?
♦
Do you have the prescription?
4. Expenditure:
♦
Case paper / card made - yes/no
♦
Case paper fee / indoor fees charged
3
♦
Did you receive a receipt for (he payment made?
♦
Were you charged excess money at the PI IC / I lospital (more than specified rates)?
♦
If yes, how much excess was charged?
Did your family have to sell assets (land, cattle, jewelry etc.) or take loans to pay for
treatment in the Govt, hospital?
5. Referral:
♦
Was the patient refused admission or referred to another hospital without giving first aid
care?
♦
If the patient was referred, was ambulance or other vehicle made available for the same?
♦
Did the Govt, doctor ask you to avail of any private services (e.g. laboratory services.
Sonography / X ray) while you were admitted in the Govt, hospital?
♦
In case you had to take the patient to a private hospital, which hospital? (name and
address of the hospital)
♦
What was the total expenditure on care at the private hospital / private lab or imaging
centre?
♦
Did your family have to sell any assets (land, cattle, jewelry etc.) or take loans to pay for
the private hospital charges?
4
I
I
i
I
[CHAIIDIWIVIIONDIIJ.UBIIJEE
u
India - Bhore
I. Historical Background:
Comprehensive
Committee Report 1948
Health Care
from
medical
promises
• unfulfilled
developments
from
pressure
• Experimentation
and
voluntary sector 1960s, 1970s
• WHO- UNICEF led Alma Ata Conference
1978.________________________ _
1
• Primary Health Care to achieve Health
for All by 2000
• Signed by 134 countries, including India
• A sociopolitical health approach
• Equitable, appropriate, affordable
response to basic health care needs.
\
7 \
NIVERSAL ACCESS TO HEALTH CARE - POLICY ASPECTS
7\/1
I
L\
,i\\
Universal access and coverage on basis of need.
Comprehensive care especially on health promotion and
disease prevention water and sanitation, nutrition, MCH, FP,
essential drugs, basic curative care, control of epidemic
diseases.
Community and individual involvement.
Self reliance
Intersectoral Action for Health.
Appropriate technology.
Cost effectiveness
Social justice and equity' were basic values and recognition
of the right to health ana Ihealth care.
I
I \
\
A
UNIVERSAL ACCESS TO HEALTH CARE - POLICY ASPECTS
2
D
Held the promise of better health, where health
is not the absence of disease, but a state of
well-being physical, mental, social, and spiritual
This implieda role for the state;
- a role for different systems
of medicine and healing.
individual responsibility;
~~7
role for families / households and communities /
civil society, NGOs
UNIVERSAL ACCESS TO HEALTH CARE - POLICY ASPj
ns?
I A
It implies
- decisions regarding resource allocations
and strategies.
- prioritization and choices.
- health system development
- developing human resources for health
UNIVERSAL ACCESS TO HEALTH CARE - POLICY ASPI
3
reflected and developed on the Alma Ata
Declaration
However
a) financial resource allocation to health and
its distribution to primary health care was
insufficient.
b) vertical programmes continued.
c) medical care aspects received greater
focus eg. Immunization,EP
d) expansion of infrastructure and personnel
took place.
e) implementation was not closely followed.
\ \
/
UNIVERSAL ACCESS TO HEALTH CARE - POLICY,
VJrom Mi
Growth of the private sector accelerated in
health care provision, drug production,
medical education.
w
The World Bank entered the health policy
arena
- the largest financier of health
programmes.
UNIVERSAL ACCESS TO HEALTH CARE - POLICY ASPECTS
4
Used loan leverage to affect health
policy.
Private sector development / privatizatio
further strengthened
- Commercialization of health care.
Entry of corporate sector and of
multinationals
WTO - TRIPS - GATS
Rising drug prices and cost of care
UNIVERSAL ACCESS TO HEALTH CARE -
/
A
.ICY ASPECTS
□
rival poverty and distress.
UNIVERSAL ACCESS TO HEALTH CARE- POLICY ASPECTS
5
I
VII Ensuring universal access to
comprehensive primary health care is
an important step to protect the health
of the pqor and to prevent more people
from becoming poor.
\
UNIVERSAL ACCESS TO HEALTH CARE - POLICY ASPECTS
n
VIII. Opportunities and Challenges
CHATand its members
r
a) Strengthen community health
capacity at head quarters,
regional units and in
congregations with people
with expertise and expenSend staff fortraining in
community health.
in
lit\V
A
UNIVERSAL ACCESS TO HEALTH CARE - POLICY ASI ’ECTS
6
(b) Develop working links with different
departments of government at local,
district, state and national level.
Be Present and contribute to policy making
bodies.
(c) Do not work in isolation - network more
actively.
(d) Participate and strengthen the Jan
Swasthya Abhiyan at village / slum and
state / national level.
UNIVERSAL ACCESS TO HEALTH CARE - POLICY ASPECTS
e)Build on strengths of CHAI
> love for and working with the poor
> Women's health
> Indian and other systems of medicine.
> Good quality training of nurses and other
health personnel
> Rational therapeutics, hospital formalities
> Value base and professional ethics.
> Health Action as a medium of communication
UNIVERSAL ACCESS TO HEALTH CARE - POLICY AS ’ECTS
i
f) Help to place health on people’s and political/
agenda
g) Involve communities / people in running the health institutions and theii
heath care.
h) Shift
comprehensive health care,
Curative
Patients*
partners in health and healing.
dependency ==>empowerment, community building
providing ■----- > facilitating, using all resources
doctors disease diagnostics drugs czzj> positive health, healing
relationships holding brokenness.
health carec=>detemninants of health
institution c=>community / people
medical approach =^» societal approach, social analysis.
UNIVERSAL ACCESS TO HEALTH CARE - POLICY ASPECTS
8
r
The Right to Health Care is a Basic Human Right!
I owa rds attaining the Right to health care...
I he Government of India has been unable to fulfill it's commitment of ‘ Health for All by 2000
I
A D.’ till now. In fact, primary health care services arc becoming more and more difficult to obtain
I
for people living ^specially in urban slums, villages or remote tribal regions. The condition of
government hospitals is worsening day by day. Nowadays, in most of the Government hospitals there
is inadequate stall, the supply of medicines is insufficient and the infrastructure is also inadequate.
I here are very inadequate facilities for safe deliveries or abortions in1 Govt, hospitals. Given the fact
that women do not even get adequate treatment for minor illnesses such as anaemia, services for
problems such as the health effects of domestic violence remain almost completely unavailable. At the
village level, there is no resident health care provider to treat illnesses or implement preventive
measures. All hospitals are located in big cities, and here too public hospitals are increasingly starved
of funds and facilities. I hus there is lack of availability of government health care services on one
hand and the exorbitant cost of private health services on the other. This ofien leaves common people
in rural areas with no other option but to resort to treatment from quack doctors who often practice
irrationally. Thus most of the population is being deprived of the basic right to health care, which is
essential for healthy living.
The Indian Constitution has granted the ‘Right to Life’ as a basic human right to every citizen of
India under article 21. In article 47 of the Directive Principles of the Indian Constitution, the
Government’s responsibility concerning public health has also been laid down. Yet the Government is
backtracking from fulfilling this responsibility. This is obvious from the fact that the Governments
proportion of expenditure on public health services has been declining in successive years.
What can be done in the near future to establish the Right to Health Care?
I’lic year 2003 is the silver jubilee year of the ‘ Health for all’ declaration. On this occasion, Jan
Swasthya Abhiyan is launching a nationwide campaign to establish the Right to health care as a basic
human right. Some of the following activities are being taken up as part of this campaign•
We can document case .studies of ‘denial of health care’ in our areas. This process has
already started in Maharashtra. Information is being collected in a specific format with the
help of a questionnaire. The cases where denial of health services has led to the loss of life,
physical damage or severe financial loss of the patient are being emphasised. These case
studies would be presented to the National Human Rights Commission. These case studies
would help us to depict the real status of provision of the primary health services by the
government, would strengthen our demand for improving public health services and would
help us in dialoguing with the public health system.
I
•
On the occasion of completing 25 years of the Alma Ata Declaration, a National
Workshop is bein{» organised by JSA on 5,h September 2003 in Mumbai, for JSA activists
from all over the country. During this workshop, the perspective, issues and campaign
strategy regarding Right to Health care would be discussed in detail, and the cases that have
been documented would be shared. This would be followed by a National Public
Consultation on uRight to Health Care" on 6th September in Mumbai, d he Chairman of
NIIRC, the Chairperson and Secretary of the Health committee of NHRC and the Health
Sccrctaiy, Central Ministry of Health and f amily Welfare are being invited to this programme
which will be in the nature of a public hearing. Various public health experts and legal experts
will also speak during this program about the Right to I lealth Care. Selected case studies of
denial of right to health care will be presented to the NHRC, and an attempt would be made to
build a social consensus on this issue, so that this can be established as a legal right.
•
A report on “ Status of Health Care in India” is under preparation, which would give an idea
about the availability of health care services, differentials in accessibility to these services,
state of health care financing and issues related to health care services for specific sections of
the population. Well-known public health experts arc authoring various chapters of this
report. This report could be released in various State capitals, along with case studies and
other information related to the state. This could be done during the ‘People's Health
Assembly anniversary’ from Is* to 8,h December 2003 (anniversary of the Kolkata and Dhaka
Health Assemblies) and would also be an occasion to highlight the situation of health services
in each state and the need to establish the Right to Health Care.
•
Filing of a Public Interest Litigation (PIL) to establish the constitutional right to health care
is also under consideration.
These are some of the steps being planned to move towards establishing the Right to health care.
Let us join this campaign and strengthen the movement to achieve health care and health for all!
Jan Swasthya Abhiyan
Let’s all join the fight,
_______________________________ For health as a basic right!
For further details contact: Dr. Ekba I (National Convenor) —ckbal@vsnl.com
Amit Sengupla (Jt. Convenor) — ctddsf@vsnl.coni
T. Sundararaman (Jt. Convenor) - sundar2@123india.com
lhelma Narayan (Jt. Convenor) - sochara@vsnl.com
Ami lava Guha (Jt. Convenor) - finrai@vsnl net
Abhay Shukla (Jt. Convenor and National Secretariat) - cchatpun@vsnl.com
Vandana Prasad (Member, National Secretariat) — chaukhat@vahoo.com
N.B. Sarojini (Member, National Secretariat) — 8amsaro@nda.vsnl.net.in
9
c
I.
Protocol to document cases of
Denial of Right to Health Care
I he purpose ol these case studies is to demonstrate how specific persons have been denied
basic health care that is expected from Public health services. The idea is to capture events where
obvious and major violations have taken place, leading to loss of life, disability, serious health or
economic consequences. We should focus on availability of those services, regarding which the public
health system cannot deny its responsibility. The idea is to document structural deficiencies and not
cases of negligence by individual doctors or staff. However, lack of availability of required medical
stall when required, because of significant understaffing should be documented. The objective is not
to target individual public health care providers, but rather to document the serious structural
deficiencies that exist, which need to be corrected by major strengthening of the public health system.
Some of the major types of cases of this kind are outlined below, however any other similar
cases, which come to the attention of activists, can be documented.
Some types of cases of denial of Right to Health Care
(1 his is not an exhaustive list but rather outlines certain broad categories with examples)
A. General Emergencies: Cases where a patient with a serious medical problem has been taken to a
Govt, health centre or hospital (PNC / Rural / Cottage / Sub-divisional / District Hospital) and has
been denied the life-saving or stabilising services expected at that facility. The patient may have
unnecessarily been referred to a higher facility, leading to delay in treatment and serious adverse
consequences, including death. Examples may include non-availability of:
• In a PIIC - Non-availability of treatment for snakebite or Anti-rabies vaccine; Non-availability
of treatment for a child with pneumonia or severe dehydration due to diarrhea resulting in death
• In a Rural hospital: Above or Lack of blood transfusion for a bleeding patient due to accident or
bleeding related to pregnancy; Non-availability of emergency drugs leading to serious delay in
treatment and death or disability of the patient
• In a Cottage / Sub-divisiona! / District Hospital: Above or Non - availability of emergency
surgery leading to death or disability of the patient; non-availability of essential or emergency drugs
B. Women’s health care: Women should receive certain basic health care related to both
reproductive and non-reproductive health problems. Denial may include for example:
• Maternal Health Care: Lack of facility or performance of a normal delivery in a PHC or higher
facility; lack of facilities for necessary cesarean operation in Rural hospital or higher facility;
unavailability of blood transfusion service to a woman before, during or after delivery; lack of
abortion facility leading to septic abortion or other adverse consequences
• Care for burns: A woman reporting with bums in a Rural hospital or higher facility and not
receiving care for bums
C. Major chronic illnesses: Any facility, PHC or above not regularly giving full range of
medication to patients with T.B. leading to deterioration of the patients condition including death;
Sub-divisional hospital or higher facility not treating/admitting a case of AIDS
D. Outbreak of immunisable or other major preventable illness such as measles, cholera, epidemic
hepatitis or malaria - due to failure of basic preventive or public health measures.
E. Mental Illnesses - Patients who have been denied health care for mental illness in a CHC or
higher facility
Some guidelines for activists documenting the case studies.
• At least two case studies should be collected from each district / by each organisation. The
attempt should be to document cases where denial of health care has resulted in significant loss to
the patient, either in physical or financial terms, to strengthen the case for a human rights
violation. Document only those case studies where incidence of denial has taken place in the last 6
months. Collect at least half of the case studies concerning women who have been denied health
care. Any case papers / prescriptions or other relevant documents should be collected as supportive
documents.
• Take oral consent of the person from whom the information will be elicited. Give that person
information about the campaign. Tell him / her that the case study may be presented to NHRC, and
in such case would have relevant implications. Fill the questionnaire only after taking oral consent
from the person.
I
Primary Health Center/ Govt. Hospital Services — Survey Questionnaire
Name of patient
AgeSexc
Address-
Dale of interview -
x
Details of care received at PHC / Hospital
♦
Location ol the PI IO / Location and type of Hospital -
♦
Illness / complaints for which PI IC / I lospital was visited
♦ Total Number of visits to PI IC / I lospital for this illness
4 Date of last visit -
1. History of last visit in the patients / attendants words-
(Here we want to collect information regarding the main symptoms of the patient, who gave
care and what kinds of examination, investigation and treatment were given)
1
•
What were the perceived shortcomings or deficiencies in care? (As perceived by the
patient or attendants)
♦
According to patient, was there any adverse outcome because of deficient care? (Death,
disability, continued or chronic health problem, severe financial loss e.g. major loan or
sale of assets)
2. Medical attention received:
♦
Name of the doctor who attended kryon
If the doctor was not available at that time, then who attended to you -
1. Nurse / ANM
2. MPW
3.
Pharmacist
4.
Any other person, specify
♦
How long after you reached the PHC / Hospital did the Medical Officer / Doctor attend to-
♦
Was examination / treatment / operation delayed or denied because of non-availability of
a nurse, doctor or specialist?
2
♦
In case of an emergency did the doctor immediately attend
to the patient? During hospital
slay, regarding conditions that required immediate care, was the doctor available to
immediately attend to the patient?
♦
Were nurses or hospital stall available to attend to the patient
as and when required?
o
♦
.
c
Do you think that non-availability of any crucial equipment or supply (oxygen,
incubator, anaesthetic equipment, blood, emergency drugs etc.) adversely affected the
quality of care?
♦
Were all the equipments required for the examination and treatment of the patient
available in working condition in the hospital?
Diagnosis- (as told by the doctor)
3. Medicines:
♦
Did you get all the required medicines at the PI IC / I lospital?
o
♦
Did you have to go to any private medical shop to buy some medicines?
♦
II so, which medicines you had to buy from private medical shop?
♦
How much did it cost?
♦
Do you have the prescription?
4. Expenditure:
♦
Case paper / card made - yes/no
♦
Case paper fee / indoor fees charged
3
♦
Did you receive a receipt lor (he payment made?
♦
Were you charged excess money at the PI IC / I lospital (more than specified rates)?
♦
If yes, how much excess was charged?
c
Did your family have to sell assets (land, cattle, jewelry etc.) or take loans to pay for
treatment in the Govt, hospital?
5. Referral:
♦
Was the patient refused admission or referred Io another hospital without giving first aid
care?
♦
II the patient was referred, was ambulance or other vehicle made available for the same?
♦
Did the Govt, doctor ask you to avail of any private services (c.g. laboratory services.
Sonography / X ray) while you were admitted in the Govt, hospital?
♦
in case you had to take the patient to a private hospital, which hospital? (name and
address of the hospital)
♦
What was the total expenditure on care at the private hospital / private lab or imaging
centre?
♦
Did your family have to sell any assets (land, cattle, jewelry etc.) or take loans to pay for
the private hospital charges?
4
*7-38
rivtocol fa document cases of
Denial of Right to Health Care
I he ptnpose oh these ciisc studies is to deiiioiistiute how speeilie persons have been
denied basic health care that is expected from Public health services. The idea is to capture
events where obvious and major violations have taken place, leading to loss of life, disability,
serious health or economic consequences. We should focus on availability of those services,
regarding which the public health system cannot deny its responsibility. The idea is to
document structural deficiencies and not cases of negligence by individual doctors or staff.
However, lack of availability of required medical staff when required, because of significant
understaffing should be documented. The objective is not to target individual public health
care providers, but rather to document the serious structural deficiencies dial exist, which
need to be corrected by ma/or strengthening ofthe public health system.
Some ol the miijor types ol cases ol this kind are outlined below, however any olher
similar cases, which come to the iillcnlioii of activists, can be docnmenled.
Some types of cases of denial of Right to Health Care
(This is not an exhaustive list but rather outlines certain broad categories with examples)
General Emergencies: Cases where a patient with a serious medical problem has been
taken to a Govt, health centre or hospital (I’llC / Rural / Cottage / Sub-divisional / District
Hospital) and has been denied the life-saving or stabilising services expected at that facility.
The patient may have unnecessarily been referred to a higher facility, leading to delay in
treatment and serious adverse consequences, including death. Examples may include non
availability of:
•
In a TUC - Non-availability of treatment for snakebite or Anti-rabies vaccine; Non
availability ot treatment for a child with pneumonia or severe dehydration due to diarrhea
resuiting in death
•
In a Rural hospital'. Above or Lack of blood transfusion for a bleeding patient due to
accident or bleeding related to pregnancy; Non-availability of emergency drugs leading to
serious delay in treatment and death or disability of the patient
•
In a Cottage / Sub-divisional / District Hospital: Above or Non
availability of
emergency surgery leading to death or disability of the patient; non-availability of essential
or emergency drugs
I
B. Women’s health care: Women should receive certain basic health care related to both
reproductive and non-rcproduclivc health problems. Denial may include for example:
•
Maternal Health Care: Lack of facility or performance of a normal delivery in a PI IC
or higher facility; lack of facilities for necessary cesarean operation In Rural hospital or
higher facility; unavailability of blood transfusion service to a woman before, during or after
delivery; lack of abortion facility leading to septic abortion or other adverse consequences
•
Care for burns: A woman reporting with burns in a Rural hospital or higher facility and
not receiving care for burns
C. Major chronic llhicsscs: Any facility. PI IC or above not regularly giving full range of
mcdicalion io patients with T.B, lending to detcriorallon of the ptillenls condition Including
dctilh: Sub-divisional hospital or higher facility not treating/admilling a ease of AIDS
D, Oulhrenk of immuiiisublc or other major preventable Illness such as measles, cholera,
epidemic hepatitis or malaria - due to failure of basic preventive or public health measures.
E. Mental Illnesses - Patients who have been denied health care for mental illness in a CHC
or higher facility
Some guidelines for activists documenting the ease studies.
•
Al least two case studies should be collected from each district / by each organisation.
•
1 he attempt should be to document cases where denial of health care has resulted in
significant loss to the patient, either in physical or financial terms, to strengthen the case
for a human rights violation
•
Document only those ease studies where incidence of denial has taken place in the last 6
months.
•
Collect at least half of the ease studies concerning women who have been denied health
care.
•
Any ease papers / prescriptions or other relevant documents should be collected as
supportive documents.
•
lake oral consent of the person from whom the information will be elicited. Give that
person information about the campaign, fell him / her that the ease study may be
presented to NHRC, and in such case would have relevant implies lions, fill the
questionnaire only after taking oral consent from the person.
1
Primary Health Center/Govt. Hospital Services - Survey Questionnaire
Name of patientAgu-
SexAddress-
Dale of interview Details of care received at PHC / Hospital
♦
Location of the PI IC / Location and type of Hospital -
♦
Illness/complaints for which P11C / Hospital was visited-
♦
Total Number of visits to PI IC / I lospilal for this illness -
♦
Date of last visit -
1. History of last visit in the patients / attendants words(Here we want to collect information regarding the main symptoms of the patient, who gave
care and what kinds of examination, investigation and treatment were given)
I
•
What were the perceived shortcomings or deficiencies in care? (As perceived by the
patient or attendants)
♦
According to patient, was there any (idverse outcome because of deficient care? (Death,
disability, continued or chronic health problem, severe financial loss e.g. major loan or
sale of assets i
2. Medical attention received:
♦
Name of the doctor who attended to you -
If the doctor was not available at that time, then who attended to you -
I. Nurse / ANM
2.
MPW
3.
Pharmacist
4. Any other person, specify
♦
How long after you reached the PHC / Hospital did the Medical Officer / Doctor attend to
you?
♦
Was examination / treatment / operation delayed or denied because of non-availability of
a nurse, doctor or specialist?
In case of an emergency did the doctor immediately attend to the patient? During hospital
♦
slny, icgiirdinp, vondilions (hut required iminediale care, was the doctor available Io
iinmcdiiilely iillcnd Io the patient?
Were nurses or hospital staff available to attend to the patient as and when required?
♦
Do >ou think that non-availability of any crucial equipment or supply (oxygen,
♦
incubator, anaesthetic equipment, blood, emergency drugs etc.) adversely affected the
quality of care?
Were all the equipments required for the examination and treatment of the patient
♦
available in working condition in the hospital?
Diagnosis- (as told by the doctor)
3. Medicines:
♦
Did you get all the required medicines at the PI IC / I lospital ?
♦
Did you have to go to any private medical shop to buy some medicines?
♦
If so, which medicines you had to buy from private medical shop?
♦
How much did it cost?
♦
Do you have the prescription?
4. Expenditure:
♦
Case p aper / card made - yes no
♦
Case piper fee / indoor fees charged
3
♦
DldyiHi icirivvn receipt lor (he piiyniciH imulc?
♦
Were you charged excess money al (he PI IC / I lospilal (more than specified rales)?
♦
If yes, how much excess was charged?
♦
Did your kimily have to sell assets (land, cattle, jewelry etc.) or take loans to pay for
treatment in the Govt, hospital?
5. Referral:
♦
Was the padent refused admission or referred to another hospital without giving lirsl aid
care?
♦
If the patient was referred, was ambulance or other vehicle made available for the same?
♦
Did the Govt, doctor ask you to avail of any private services (e.g. laboratory services.
Sonography / X ray) while you were admitted in the Govt, hospital?
♦
In case you had to take the patient to a private hospital, which hospital? (name and
address of ihe hospital)
♦
What was the total expenditure on care al the private hospital / private lab or imaging
centre?
♦
Did your family have to sell any assets (land, cattlejewelry etc.) or take loans to pay for
the private hospital charges?
4
CASE STUDY REGARDING DENIAL OF HEALTH CARE FROM
CHEGUNTA MANDAL, MEDAK DISTRICT, ANDHRA PRADESH
Respondent
Mrs. Nagalakshmi, Karimnaggar Village
Date of Interview
8lh August 2003
Investigator
Dr. Abraham,
Community Health Fellow,
Community Health Cell,
# 367, Jakkasandra lsl Main, lsl Block, Koramangala,
Bangalore. - 560 034.
(currently on a field placement with Sanghamitra, working in
Medak District, Andhra Pradesh)
Case Sheet
Mrs. Nagalakshmi, aged 20 years, from Karimnagar village, had her second baby, a
girl a fortnight ago. She did not have any complications during her pregnancy or
delivery.
She and her husband Siddanamulu (25 years old) are daily wage workers
who have less than half an acre of land in Karimnagar, a drought prone area 65 kins
from Secunderabad. They both had decided that they did not want more children and
on the advice of their health worker
(Junior Health Assistant
female). Ms.
Anuradha of Mutharajpet sub-centre, they opted for the ‘operation’ al the Chegunta
Primary Health Centre (PHC) (i.e., for tubal ligation or tubectomy). She and her
husband, their two children and Nagalakshmi’s mother and father visited the PHC on
8lh August 2003 to seek a tubectomy.
She was informed at the PHC by the doctor Dr. Nayeem that she could not have her
tubectomy in the PHC and was referred to a town ‘Toopran’ (25 kms from Kanyaram)
for a tubectomy camp. The PHC medical officer also told her that she suffered high
blood pressure and that she should take some Atenolol tablets when she returned
home. This prescription was given on a sheet of paper with no prescription date, no
dosage, no PHC name or address and no doctor’s signature. There was no case sheet
prepared. The diagnosis was based without recording the blood pressure and w as
probably an excuse to justify why she could not get a tubectomy done at the PHC
closest to her home on request.
Tkj ?
<yy'
Some important issues concerning Denial of Health Care
1. The respondent and her husband, both illiterate daily wage workers were
motivated enough to limit their family size that they come to the PHC seeking a
terminal family planning operation.
2. They came from their village, Pothanapalli, 14 kms from Chegunta at their own
expense, which also meant loss of daily wages for both (also an indication of their
high level of motivation).
3. They were referred to the PHC by the sub-centre health worker covering their
region. This referral was not honoured. This will adversely affect the motivation
and credibility of the worker.
4. At the PHC they are told that she has high BP without any examination leave
alone repeated BP readings, and prescribed a drug without a proper prescription or
explanation about usage of medicine.
5. Also she was referred to another town for a FP camp without proper or adequate
details of date or time of camp, whom to meet or referral slip to an institution in a
town which is 25 kms away.
| A case of both denial of‘right to’ and ‘quality’ health care|
JJ
CASE STUDY REGARDING DENTAL OF HEALTH CARE FROM
CHEGUNTA MANDAL, MEDAK DISTRICT, ANDHRA PRADESH
Respondent
Mrs. Nagalakshmi, Karimnaggar Village
Dale of Interview
8"’ August 2003
ln\ estigator
Dr. Abraham,
Community Health Fellow.
Community Health Cell.
# 367, Jakkasandra 1" Main, lsl Block. Koramangala.
Bangalore. - 560 034.
(currently on a field placement with Sanghamitra. working in
Medak District, Andhra Pradesh)
Case Sheet
Mrs. Nagalakshmi. aged 20 years, from Karininagar village, had her second baby, a
girl a fortnight ago. She did not have any complications during her pregnancy or
delivery.
She and her husband Siddanamulu (25 years old) are daily wage workers
w ho have less than half an acre of land in Karimnagar, a drought prone area 65 kms
from Secunderabad. They both had decided that they did not want more children and
on the advice of their health worker
(Junior Health Assistant
female). Ms.
Anuradha of Mutharajpet sub-centre, they opted for the ‘operation' at the Chegunla
Primary Health Centre (PHC) (i.e., for tubal ligation or tubectomy). She and her
husband, their two children and Nagalakshmi's mother and father visited the PHC on
Sl August 2003 to seek a tubectomy.
She w as informed at the PHC by the doctor Dr. Nayeem that she could not have her
tubectomy in the PHC and was referred to a town ‘Toopran’ (25 kms from Kanyaram)
for a tubectomy camp. The PHC medical officer also told her that she suffered high
blood pressure and that she should take some Atenolol tablets when she returned
home. This prescription was given on a sheet of paper with no prescription dale, no
dosage, no PHC name or address and no doctor’s signature. There was no case sheet
prepared. The diagnosis was based without recording the blood pressure and was
probably an excuse to justify why she could not get a tubectomy done al the PHC
closest to her home on request.
/o />e
,A
(1LY
Yie-c
A15
Some important issues concerning Denial of Health Care
1. The respondent and her husband, both illiterate daily wage workers were
motivated enough to limit their family size that they come to the PHC seeking a
terminal family planning operation.
2. They came from their village. Pothanapalli, 14 kms from Chegunta at their own
expense, w hich also meant loss of daily wages for both (also an indication of their
high level of motivation).
3. They were referred to the PHC by the sub-centre health worker covering their
region. This referral was not honoured. This will adversely affect the motivation
and credibilitv of the worker.
4. At the PHC they are told that she has high BP without any examination leave
alone repeated BP readings, and prescribed a drug without a proper prescription or
explanation about usage of medicine.
5. Also she was referred to another town for a FP camp without proper or adequate
details of date or time of camp, whom to meet or referral slip to an institution in a
town which is 25 kms away.
[A case of both denial of‘right to' and ‘quality’ health care|
t
The Right to Health Care is a Basic Human Right!
I owa rds attaining the Right to health care...
I he Government of India has been unable to fulfill it's commitment of ‘ Health for All by 2000
A.D. till now. In fact, primary health care services are becoming more and more difficult to obtain
for people living ^specially in urban slums, villages or remote tribal regions. The condition of
government hospitals is worsening day by day. Nowadays, in most of the Government hospitals there
is inadequate staff, the supply of medicines is insufficient and the infrastructure is also inadequate.
I here are very inadequate facilities for safe deliveries or abortions in Govt, hospitals. Given the fact
that women do not even get adequate treatment for minor illnesses such as anaemia, services for
problems such as the health effects of domestic violence remain almost completely unavailable. At the
village level, there is no resident health care provider to treat illnesses or implement preventive
measures. All hospitals are located in big cities, and here too public hospitals are increasingly starved
of funds and facilities. 1 bus there is lack of availability of government health care services on one
hand and the exorbitant cost of private health services on the other. This often leaves common people
in rural areas with no other option but to resort to treatment from quack doctors who often practice
irrationally. Thus most of the population is being deprived of the basic right to health care, which is
essential for healthy living.
The Indian Constitution has granted the ‘Right to Life’ as a basic human right to every citizen of
India under article 21. In article 47 of the Directive Principles of the Indian Constitution, the
Government’s responsibility concerning public health has also been laid down. Vet the Government is
backtracking from fulfilling this responsibility. This is obvious from the fact that the Governments
proportion of expenditure on public health services has been declining in successive years.
What can be done in the near future to establish the Right to Health Care?
Hie year 2003 is the silver jubilee year of the ‘ Health for all’ declaration. On this occasion, Jan
Swasthya Abhiyan is launching a nationwide campaign to establish the Right to health care as a basic
human right. Some of the following activities are being taken up as part of this campaign•
We can document case .studies of ‘denial of health care’ in our areas. This process has
already started in Maharashtra. Infonnation is being collected in a specific format with the
help of a questionnaire. The cases where denial of health services has led to the loss of life,
physical damage or severe financial loss of the patient are being emphasised. These case
studies would be presented to the National Human Rights Commission. These case studies
would help us to depict the real status of provision of the primary health services by the
government, would strengthen our demand for improving public health services and would
help us in dialoguing with the public health system.
I
•
On the occasion of completing 25 years of the Alma Ata Declaration, a National
Workshop is beinf» organised by JSA on 5,h September 2003 in Mumbai, for JSA activist^
from all over the country. During this workshop, the perspective, issues and campaign
strategy regarding Right to Health care would be discussed in detail, and the cases that have
been documented would be shared.
I his would be followed by a National Public
Consultation on “Right to Health Care11 on 6th September in Mumbai, The Chairman of
NIIRC, the Chairperson and Secretary of the Health committee of NHRC and the Health
Secretary, Central Ministry of Health and Family Welfare are being invited to this programme
which will be in the nature of a public hearing. Various public health experts and legal experts
will also speak during this program about the Right to Health Care. Selected case studies of
denial of right to health care will be presented to the Nl IRC, and an attempt would be made to
build a social consensus on this issue, so that this can be established as a legal right.
•
A report on “ Status of Health Care in India” is under preparation, which would give an idea
about the availability of health care services, dilFcrentials in accessibility to these services,
state of health care Financing and issues related to health care services for specific sections of
the population. Well-known public health experts are authoring various chapters of this
report. This report could be released in various State capitals, along with case studies and
other information related to the stale. This could be done during the ‘People’s Health
Assembly anniversary’ from Is1 to 8,h December 2003 (anniversary of the Kolkata and Dhaka
Health Assemblies) and would also be an occasion to highlight the situation of health services
in each state and the need to establish the Right to Health Care.
•
Filing of a Public Interest Litigation (P1L) to establish the constitutional right to health care
is also under consideration.
These are some of the steps being planned to move towards establishing the Right to health care.
Let us join this campaign and strengthen the movement to achieve health care and health for all!
Jan Swasthya Abhiyan
Let’s all join the fight,
___________________For health as a basic right!
For further details contact: E)r. Ekbal (National Convenor) - ckbal@vsnl.com
Amit Sengupta (Jt. Convenor) - ctddsf@vsuJ.com
T. Sundararaman (Jt. Convenor) - sundar2@123india.com
Ihclma Narayan (Jt. Convenor) - sochara@vsnl.com
Ami lava Guha (J I. Convenor) - finrai@vsnlnct
Abhay Shukla (Jt. Convenor and National Secretariat) — cehfltpun@vsnl.com
Vandana Prasad (Member, National Secretariat) - chaukhat@vahoo.com
N.B. Sarojini (Member, National Secretariat) - samsaro@nda.vsnl.net.in
□
Protocol to document cases of
Denial of Right to Health Care
I
I
I'he purpose of these case studies is to demonstrate how specific persons have been denied
basic health care that is expected from Public health services. I'he idea is to capture events where
obvious and major violations have taken place, leading to loss of life, disability, serious health or
economic consequences. We should focus on availability of those services, regarding which the public
health system cannot deny its responsibility. The idea is to document structural deficiencies and not
cases of negligence by individual doctors or staff. However, lack of availability of required medical
staff when required, because of significant understaffing should be documented. The objective is not
to target individual public health care providers, but rather to document the serious structural
deficiencies that exist, which need to be corrected by major strengthening of the public health system.
Some of the major types of cases of this kind are outlined below, however any other similar
cases, which come to the attention of activists, can be documented.
Sonic types of cases of denial of Right to Health Care
(1 his is not an exhaustive list but rather outlines certain broad categories with examples)
A. General Emergencies: Cases where a patient with a serious medical problem has been taken to a
Govt, health centre or hospital (PIIC / Rural / Cottage / Sub-divisional / District Hospital) and has
been denied the life-saving or stabilising services expected at that facility. The patient may have
unnecessarily been referred to a higher facility, leading to delay in treatment and serious adverse
consequences, including death. Examples may include non-availability of:
• In a PIIC - Non-availability of treatment for snakebite or Anti-rabies vaccine; Non-availability
of treatment for a child with pneumonia or severe dehydration due to diarrhea resulting in death
• In a Rural hospital-. Above or Lack of blood transfusion for a bleeding patient due to accident or
bleeding related to pregnancy; Non-availability of emergency drugs leading to serious delay in
treatment and death or disability of the patient
• In a Cottage / Sub-divisional / District Hospital: Above or Non - availability of emergency
surgery leading to death or disability of the patient; non-availability of essential or emergency drugs
B. Women’s health care: Women should receive certain basic health care related to both
reproductive and non-rcproductive health problems. Denial may include for example:
• Maternal Health Care-. Lack of facility or performance of a normal delivery in a PHC or higher
facility; lack of facilities for necessary cesarean operation in Rural hospital or higher facility;
unavailability of blood transfusion service to a woman before, during or after delivery; lack of
abortion facility leading to septic abortion or other adverse consequences
• Care for burns: A woman reporting with bums in a Rural hospital or higher facility and not
receiving care for bums
C. Major chronic illnesses: Any facility, PHC or above not regularly giving full range of
medication to patients with T.B. leading to deterioration of the patients condition including death;
Sub-divisional hospital or higher facility not treating/admitting a case of AIDS
D. Outbreak of immunisable or other major preventable illness such as measles, cholera, epidemic
hepatitis or malaria - due to failure of basic preventive or public health measures.
E. Mental Illnesses - Patients who have been denied health care for mental illness in a CHC or
higher facility
Some guidelines for activists documenting the case studies.
• At least two case studies should be collected from each district / by each organisation. The
attempt should be to document cases where denial of health care has resulted in significant loss to
the patient, either in physical or financial terms, to strengthen the case for a human rights
violation. Document only those case studies where incidence of denial has taken place in the last 6
months. Collect at least half of the case studies concerning women who have been denied health
care. Any case papers / prescriptions or other relevant documents should be collected as supportive
documents.
• Take oral consent of the person from whom the information will be elicited. Give that person
information about the campaign. Tell him / her that the case study may be presented to NHRC, and
in such case would have relevant implications. Fill the questionnaire only after taking oral consent
from the person.
1
Primary Health Center/ Govt. Hospital Services - Survey Questionnaire
Name of patient-
AgeSexc
Address-
Date of interview —
,
J- 0,
Details of care received at PHC / Hospital
♦
Location ol the Pl IC / Location and type of Hospital
♦
Illness / complaints for which PI IC / Hospital was visited -
4 Total Number of visits to PI IC / I lospital for this illness
4 Date of last visit -
1. History of last visit in the patients / attendants words (Here we want to collect information regarding the main symptoms of the patient, who gave
care and what kinds of examination, investigation and treatment were given)
I
•
What were the perceived shortcomings or deficiencies in care? (As perceived by the
patient or attendants)
♦ According to patient, was there any adverse outcome because of deficient care? (Death,
disability, continued or chronic health problem, severe financial loss e.g. major loan or
sale of assets)
2. Medical attention received:
♦ Name of the doctor who attended kv-you -
If the doctor was not available at that time, then who attended to you 1. Nurse / ANM
2. MPW
3. Pharmacist
4. Any other person, specify
♦ How long after you reached the PHC / Hospital did the Medical Officer / Doctor attend te^©u?
♦ Was examination / treatment / operation delayed or denied because of non-availability of
a nurse, doctor or specialist?
2
♦
In case ol an emergency did the doctor immediately attend to the patient? During hospital
slay, regarding conditions that required immediate care, was the doctor available to
immediately attend to the patient?
♦
Were nurses or hospital sta O'a vailable to attend to the patient as and when required?
c
o
♦
Do you think that non-availability of any crucial equipment or supply (oxygen,
incubator, anaesthetic equipment, blood, emergency drugs etc.) adversely affected the
quality ofcarc?
♦
Were all the equipments required for the examination and treatment of the patient
available in working condition in the hospital?
Diagnosis- (as told by the doctor)
3. Medicines:
♦
Did you get all the required medicines at the PI IC / 1 lospital?
o
♦
Did you have to go to any private medical shop to buy
♦
If so, which medicines you had to buy from private medical shop?
♦
How much did it cost?
♦
Do you have the prescription?
some medicines?
4. Expenditure:
♦
Case paper / card made - yes/no
♦
Case paper fee / indoor fees charged
3
♦
Did you receive a receipt for the payment made?
♦
Were you charged excess money at the Pl 1C / I lospital (more than specified rates)?
♦
If yes, how much excess was charged?
♦
Did your family have to sell assets (land, cattle, jewelry etc.) or take loans to pay for
treatment in the Govt, hospital?
5. Referral:
♦
Was the patient refused admission or referred to another hospital without giving first aid
care?
♦
If the patient was referred, was ambulance or other vehicle made available for the same?
♦
Did the Govt, doctor ask you to avail of any private services (e.g. laboratory services.
Sonography / X ray) while you were admitted in the Govt, hospital?
♦
In case you had to take the patient to a private hospital, which hospital? (name and
address of the hospital)
♦
What was the total expenditure on care at the private hospital / private lab or imaging
centre?
♦
Did your family have to sell any assets (land, cattle, jewelry etc.) or take Ioans to pay for
the private hospital charges?
4
The Right to Health Care is a Basic Human Right!
Towards attaining the Right to health care...
I he Government of India has been unable to fulfill it’s commitment of ‘ Health for All by 2000
A.D.’ till now. In fact, primary health care services are becoming more and more difficult to obtain
for people living ^specially in urban slums, villages or remote tribal regions. The condition of
government hospitals is worsening day by day. Nowadays, in most of the Government hospitals there
is inadequate staff, the supply of medicines is insufficient and the infrastructure is also inadequate.
There are very inadequate facilities for safe deliveries or abortions in Govt, hospitals. Given the fact
that women do not even get adequate treatment for minor illnesses such as anaemia, services for
problems such as the health effects of domestic violence remain almost completely unavailable. At the
village level, there is no resident health care provider to treat illnesses or implement preventive
measures. All hospitals are located in big cities, and here too public hospitals are increasingly starved
of funds and facilities. T hus there is lack of availability of government health care services on one
hand and the exorbitant cost of private health services on the other. This often leaves common people
in rural areas with no other option but to resort to treatment from quack doctors who often practice
irrationally. I bus most of the population is being deprived of the basic right to health care, which is
essential for healthy living.
The Indian Constitution has granted the ‘Right to Life’ as a basic human right to every citizen of
India under article 21. In article 47 of the Directive Principles of the Indian Constitution, the
Government’s ^responsibility concerning public health has also been laid down. Yet the Government is
backtracking from fulfilling this responsibility. This is obvious from the fact that the Governments
proportion of expenditure on public health services has been declining in successive years.
What can be done in the near future to establish the Right to Health Care?
The year 2003 is the silver jubilee year of the 4 Health for all* declaration. On this occasion, Jan
.W"
Swasthya Abhiyan is launching a nationwide campaign to establish the Right to health care as a basic
human right. Some of the following activities are being taken up as part of this campaign•
We can document case,studies of ‘denial of health care’ in our areas. This process has
already started in Maharashtra. Information is being collected in a specific format with the
help of a questionnaire. The cases where denial of health services has led to the loss of life,
physical damage or severe financial loss of the patient are being emphasised. These case
studies would be presented to the National Hyman Rights Commission. These case studies
■ ■•W-
would help us to depict the real status of provision of the primary health services by the
government, would strengthen our demand for improving public health services and would
help us in dialoguing with the public health system.
I
•
On the occasion of completing 25 years of the Alma Ata Declaration, a National
Workshop is being organised by JSA on 5lh September 2003 in Mumbai, for JSA activists
from all over the country. During this workshop, the perspective, issues and campaign
strategy regarding Right to Health care would be discussed in detail, and the cases that have
been documented would be shared. This would be followed by a National Public
Consultation on “Right to Health Caref1 on 6th September in Mumbai. The Chairman of
NIIRC, the Chairperson and Secretary of the Health committee of NHRC and the Health
Secretary, Central Ministry of Health and f amily Welfare are being invited to this programme
which will be in the nature of a public hearing. Various public health experts and legal experts
will also speak during this program about the Right to Health Care. Selected case studies of
denial of right to health care will be presented to the Nl IRC, and an attempt would be made to
build a social consensus on this issue, so that this can be established as a legal right.
•
A report on “ Status of Health Care in India” Is under preparation, which would give an idea
about the availability of health care services, differentials in accessibility to these services,
state of health care financing and issues related to health care services for specific sections of
the population. Well-known public health experts are authoring various chapters of this
report. This report could be released in various State capitals, along with case studies and
other information related to the slate. This could be done during the ‘People’s Health
Assembly anniversary’ from 1st to 8‘,, December 2003 (anniversary of the Kolkata and Dhaka
Health Assemblies) and would also be an occasion to highlight the situation of health services
in each state and the need to establish the Right to Health Care.
•
Filing of a Public Interest Litigation (PIL) to establish the constitutional right to health care
I,
is also under consideration.
These are some of the steps being planned to move towards establishing the Right to health care.
Let us join this campaign and strengthen the movement to achieve health care and health for all!
Jan Swasthya Abhiyan
Let’s all join the fight,
_______________________________ For health as a basic right!
I
For further details contact: Dr. Ekbal (National Convenor) — ckbal@vsnl.com
Amit Sengupta (Jl. Convenor) - ctddsf@vgnl.com
T. Sundararaman (Jl. Convenor) - gundar2@) 23india.com
I he 1 ma Narayan (Jl. Convenor) - sochara@vsnl.com
Ami lava Guha (Jl. Convenor) - fmrai@vsnl.net
Abhay Shukla (Jt. Convenor and National Secretariat) — CChatpun@VSnl.COm
Vandana Prasad (Member, National Secretariat) - chaukhat@Yahoo.com
N.B. Sarojini (Member, National Secretariat) — samsaro@nda.vsnl.net.in
2
o
Protocol to document cases of
Denial of Right to Health Care
I he purpose ol these case studies is to demonstrate how specific persons have been denied
basic health care that is expected from Public health services. The idea is to capture events where
obvious and major violations have taken place, leading to loss of life, disability, serious health or
economic consequences. We should focus on availability of those services, regarding which the public
health system cannot deny its responsibility. The idea is to document structural deficiencies and not
cases of negligence by individual doctors or staff. However, lack of availability of required medical
staff when required, because of significant understaffing should be documented. The objective is not
to target individual public health care providers, but rather to document the serious structural
deficiencies that exist, which need to be corrected by major strengthening ofthe public health system.
Some of the major types of cases of this kind are outlined below, however any other similar
cases, which come to the attention of activists, can be documented.
Sonic types of cases of denial of Right to Health Care
('Ihis is not an exhaustive list but rather outlines certain broad categories with examples)
General Emergencies: Cases where a patient with a serious medical problem has been taken to a
Govt, health centre or hospital (PHC / Rural / Cottage / Sub-divisional / District Hospital) and has
been denied the life-saving or stabilising services expected at that facility. The patient may have
unnecessarily been referred to a higher facility, leading to delay in treatment and serious adverse
consequences, including death. Examples may include non-availability of:
• In a PHC - Non-availability of treatment for snakebite or Anti-rabies vaccine; Non-availability
of treatment for a child with pneumonia or severe dehydration due to diarrhea resulting in death
• In a Rural hospital-. Above or Lack of blood transfusion for a bleeding patient due to accident or
bleeding related to pregnancy; Non-availability of emergency drugs leading to serious delay in
treatment and death or disability of the patient
• In a Cottage / Sub-divisional / District Hospital: Above or Non - availability of emergency
surgery leading to death or disability of the patient; non-availability of essential or emergency drugs
B. Women’s health care: Women should receive certain basic health care related to both
reproductive and non-reproductive health problems. Denial may include for example:
• Maternal Health Care-. Lack of facility or performance of a normal delivery in a PHC or higher
facility; lack of facilities for necessary cesarean operation in Rural hospital or higher facility;
unavailability of blood transfusion service to a woman before, during or after delivery; lack of
abortion facility leading to septic abortion or other adverse consequences
• Care for burns: A woman reporting with bums in a Rural hospital or higher facility and not
receiving care for bums
C. Major chronic illnesses: Any facility, PHC or above not regularly giving full range of
medication to patients with T.B. leading to deterioration of the patients condition including death;
Sub-divisional hospital or higher facility not treating/admitting a case of AIDS
D. Outbreak of immunisable or other major preventable illness such as measles, cholera, epidemic
hepatitis or malaria — due to failure of basic preventive or public health measures.
E. Mental Illnesses - Patients who have been denied health care for mental illness in a CHC or
higher facility
Some guidelines for activists documenting the case studies.
• At least two case studies should be collected from each district / by each organisation. The
attempt should be to document cases where denial of health care has resulted in significant loss to
the patient, either in physical or financial terms, to strengthen the case for a human rights
violation. Document only those case studies where incidence of denial has taken place in the last 6
months. Collect at least half of the case studies concerning women who have been denied health
care. Any case papers / prescriptions or other relevant documents should be collected as supportive
documents.
• Take oral consent of the person from whom the information will be elicited. Give that person
information about the campaign. Tell him / her that the case study may be presented to NHRC, and
in such case would have relevant implications. Fill the questionnaire only after taking oral consent
from the person.
1
Primary Health Center/ Govt. Hospital Services — Survey Questionnaire
Name of patientAgeScxc
Address-
Details of care received at PHC / Hospital
♦
Location of the PHC / Location and type of Hospitalj
♦
Illness / complaints for which PHC / Hospital was visited —
4 Tbtal Number of visits to PI IC / Hospital for this illness
4 Date of last visit -
1. History of last visit in the patients / attendants words (I lere we want to collect information regarding the main symptoms of the patient, who gave
care and what kinds of examination, investigation and treatment were given)
I
•
What were the perceived shortcomings or deficiencies in care? (As perceived by the
patient or attendants)
♦ According to patient, was there any adverse outcome because of deficient care? (Death,
disability, continued or chronic health problem, severe financial loss e.g. major loan or
sale of assets)
_ . i"'
2. Medical attention received:
♦ Name of the doctor who attended kr-yon -
If the doctor was not available at that time, then who attended to -you 1. Nurse /ANM
2. MPW
3. Phannacist
4. Any other person, specify
♦
How long after you reached the PHC / Hospital did the Medical Ofllcer / Doctor attend te-
♦
Was examination / treatment / operation delayed or denied because of non-availability of
a nurse, doctor or specialist?
2
♦
In case of an emergency did the doctor immediately attend to the patient? During hospital
stay, regarding conditions that required immediate care, was the doctor available to
immediately attend to the patient?
♦
Were nurses or hospital stafTavailable to attend to the patient
as and when required?
O
♦
C
Do you think that non-availability of any crucial equipment or supply (oxygen,
incubator, anaesthetic equipment, blood, emergency drugs etc.) adversely aflected the
quality ofcarc?
o
♦
Were all the equipments required for the examination and treatment of the patient
available in working condition in the hospital?
Diagnosis- (as told by the doctor)
3. Medicines:
♦
Did you get all the required medicines at the Pl IC / I lospital?
o
♦
Did you have to go to any private medical shop to buy some medicines?
♦
If so, which medicines you had to buy from private medical shop?
♦
I low much did it cost?
♦
Do you have the prescription?
4. Expenditure:
♦
Case paper / card made - yes/no
♦
Case paper fee / indoor fees charged
3
♦
Did you receive a receipt for (he payment made?
♦
Were you charged excess money at the PI IC / I lospital (more than specified rates)?
♦
If yes, how much excess was charged?
c
Did your family have to sell assets (land, cattle, jewelry etc.) or take loans to pay for
treatment in the Govt, hospital?
5. Referral:
♦
Was the patient refused admission or referred to another hospital without giving first aid
care?
If the patient was referred, was ambulance or other vehicle made available for the same?
♦
Did the Govt, doctor ask you to avail of any private services (c.g. laboratory services,
Sonography / X ray) while you were admitted in the Govt, hospital?
♦
In case you had to take the patient to a private hospital, which hospital? (name and
address of the hospital)
♦
What was the total expenditure on care at the private hospital / private lab or imaging
centre?
♦
Did your family have to sell any assets (land, cattle, jewelry etc.) or take loans to pay for
the private hospital charges?
Page 1 o
From:
“Jose Utrera" <iose utrera@wemos nl>
To:
Sent:
Attach:
Subject:
Thursday, December 04, 2003 3:28 PM
Globalisation and the right to health - presentation Canada&Germany.ppt
from Memos case study and presentation Germany
<scchara@vsnl.com>
Dear Thelma,
Greetings from Holland, it is good to hear from you. i had the intention to write you this week, so i do it
now Did you have a good trip in Germany?
As you asked to Annelies I am sending you attached a copy of Wemos’ presentation in Germany
I wanted to ask you m SEND US AS SOON AS POSSIBI E THE PROPOSAL FOR THE CASE STUDY OF
COMMUNITY HEALTH CELL. After receiving it we need to write a contract that Wemos and CHC should
sign in order to transfer the financial resources for carrying out the case study It is so that we need at
ieast to sign the contract before the end of next week,, so that the authorization for the payment is
approved before the end of the year, otherwise we will lose the money because the resources tor the
case studies car not be transferred to next year. The Wemos administration will close by December 18
SO WE NEED TO ARRANGE IT WITHOUT DEI AY
so
It will be a pity if CHC does not get rhe
resources for carrying out the case study.
I hope you will find the time to write the proposal very soon. As you know, Wemos doesn’t need an
extensive proposal, only 3-4 pages, i sent you before the guideline for writing the proposal, if you need it
anain l^t msi knnw
Regards to Ravi and every body there.
All the best!
Jos& (Jtrera
Project Manager
Health and the Role of the Private Sector
Please reply to tose utrera^wempsru
tel +31-20-4352059
Minder schulden, een betere gezondheid. Steun onze oproep voor
schuidkwijtscheidinq. Kijk op http://www.wemos.nl/campagne
iST
Drop the debt foi better health. Support our campaign for debtrelief. See
httpjTwww, wenips. ni/campagne
Wemos Foundation, P.O. Box 1693. 1000 BR Amsterdam, The Netherlands
tel +31-20-4352050, fax +31-20-4.686.008 http://www wemos.nl
The following seciion of ibis message contains a file attachment
prepared for transmission using rhe Internet MIME message format
If you are using Pegasus Mail, or any other MIME-ccmipliant sysiern,
you should be able to save it or view it from within your mailer.
-— File information--------File: Globalisation and lhe right to health - presentation Canada&Germany.ppt
Date: 10 Nov 2003; 10:18
Size: 107008 bytes.
12/5/03
r
MOVING TOWARDS A CAMPAIGN ON RIGHT TO HEALTH AND HEALTH CARE ■
INDIAN CONTEXT
Analysis of cases related to Access to Health Care
Project Assignment
Interface of Law, Health and Medicine
Submitted by
Amulya Nidhi
ID No. ML&E521/2002
2002-2004
NATIIONAL LAW SCHOOL OF INDIA UNIVERSITY
BANGALORE
JUNE 2004
Movnig tiaras a cwnpagn on Rigtrt ro Heartii and Health Care. Indien context - Amulya Nldhi
I
ACKNOWLEDGEMENT
My inspiration to work in the area of Right to health has developed while
interacting with several groups across the country through Jan Swasthya
Abhiiyan. I am grateful to them for channelising my efforts in a proper
direction. I would like to deeply acknowledge the contribution of Ms. Shelley
Saha, who provided valuable inputs in conceptualizing and for specific response
to various drafts. I am also thankful to Dr. Abhay Shuk/a Dr. Anant Phadke for
his time and feedback given for this project.
I wouid also tike to acknowledge the libraries of Centre for Enquiry into Health
and Allied Themes (CEHAT), Mumbai, Pune, Indore and National Centre of
Advocacy Studies, Pune. In addition I would like to thank my colleague Kaja!
Jain for providing me time so as to complete this project. I recognize the
financial and organisational support provided to me by CEHA T for pursuing this
course.
Moving towards a campaign on Right to Heatth and Health Care: Indian context - Amutya Nidhi
2
TABLE OF CONTENTS
Abbreviations
I.
Hearth in todays context
5
II.
Right to health and health care - Conceptual framework
8
III. Legal provisions related to Right to health and health care
12
IV. Demal of Right to health care
16
V. Ways ahead - Building a Campaign on the Right to health and health care
20
VI. Conclusions and Recommendations
24
References
4
I
Moving towards a campaign on Right to Health and Health Care: Indian context - Amufya Nidhi
■
3
ABBREVIATIONS
: Adivasi Mukti Sanghthan
: Convention on the Elimination of All Forms of Racial Discrimination
: Centre For Enquiry into Health and Allied Themes
: Consumer Protection Act
: Expanded programme on immunization
: Growth, Oral rehydration, Breastfeeding, Immunization Female literacy,
Family planning and Food supplements
:
International
Covenant on Civil and Political Rights
ICCPR
: International Covenant of Economic, Social and Cultural Right
ICESCR
: Infant Mortality Rate
IMR
: Jan Swasthya Abhiyan
JSA
: Multi Purpose Worker
MPW
: National Family Health Survey
NFHS
: Non-Governmental Organisations
NGO
: National Health Policy
NHP
: National Human Rights Commission
NHRC
: Primary Health Care
PHC
: Public Interest Litigation
PIL
SPHC : Selected Primary Health Care
: Universal Declaration of Human Rights
UDHR
: United Nations International Children's Emergency Fund
UNICEF
: World Health Organisation
WHO
AMS
CEDAW
CEHAT
CPA
EPI
GOBIFFF
Moving towards a campaign on Right to Health and Health Can: Indian context - Amulya Nidhi
4
1.
HEALTH IN TODAY’S CONTEXT
INTERNATIONAL SCENARIO:
In 1978, at Alma Ata the World Health Organisation (WHO) and the UNICEF presented a radical new
strategy as a part of the target of achieving ‘health for all by the year 2000’. Important principle of the AJma
Ata declaration is that health for all can be achieved through primary health care (PHC). It says, “that
primary health care is the key to attaining this target. It is essential health care based on practfoal.
scientifically sound and socially acceptable methods and technology made universally accessible to
individuals and families in the community through their full participation,,1. The central message of the PHC
strategy was a call for equity and social justice.
Such a radical strategy was bound to have its opponents. Within a year of signing the declaration, an
alternative approach to PHC, the selected primary health care (SPHC) was being widely disseminated. This
approach argued that PHC is not oost-effective, in fact it was too expensive. A more effective metho-d of
decreasing mortality and morbidity lay in the selection and prioritisation of selected number of diseases2.
This approach quickly gained acceptance among donors. UNICEF introduced the growth, oral rehydrabon.
breast feeding, immunization female literacy, family planning anf food supplements (GOBIFFF). The
expanded programme on immunization (EPI) was given considerable support by multi-national donors.
These selective programmes are, as Rifkin and Walt have argued, a departure from the key principles of
PHC3. Its approach is efficiency rather than equity; the market rather than social justice; the disease raiher
• than social, economic and political development. The WHO’s Strategy of ‘Health for All for the 21* Century’
is a benign neglect for those who cant afford to be part of the market4. For the poor, of both South and
North, health for all for the 21* century will not lead to a world where health will be a fundamental human
right - a state of complete physical, mental and social well-being and not just the absence of disease and
infirmity.
NATIONAL CONTEXT
Health Policy
In the first two Five-year Plans following India’s independence there appeared to be a commitment to
address the health needs of the populations comprehensively - with preventive, promotive and curative care
provided through a wide network of community based health centres, in tune with the recommendations of
the Bhore Committee. But in the years that followed, the health sector was driven by technological forces
and has become physician centred, reducing the pursuit of health to the provision of medical care, ignonng
the broader determinants of health5.
Despite significant strides in eradicating communicable diseases and smallpox and in containing malaria and
tuberculosis, the health status of vast majority of the people are far from satisfactory. Even though the
country had aimed at attaining health for ail by year 2000 it has become a distant dream even in the
beginning of 21* century. The 1983 National Health Policy (NHP) was meant to arrive at *an integrated,
comprehensive approach towards the future development of medical education, research and health
services to serve the actual health needs and priorities of the country"8. Critical of the curative model of
' Intemationai Conference on Primary Hearth Care, ^irna Ata, USSR, 6-12 September, (1978).
2 J.A. Walsh and K.S. warren, 'Setecbve Primary Health Care’, 301 (18) New England Journal of Madkine, 967-74 (1979).
3 S B. Rifkin and G. Wait, 'Why Health improves: Defining the issues concerning Prin«y Health care and Setective Primary Health Care’. 23(6)
Social Saence and UMkine (1988).
4 WHO ’Investigating in Health Research and DevetopmenT, World Health Organisation (1996).
5 S, Saha and TKS Ravinctan, ’Gender gaps in Research on Health Services in Inda*, 4 (2) Journal of Health Management, 18S-214 (2002).
6 Government of Inda, ’Statement on National Health Policy’, Ministry of Health and Family Wertare, New Delhi, (1982).
Wovmg towards a campagi on Right to Health and Health Care; Indian context • Amulya Nidhi
5
health care, it emphasised a primary health care approach to prevent illness and promote good health. The
next decade saw the rural health infrastructure develop with a massive expansion of primary health carefacilities. However, this effort was sabotaged by a combination of poor quality facilities, inadequate supplies,
ineffective managerial skills, poor planning, monitoring and evaluation. The private health sector has grown
phenomenally since, thanks to state subsidies in the form of medical education, soft loans to set up medical
practice, etc. accounting for 70-80 percent of all primary care sought, and over 40 percent of ail hospital
care, in a country where over three-fourths of the population lives below subsistence level. In fact the Draft
National Health Policy released by the Ministry of Health and Family Welfare in 2001 further legitimized
these trends. It completely omits the very concept of comprehensive and universal health care. The Draft
departs from the fundamental concept of the NHP1983 and the Alma Ata Declaration. The draft, for all the
rhetoric on community participation, is replete with “top down’ prescriptions. While admitting the wastage
involved in running centrally sponsored vertical programmes, it goes on to recommend that we would need
to retain many of them!7 The draft legitimizes further pnvatization of the heath sector.
Therefore today we find that the private sector has virtual monopoly of ambulatory curative services in both
rural and urban areas and over half of hospital care. The health care market is based on a supply-induced
demand and leading to an increase of the cost of health services. Thus India today has a large, unregulated,
poor quality, expensive and dominant private health sector, and an inadequately resourced, selectively
focused and declining public health sector.
Besides not formulating people’s friendly health policy, the State’s insufficient commitment to provide health
care for its citizens is reflected in the inadequacy of the health infrastructure, low levels of financing and also
in declining support to vanous health care demands of the people. Under structural adjustment since 1991
there has been further compression in government spending in its e forts to bring down the fiscal deficit to
the level as desired by the World Bank. This global pressure on tne Indian State is evident through its
policies of focusing on selective services, for instance RCH and AIDS receive overriding support over
primary health care or basic referral services. Another trend that further reduces access is the increasec
corporate control of health care. New medical technologies have helped complete the commodification of
health care.
Given the above context, it is natural that health status of the Indian population would be unsatisfactory
There is no dearth of evidence to show that India’s health indicators are one of the worst in the world. India's
population is characterised by high levels of morbidity especially among infants and children, women, and
the elderly; and high incidence of communicable diseases associated with low levels of sanitation, puoiic
hygiene and poor quality of drinking water8. Infact the latest Human Development Report shows a downward
trend in India’s global ranking9. For millions of people the enjoyment of the right to health remains a distant
goal.
Health Infrastructure
India has a vast health sector, which is broadly divided into the public sector, the private sector and the
household. The public sector is comprised of the health care facilities set up by central and the state
governments, municipal and local bodies. The private sector consists of private physicians and a range of
other practitioners including those practicing non-allopathic systems of medicine, health facilities and
corporate hospitals operating for profit and non-governmental organisations (NGOs) operating as non-profit
enterprises. Households or self-medication provide first level care in many settings as in many places as
health services are unavailable or unaffordable to a large section of the population. Various national level
7 Response of the Na^onai Coordnatjon Gommrttee of the Jan Swaathya ^brtyan to Draft National Hearth Ftohcy, 2001 (unpublished).
*.
8 Abusaleh Shanff, India Human Development Report' New Delhi: Oxford Unversty Press for the National Council for Applied Economic
Research (1999).
9 UNDP Human Development Report (2000).
Moving towards a campaign on Right to Hearth and Hearth Care: Indian context - Amufya Mofw
6
studies have shown that people’s utilisation of healrh care is limited by their ability to pay, as well by the
availability of services.
In any case today, studies on household expenditure on medical care have shorn that poor people trend to
seek medical care from the private sector. The irony is that this observation is being seen as a proof of their
“willingness to pay” for treatment costs, while this may be more a reflection of an absence of other options
than an exercise of 'real choice”. These observations have legitimized the introduction of “user fees” in
public health facilities. We need to understand the move to phase out the state owned services in this
context as a logical step towards unregulated primate monopoly in curative medical care.
As argued above, the health sector, today, faces three major challenges: adequate prevention, enhancing
equity in access to health care and health status, and getting more value for money. Unfortunately there are
no significant initiatives in this regard. There is no visible movement to improve imptementation in public
sector, or target public sector expenditure to the poor, or restructure private sector to remedy deficiencies of
health care market through health insurance and appropriate regulation.
METHODOLOGY
Purpose of the research
Having stated the health scenario of our country and having been invoked with various initiatives for righr to
health and health care', I saw this as an opportunity to analyse the concept of 'Right to health and health
care' so as to move awards building a campaign for right to health and health care.
Focus of research
The primary questions researched into, the course of the paper is:
1. What does right to health and health care mean?
2. What are the various legal provisions related to right to health and health care?
3. To exam ne how health care providers in our country are violating these various provisions.
4. What are the various initiatives that have taken place towards achieving right to health and health
care.
Research methodology
This research is an analysis of secondary materials. Primary data is also used for analysis.
Moving towards a campaign on Right to Health and Health Care: Indian context- Amulya N^dhi
7
II.
RIGHT TO HEALTH AND HEALTH CARE - CONCEPTUAL FRAMEWORK
Human rights are legally guaranteed by human rights law, protecting individuals and groups against actions
that interfere with fundamental freedoms and human dignity. They exist to protect individuals from abuses of
state power and obligate states to provide the conditions necessary for prosperity and well being. This does
not mean mat human rights apply exclusively to the relations between the state and the individuals, they,
and the principles underlying them, also inform and structure relationship among individuals, particularly
where there are power inequalities among those involved (eg between health care provider and patient)10.
Human rights empower the poor by granting them rights that are legally guaranteed, while at the same time
imposing obligations on governments and public bodies such as international organizations. Because
human rights are generally legally binding, these bodies are accountable for ensuring that these entitlements
cannot be reauced to mere privileges or luxuries or left to the whim of markets.
Every human being has the right to the highest attainable standard of physical and mental health (referred to
as “right to health’), conducive to living a life in dignity was first reflected in the WHO constitution (1946) and
then reiterated in the 1978 Declaration of Alma Ata and in the World Health Declaration adopted by the
World Health Assembly in 1998. According to the General Comment 14 of the International Covenant on
Economic. Social and Cultural Rights ‘The right to health must be understood as a right to the enjoymeni of
a variety of facilities, goods, services and conditions necessary for the realization of the highest attainable
standard oi Health'1This right is one of the fundamental human rights and is closely related to and
depenaent uoon me realization of other human rights which are the underlying determinants of health, that is
access to safe and potable water, adequate food, nutrition, housing, work and education and on provision of
health care service.
The Right to health care as a component of the Right to Health
Looking 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 incident. It constitutes the
daily denial of a healthy life because of profound structural injustice, within and beyond the health sector
The denial needs to be addressed in a rights-based framework that has gathered momentum in the late
90’s, by systematically establishing the right of every citizen to a healthy life. Right to Health is a part of the
Right to Life the Right to Life with dignity and right to livelihood. Right to health care means having
appropriate, accessible and quality health services for all people. According to WHO, to promote the right to
health, action is required on two related fronts as depicted in figure 1.
Figi
THE RIGHT TO HEALTH
Underiying
Determinants
Health care
In May 2000. the Committee on Economic, Social and Cultural Rights, which monitor the International
Covenant of Economic, Social and Cultural Right adopted a General Comment on the right to health.
10 National Ceors for ^cacy Studios, 'Rtfit to Health*, 3(5) Advocacy Internet, sept-oct (2001).
11 General Comment 14. CESCR, E/C. 12/2000/4. Twenty second session Geneva, 25<Apnl - 12 May (2000).
Moving towards a zamoagn on Right to Health and Health Cae Indian context - Amulya Ndhi
8
General Comment applies to nations that have ratified ICESCR and India is one of the states to ratify it. It
addresses the content of right to health and the implementation and enforcement of the right to health
According to that the following criteria was set to evaluate the right to health a) Availability - adequate number of functioning public health and health care facilities, goods and
services.
b) Accessibility - health facilities should be accessible and affordable to everyone without any
discrimination.
C) Acceptability - all health facilities should be appropriate and sensitive.
d) Quality - health facilities must be scientifically and medically appropriate and of good quality12.
General Comment 14 reaffirms that several “core" obligations have been established in prior human rights
instruments: These core obligations, as well as additional obligatons are presented in Figure 213.
' “
! Figure 2
GENERAL COMMENT 14
OBLIGATIONS REGARDING THE HUMAN RIGHT TO HEALTH
i
Core Obligations Established in Prior International Human Rights Instruments:
I To ensure the nght of access to health facilities, goods and services on a non-discriminatory basis,
especially for vulnerable or marginalized groups:
I To ensure access to the minimum essential food which is nutritionally adequate and safe, to ensure freedom
■ from hunger to everyone;
! To ensure access to basic shelter, housing and sanitation, and an adequate supply of safe and potable
i water;
i To provide essential drugs, as from time to time defined under the WHO Action Programme on Essential
: Drugs;
To ensure equitable distribution of all health facilities, goods and services;
To adopt and implement a national public health strategy and plan of action, on the basis of epidemiological
evidence, addressing (he 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 alt vulnerable or marginalizea groups.
Obligations of Comparable Priority:
To ensure reproductive, maternal (pre-natal as well as post-natal) and child health care;
To provide immunization against the major infectious diseases occurring in the community;
To take measures to prevent, treat and control epidemic and endemic diseases;
To provide education and access to information concerning the main health problems in the community,
including methods of preventing and controlling them;
To provide appropriate training for health personnel, including education on health and human rights.
2Kinney, E D. ^001. The International Human Ri^it to Health: What does this mean for our Nation and World?',
Mian Law Review, pp 14571475.
3 General Comment 14, CESCR, E/C. 12/2000/4. Twenty second session Geneva, 25Apnl -12 May (2000).
Moving towards a campaign on Right to Health and Health C^e: Indin context - Amulya Ndhi
9
A rights-based approach to health entails recognizing the individual characteristics of the population groups
concerned. In the 70s and 80s in India there was an initiative to move from health care centred health
service delivery to community based health worker programmes, trying to provide affordable and rabonai
care to the villages. The same period also saw the emergence of specific campaigns related to drug policy,
hazardous contraceptives, etc. This approach received a setback at the turn of the nineties when resource
commitments in ttie public health sector declined.
This is reflected at one level in slowing down of improvements in health outcomes and the widening ruralurban gap of these outcomes. And at another level the public health care facilities are getting incapacitated
because the necessary inputs that are needed to run these facilities are not being adequately provided for.
The 2002 National Health Policy unashamedly acknowledges that the public health care system is grossly
short of defined requirements, functioning is far from satisfactory, that morbidity and mortality due to easily
curable diseases continues to be unacceptably high, and resource allocations generally insufficient
(MOHFW4). The evidence for this is clearly brought out in the changes one sees across the 42nd and 52nd
Round National Sample Surveys'5, when over this decade utilisation of private health services, especially in
the hospital sector, increased substantially, out-of pocket spending galloped, indebtedness due to heaith
care affected half the users and the proportion of non-utilisation also increased.
Therefore besides having poor health indicators, India also has the dubious distinction of being among the
most inequitous countries of the world, as far as health status of the poor compared to the rich is concerned.
What is even more serious is the fact that these inequities, instead of decreasing over time, are increasing.
Some striking facts in this regard are16 • Infant mortality among the economically lowest 20 percent of the population is 109, which is 2.5 times
the infant mortality rate (IMR) among the top 20 percent population of the country.
• Under-five mortality among the economic bottom 20 percent of the population is 155, which is not omy
unacceptably high but is also 2.8 times the rate of the top 20 percent.
• Child mortality (1-5yrs age) among children from the 'Low standard of living index1 group is 3.9 times
that for those from the 'High standard of living index' group according to recent NFHS data.
• Tribals, who account for only 8% of India's population, bear the burden of 80 percent of malarial deaths
in the country.
Such gross inequalities are of course morally unacceptable and are a serious social and economic issue,
and also exemplify the impact of globalisation-liberalisation policies in widening the gap between the rich
and the poor. In addition, such a situation may also be considered a gross violation of the rights of the
deprived sections of society, an invisible daily Holocaust. This becomes even more serious when viewed in
the context of gross disparities in access to health care17• The richest quintile of the population, despite overall better health status, is six times more likely to
access hospitalisation than the poorest quintile of the population. 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 accounts for 38.5 percent of inpatient days, while the poorest quintile accounts for
just 6.6 percent, out of the total hospitalisation days for the population.
Government o( Inda, ‘Naticnai Heaith Paicy 2002*, Ministry of Heefth and Family Welfare, New Delhi, (2002).
,5NSS-1987:Mo(t><ity and UWisation of Medcai Services, 42"d Rond, Report No. 384, National Sanpie Stiwy Organisation, New Detu; and
NSS-1996:Report No. 441,52* Rand, NSSO, New Delhi, 2000
Ahhay Shukia Creating a oonsensus on the Right to Health Care, Paper presented at National Meeting on Right to Heaith Care, Murrta,
Febntary 14, (2002).
17 Abhay Shuida Creating a ocneensus on the Right to Heaith Care, Paper presented at Natiotwi Meeting on Ri^it to Health Care, Murtoei,
February 14, (2002).
Moving fowanis a campaign on Right to Hearth and Health Can: Indan context - Amulya Nidhi
10
As high of 82 percent of outpatient care is accessed from the private sector, which is 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. This often pushes the already vulnerable poor into indebtedness, and in over 40 percent of
hospitalisation episodes, the costs are met by either sale of assets or taking loans.
•
It is at this context the issue of ‘Right to Health and Health Care’ is being raised today. The next chapter
would highlight how this right can be addressed.
Moving towards a campaign on Rigflt to rieM and Health Care. Indian
Amulya Ndhi
11
HI. LEGAL PROVISIONS RELATED TO RIGHT TO HEALTH AND HEALTH CARE
We can view the justification for this right at three levels - human rights issue, constitutional-legal and socio
economic issue.
Human rights justification
The right to health is solidly embedded in international human rights law. It is explicit in Article 25 of the
Universal Declaration of Human Rights (UDHR), adopted by the United Nations (UN) General Assembly in
1948 (WHO). It is not a treaty but a statement of policy and a call to action much like the Declaration of
independence. It affirmatively states a human right to health18:
"Everyone has the right to a standard of living adequate for the health and well-being of h’mself and of
his family, including...medical care... and the right to security in the event of ...sickness, disability..."
Numerous subsequent international and regional human rights treaties have given further definition to the
right (o health. In (ho 1960*5 the UN sponsored the development of two international covenants that
articulate the human rights recognized in the Universal Declaration of Human Rights. These two covenants
are the International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on
Economic, Social and Cultural Rights (ICESCR).
The International Covenant on Economic, Social and Cultural Rights (ICESCR)-the so-called Economic
Covenant-is the most important in terms of the right to health. Article 12 of ICESCR states that the right to
health includes "the enjoyment of the highest attainable standard of physical and mental health19." The
relevant provisions of this covenant are presented in figure 3.
Figure 3
The International Covenant on Economic, Social and Cultural Rights (ICESCR)
Article 12
i
i 1. The States Parties to the present Covenant 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 ail 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.
A human right to health is also recognized in numerous other international human rights authorities that
establish prohibitions against government conduct that is detrimental to health. Such treaties include the
International Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) of
1979, Convention on the Elimination of All Forms of Racial Discrimination, and the Convention on the Rights
of the Child of 1989. Figure 4 presents the health contexts of these conventions:
3 Urwersal Dedaration of Human Rights. Adopted by the UN Genera Assemtiy Resolution 217 A (III) of 10 Deoetrioer 1948.
19 International Covenant on Economic, Soda and Cultural Rights, Adopted by UN Genera Assemtiy Resolution 2200 A (XXI) of 16
December (1966). Enforced on SJanuary 1976 in accordance with Article 27.
Mowng towards a campaign on Right to Health and Health Care: Indian context - Amulya Nidhi
12
Figure 4
♦ States shall
ensure to (women)
access to spedfic educational information to help to
ensure the health and well-being of families, including information and advice on family
planning
States shall
eliminate discrimination against women in
health care
to
ensure, on a basis of equality of men and women, access to health care services
; ensure.....
appropriate services in connection with pregnancy
States shall
ensure..
. that [women
in rural areas]
have access to adequate health care facilities, including information counseling,
and services in family planning
(Convention on the Elimination of Ail Forms of
Discrimination Against Women, Articles 10,12 and 14)
♦ States undertake to
eliminate racial discrimination
and to guarantee the right of
everyone the right of everyone, without distinction as to race, colour or national or equality before
law,
the right to public health, medical care, social security and social services......
(Convention on the Elimination of All Forms of Racial Discrimination, Articles 5)
♦ States recognize the right of the child to the enjoyment of the highest attainable standard of health i
and to facilities for the treatment of illnesses and rehabilitation of health
(Convention on thy
Rights of the Child, Articles 2420)
J/
K
Also of interest, is the 1993 Vienna Declaration and Programme of Action emphasizes the fundamental inter
relatedness of political and civil human rights and economic social and cultural human nghts. The Vienna
Declaration specifically provides:
“All human rights are universal, indivisible and interdependent and interrelated. The international
community must treat human rights globally in a fair and equal manner, on the same footing, and with
the same emphasis. While the significance of national and regional particularities and various historical,
cultural and religious backgrounds must be borne in mind, it is the duty of States, regardless of their
political, economic and cultural systems, to promote and protect all human rights and fundamental
freedoms.”
The Vienna Declaration has become a crucial principle in international human rights law recognizing the
irreducible truth that all human rights must be recognized if specific human rights are to have concrete
meaning21.
Reference can be made to other similar international conventions, wherein Government of India has
committed itself to provide services related to right to health, for instance the Alma Ata Declaration. National
Human Rights Commission (NHRC) has also concerned itself with this issue of right to health.
Constitutional and Legal Justification
The issue is, how far these international obligations, agreements, treaties and covenants bind the Indian
state and Nationals? Unfortunately, in the Indian Constitution, health is not a fundamental right of citizens,
but has to be inferred from the broader parameters of social and economic justice. For instance, the
Preamble of the Constitution of India directs the State to initiate measures aiming at improving, the health of
the people. The same logic can be stretched to the Fundamental Right - Protection of Life and Personal
Liberty.
Only in the Directive Principles is it categorically stated about State’s responsibility to health of its citizens
and regarding provision of health care. Article 39 states that
20 United Nations Convention on the Rights of the Child, 1989, Adopted by UN General Assembly Resolution 44/25 of 20 November (1989).
21 E.D. Kinney. 'The Intematic i Human Right to Health: What does this mean for our Nation and World?', Indian Law Review, 1457- 1475,
(2001).
Moving towards d campaign on Right to Fia/fh and Health Care: Indian context - Amuiya Nidhi
13
“The state shall, in particular, direct its policy towards securing; that the health and strength of
workers, men and women, the tender age of children be not abused and that citizens are not forced
by economic necessity to enter a vocation unsuited to their age or strength”.
Article 4T22 of the Constitution states that
“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......’
Thus, the article 47 of the constitution under the directive principles of state policies define health both in
general terms as well as and spec ifically in terms of health care. Conceptually, this is a great advantage, as
the healthy living is not construed only to medical care but also of good nutrition and living standards. This
provides a wider scope for legislating on the issue of health and health care.
Though right to health and health care has not been expressly incorporated in the Constitution as a
fundamental right, but due to some pioneering and progressive judgments, right to health has acquired that
status. Scope for such a kind of interpretation has created by the important judgment of the Supreme Court
in the Pasctiim Banga Khet Mazdoor Samiti and others V. State of West Bengal and other, 1996, while
interpreting Article 21 the Supreme Court has indisputably held that providing adequate medical facilities for
the people is an essential part of the obligations undertaken by the Government in a welfare state. Similarly
in the cases Bandhua Mukti Morcha v. Union of India and others, 1982 concerning bonded labourers, the
Supreme Court gave orders interpreting Article 21 as mandating the right to medical facilities for the
workers23. In another landmark judgment in 1995, the Supreme Court stated that right to health and medical
aid of workers during services and thereafter, is a fundamental right24. Similar judgments by Supreme Court
by interpreting Article 21 has established right to treatment in emergency situation, worker’s right to clean
environment and health care facilities, right to privacy as a component of health care and also other aspects
related to issues of quality of health care services25.
Other Constitutional obligations related to health are that Public health and Sanitation is a state subject as
given in the Seventh Schedule, Article 246, list II-6 of the Indian Constitution. This provision assumes
importance as this means that without changing any constitutional provisions, the states can make
provisions for improving public health. The 73rd and 74* Constitutional Amendments Act, 1992 provide for
involvement of Panchayati Raj institutions and Nagar Palikas in all developmental programmes including
Public health.
The Consumer Protection Act (CPA) addresses the aspect of medical negligence in the country. But many
times CPA acts as a hindrance to provision of emergency medical care as doctors are scared that if the
condition of the patient detonates they may be charged for medical negligence.
The social and economic justification
Health as a basic human right should be viewed holistically and its positive aspect, that is well-being should
be acknowledged which would lead to achievement of a socially and economically productive life. The right
to equality encompasses within itself the right to a poor patient to get adequate treatment from the state
irrespective of the cost.
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
22 P.M. Baksrt, The Constitution of I nda’, Deih: Urwarsai Law PliXishtng Co. Pvt Ltd. (2000).
23 A. Shukla, The Rj^it to Health Care Moving from Idea to Reality’, Paper presented in Media Workshop on Key Issues of Hedth and Hedth
Care, 21,t February, Indan Social Institute, New Delhi, organised by CEHAT (2004).
24 Centre for Social Justice 'Constitutional Provisions and Supreme Court Judgments on Right to Health’, Atmecfabad (urpublisbed).
25 S.V. Joga Rao, ‘Fundamental Right to Health and Health Care', Country Report on Status of Health cae, CEHAT, (upublished).
Moving towards a campaign on Right to HeaKn and Health Care: Indian context - Amulya Nidhi
14
proponents of 'economic growth above all1 may de 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 contrbution 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 valuabte... 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)
This chapter briefly dealt with relevant constitutional provisions and legal enactments regarding health. It is
in this enforcement of these obligations that the Courts can play an effective role in safeguarding the rights
of tne citizens. Supreme Court has upheld right to health through some progressive judgments but it should
not be left to the interpretation of judges only. The following chapter would highlight how right to health and
health care has been systematically denied to people.
Mowng towarOs a campap on Ript to HeM’ and f^ Hh Care: Indian context - Amu/ys Hdhi
15
IV.
DENIAL OF RIGHT TO HEALTH CARE
tllSSSSS?
Swasthya Abhiyan. i hese cases were collected by volunteer/staff of CEHAT, activists of Adivasi Mukti
Shoshi!Ja^A^ddan MaZd°Or Chetna San9hatana/Narmada Bachao Andolan and activists associated with
Case Study 1
the mnhtS^E
fl
°f 6 TCmberS " J Village Of 3 b,0CK °f Barwani distnct
the night of 23* June. 2003 his son K had a severe problem of vomiting and loose motions. Next day the
Multi Purpose Worker (MPVO gave him an ORS packet. When no improvement was observed in the child's
condition, it was suggested that he be taken to the nearest Primary Health Centre (PHC), where the medical
officer treated him. But after sometime bleeding started from inside the mouth and nose of the child At
another doctor’s suggesoon, Mr. N had to shift his child to Sendhwa PHC. Due to lack of money he had to
eSge^cy&Stion^
3
The eartier PHC didnl have ambu|an<« for this
LS™Hh?a PJit00’ ne nad to purchase injections and syringes worth over hundred rupees. Later when
SN a
^n°U::' rt *aS su9gested that he take the chi|d to Barwani disffict hospital. But
^mN’h
’^J?0 have money for the ^nsP011 and further treatment and ultimately decided to
come back to home. On the way back home his child died.
This case study demonstrates how a PHC is not able to provide essential health services, not even an
^buance in an emergency condition, to save the life of an ill child. This case shows violation of Right to a
°f basic health servK^ which is guaranteed to us byArtide 21 of the Indian Constitution and aisoMide
24 of the Convention on the Rights of the Child.
Case Study 2:
In this emergency condition, the family had to take the patient to Karuna Hospital where the doctor was
surprised that cathensauon which is easy treatment, could not be given to this old man in the PHC HenJ
the person had to suffer and had to spend Rs. 1200/- on treatment, which could have been freely available.
^^^RXttoe^^'r^iCalcare’ andr^ht to essential drugs at an affordable
cost This case shows that these eolations amount to violation of Wide 21 of the Indian Constitution,
28 The process of Jan Sunwa is presented in the next ch^iter.
Mwng tMfards a cani^ on R-yv to Health and Health Care: Indian context - Amulya Nidhr
16
Artide 12 of the international Covenant on Economic, Sodal and Cultural Rights and also Article 25 of the
Universal Dedaration cf Human Rights.
Case study 3 s
The only family planning service that is mostly provided in the PHC is tubectomy. It is generally conducted in
overcrowded camps held occasionally by the government at the PHCs. The main aim of doctors and ANMs in
these camps is to fulfill the set target and therefore the operations are often done insensitively and in
unhygienic conditions. No attempt is made to explain to the women what is being done to them. Often women
from the interior villages are forced to walk long distances to get home the same day.
In one of these type of camps, Ms. M, a 30 year old women from K village, went to the family planning camp
held at Sondhwa PHC in Sondhwa block. After her operation, which was conducted in overcrowded conditions
she returned home the same day. A week later she went to the PHC to get the stitches removed and returned
home the same day. Two days later she developed severe abdominal pain and was admitted to the civil
hospital in Alirajpur. Here she was diagnosed with tetanus and was also told that treatment will not be possible
in that hospital and she would have to be taken elsewhere. Since the family did not have the money for further
expenses they took her back home where she died three days later.
♦He^reJn 10356 °f 2egligence by the 90vemn^nt health facility and reflects the over-keenness of its personnel
to fumll their agenda and targets rather than provide quality health services. Also there is extreme insensitivity
as when she was detected to have suffered from tetanus they simply referred her abdicating themselves of ail
moral responsibility of heath care provider.
This case shows the violation of Right to monitoring and accountability mechanisms and the Right to privacy
and the provisions that was spedally provided to women under various artides of CEDAW.
Case Study 4
Mr. N, age 65 years, resident of taluka Mokhada had diarrohea. On June 7, 2003 after four to five bouts of
loose motions he got dizzy, broke into a cold sweat and became semi-conscious. His wife and some other
villagers carried him to the Khodala PHC and the wife went to look out for the lady doctor. It was about 5.00
p.m. The wife met the doctor and told her about her husband's condition. The doctor got very irritated and told
the woman that her duty hours were over and she was about to go home. She then asked her to move the
patient to Mokhada Rural hospital and left the premises. The woman then went to the residences of the three
resident nurses and begged them to treat her husband. They refused saying that they were not on duty and
the nurse on night duty would attend to him. The nurse on night duty never turned up so once again she went
to the houses of the resident nurses. Finally one nurse Ms. Z took pity and came to the PHC. She gave the
patient an injection and administered a bottle of saline. The nurse told them they could not stay in the PHC as
there was nobody to attend to them, and she could not stay any longer. Finally the patient was taken to a
pnvate doctor, Dr. K in Khodala. He administered another bottle of saline and asked them to go home and
return the next day as there was no facility to admit him. The patient spent a total of Rs. 300 for treatment with
the pnvate doctor.
4 patient with diarrhoea, requiring rehydration could not get admission in a PHC. The doctor, supposed to be
on call around the dock, refused to attend to the patient and no nurse was available to attend to an admitted
Patient, forcing the relatives to pay for the expensive services of a private doctor. This case shows the violation
of Right to emergency medical care. This case shows that besides violating Article 47 of the Constitution it
also violated provisions of the International Covenant on Economic, Sodal and Cultural Rights and Universal
Dedaration of Human Rights, which India is a signatofy.
Moving towards a campaign on Right to Health and Health C&e: Indian context-Amulya Nidhi
17
Case Study 5
Mr. M, age 44 years, resident of Taluka Mokhada, fell from a tree on IS” November 2003. He was brought to
the Mokhada Rural hospital immediately. The doctor admitted him and asked the relatives of the patient to
purchase two bottles of saline, which were administered to him. They then asked them to shift the patient to
Nashik Civil Hospital and informed them to hire a private vehicle as no ambulance was available. The next day
the patient was taken to Nashik Civil hospital where he was admitted. The doctors there advised the relatives
to take him to a private hospital for a C.T. scan as the equipment in the Civil hospital was out of Older. The
relatives could not afford a C.T. scan so the patient was discharged after fourteen days and has now become
crippled due to lack of proper treatment.
A taluka level Rural Hospital there was no ambulance available to transport such a needy patient. The Civil
Hospital in a large city like Nashik could not provide the CT scan facility, resulting in a person becoming
permanently disabled due to denial of health care. This case shows the violation of Right to a set of basic
public health services. Article 12 of the International Covenant on Economic, Social and Cultural Rights, which
says that everyone has the right to the enjoyment of highest attainable standard of physical and mental health
and also the interpretation of Article 21 of the Constitution as mandating the right to treatment in emergency
situation.
Case Study 6
Mr. G, age 2 years, was suffering from diarrohea and vomiting. He was taken to the Tokavda PHC by his
mother on the morning of December 25, 2003. The doctor did not examine the child and gave only a packet of
ORS. A couple of hours later the mother informed the doctoi that the child was running temperature. The
doctor did not examine the child but wrote out a prescription for medicine, injection and disposable syringe, all
to be purchased from outside. The child was administered the medicines purchased from the private medical
store and sent home. The next day the mother returned with the child and she was once again asked to
purchase medicines from outside. On the third day the mother did not return with the child as she had no more
money to purchase medicines.
a
Adequate treatment for diarrhoea, one the simplest and commonest illnesses, could not be given by the PHC.
This case shows the violation of Right to essential drugs at an affordable cost, which is guaranteed to us by
Article 21 of the Indian Constitution and also Article 24 of the Convention on the Rights of the Child.
Case Study 7
Mr. J, age 62 years, resident of Dahanu taluka, was suffering from continuous cough and breathlessness for
some time. He approached the Multi Purpose Worker (MPW) of his village working through Kasa PHC for help.
The MPW did not give him any assistance so he came to the Cottage Hospital in Dahanu where an X-ray was
taken, they examined his blood and sputum and directed him to go to the Kasa PHC to get his treatment for
T.B. under the DOTS programme. He was told that the MPW would come to his house and give him his tablets
daily, which he was supnosed to consume in the presence of the MPW. After a few visits from the MPW, he
went on leave for 15 days and the treatment stopped. The patient went to the MPWs house to ask for the
tablets but he refused to give them to him and said that he would personally administer them to him at his
house. After repeated requests to the MPW, the patient complained to the doctor about the abrupt stoppage of
his treatment. The MPW made only one visit gave him tablets for a few days after which the treatment was
stopped till today.
Moving towards a campaiffi on
to Health and Health Care: liman context - Amulya Nidhi
18
Regular treatment for a case of tuberculosis, the core activity of the National TB Control Programme, was
denied despite his taking repeated initiative to obtain treatment ano the patient being enrolled under the muchpublicised ‘DOTS' programme. This case shows the violation of Right to a set of basic public health services.
This is a violation of the International Covenant on Economic. Social and Cultural Rights and also the
provisions guaranteed by the constitution.
Case Study 8
Ms. U, age 12 years, resident of Jawhar taluka went to school on 27th November 2003 as usual, after an early
lunch at about 10.00 a.m. She vomited three times in school and then came home. She continued vomiting a
number of times. At about 7.00 p.m. when her parents returned from work they rushed her to the Jawhar
Cottage Hospital. She was admitted in the hospital, given one injection and some tablets but her vomiting did
not stop. Her father requested the nurse on duty to attend to her but she did not pay any heed instead she
scolded the parents, saying that the girl was dirtying the hospital. The parents were asked to give her glucose
water orally which they administered the whole night The girl could not sleep, she had high fever and she was
crying incessantly, however no medical staff came to see her despite several requests. At about 6.00 a.m. the
next day the girl's stomach become distended. Even then no medical staff on duty attended the patient. At
11.00 a.m. the doctor came on his routine round, examined her pulse and moved on. The parent requested
the doctor to give the child intravenous saline, since she was not able to swallow the glucose water but he did
not pay any heed. At about 12 noon the child became unconscious. The father rushed to the doctor who was
on duty at Jawhar cottage hospital, informed him. The doctor asked him to bring the patient to his chamber. By
the time they brought the patient to the chamber, she had expired.
Wh//e in the Cottage hospital, the child was in severe distress for more than 12 hours, but was not given
adequate attention required to diagnose or treat the underlying problem. The child died, and adequate medical
attention not being given in time was a likely contributory cause. This case shows the violation of Right to a set
of basic public health services. This is a violation of the International Covenant on Economic, Social and
Cultural Rights, the Right to life, guaranteed by the constitution and the right of the child recongnised by the
Convention on the Rights of the Child.
The above cases show that the existing situation is very dismal and the changing political economy does not
show too much promise of change for the betterment of health, unless of course there is a radical
transformation in the political commitment. For this to happen the support of civil society pressures and
demands for a transformation of the healthcare and rehabilitation dispensation will be needed. We need to
move towards the objective of establishing health care a Fundamental Right in the Indian Constitution. This
would be a prolonged and challenging process, and would involve political mobilization and widespread public
awareness besides other things. The time has come to begin asking as to how the human rights related
commitments and concerns will be translated into action in a realistic, time bound and accountable framework.
The following chapter would present the efforts undertaken so far in this direction.
J
Moving towards a campaign on Right to Health and Health Care. India,! context - Amulya Nidhi
19
V.
WAYS AHEAD- BUILDING A CAMPAIGN ON THE RIGHT TO HEALTH AND HEALTH CARE
Right to health and healthcare is a fundamental social and economic right recognised by the International
Covenant. But such a demand is not on the political agenda in India. This massive health care deprivation
amidst potentially adequate health care resources needs to be addressed by establishing the right to every
citizen to basic health care, accompanied by operationalising a system, which would ensure universal
access to health care. The first step towards this direction was taken in the International Conference on
Primary Health Care, meeting in Alma Ata in 1978. The Conference reaffirmed that health is a fundamental
human right and that the attainment of the highest possible level of health is a most important worldwide
social goal27. It says that governments have a responsibility for the health of their people, which can be
fulfilled only by the provision of adequate social measures.
For building an effective campaign for rigtit to health the central task must necessarily be the task of
mobilizing those who are personalty facing the brunt of the anti-people policies. Any movement that Is not
based on the mobilization of this section is seriously limited. Though the slogan is People's health in
People's hand, it is yet to be placed in people’s hand because most organisations and networks currently
focusing on right to health come from middle class backgrounds. Though even with this limitation certain
demands like increase in budgetary allocation and expansion of public health services form a ground for
action - but they are not adequate to form a movement.
For mobilizing this section, two approaches are useful. One is the articulation of comprehensive radical
critiques, if possible with alternatives, for making out the correct political position. Another approach is to
engage in lobbying and advocacy for policy changes and shaping of a public opinion. One way to generate a
public debate is to take the formal judicial route, filing of Public Interest Litigation (PIL), which would draw
media attention and would put pressure on the political sphere. This could lead to short term gains and this
can help in sustaining mass action. But to build a larger public campaign for the ‘right to health and health
care’ - a nation wide initiative Jan Swasthya Abhiyan (People's Health Movement- India) was initiated. Jan
Swasthya Abhiyan is a campaign platform that has emerged from the People’s Health Assembly process in
India in 2000. It forms the Indian regional drde of the global People’s Health Movement, and is a coalition of
20 National networks and several hundred organisations from all over the country working in the area of
health, people's science, women’s issues and development
Jan Swasthya Abhiyan (JSA) in India has voiced a demand to make health cam a right, but this requires a
widespread awareness campaign and participation of many more civil society groups. This chapter would
describe the various initiatives that are undertaken in the country by JSA in the direction of making health
care a right
In India to achieve right to health and health care two parallel process is needed, firstly by demanding from
the Government, amendments in law and secondly by building pressure from people. As at present asking
right from the formal judiciary is a long way process and it is expensive for a common man to fight with the
system individually, therefore a parallel Judicial System was initiated, which is accessible and affordaole to a
layperson. It was known as people court. In ancient time also in villages there was a system of panch
system, which solved day4o-day crime and conflicts in villages. Still in some parts of Rural India this system
is functioning.
27 international Conference on Primary Heaitti Care, Alma Ata, USSR, 6-12 September, (1978).
Moving towards a campaign on Ri&t to HeaWi and Health Can Indian context-Amulya Nkfai
20
Public hearing as a means for creating public discourse and people's mobilization-
In India, Jun sunwai as an innovative advocacy strategy was initiated by Mazdoor Kisan Shakti Sanghatana
(MKSS), Rajasthan. It was initiated as part of Right to information campaign. After this in several parts of
country Public hearing was organised on different social issues.
Jan Swasthya Abhiyan has emerged as a premier national level platform in India with a clear Rights-based
approach to health. State ano national level activities have included facilitation of ‘People’s Health Enquiries’
in over 200 districts all over the country. In continuation with its pursuance of health rights, JSA organised
Public hearings {Jan Sunwai) in various parts of the country. Here I am going to present the process of
conducting Public Hearings.
Meaning of Jan Sunwai“Jan Sunwai is a process in which any issues related to social sector is addressed to a panel of
experts from related field’. In past few years Jan Sunwai (Public hearing)- as a model has become very
popular in which experts from related field act as a judge and activist as a lawyer and government
representative as a third party. In public hearing public officials and representative are invited to defend
themselves in these hearings. This strategy encourages people to speak out fearlessly and give evidence
against the misdeeds of the administration. Like in court, common people are allowed to listen to the
judgments, in the same way the Public hearings is not limited only to the people actually suffered, but
lawyers, intellectuals, academicians, and journalists can also be a part of the process. The judge or pane!
gives recommendations after listening to people’s voices for immediate action so as to make relevant
changes in the policy. In public hearing villagers/ common people are informed in advance about place,
date and others details to be discussed. A large number of people from ail walks of life participate in the
hearings.
The strength of public ..earing is it is being organised in local language. This encourages the poor, wno are
otherwise unheard of to express their negative encounters with the government system. Public hearing was
not only effective as an advocacy strategy, but as a means to give the poor an opportunity to voice their
dissent. It helped to increased the strength and bargaining power of people in relation to state machinery.
The well planned public hearing not only serve as a means to create mass mobilization and grassroots
mobilization, but also created a lot of news value in the media. So public hearing had multiple strategic
functions. Here I would present few instances of Jan Sunwai held in the country in the last one year on the
issue of health care.
Regional level - Jan Sunwai- Sepdhwa, Madhya Pradesh
Jan Swasthya samiti, Sendhwa, Madhya pradesh had organised a public hearing, which was hosted by
Adivasi mukti Sanghatana, Sendhwa on the issue of peoples right to health on 4* September 2003. The
idea of organising a Jan Sunwai was initiated in a meeting of Adivasi Mukti Sangathana at Niwali
in July 2003. The process details of this important step forward in the health movement in Western
Madhya Pradesh (MP) are as follows.
Organisational groundwork: in this process at first village meetings were held and specific cases of denial of
health services, which led to either loss of life or endangered life were documented. Activists of POs,
Volunteer, MSW fieldwork students and staff associated with CEHAT and Ashagram, documented these
cases. Simultaneously a meeting was organised in the month of August in Sendhwa by the Jan Swasthya
Samiti, Sendhwa to discuss the present situation of public health services after 25 years of Alma Ata
Declaration. In that meeting it was felt that these findings should be discussed with the people to make a
wider impact.
Moving towards a campaign on Right to Health and Health C^e: Indian context - Amulya Nidhi
21
i
Documenting situation of staff, services and infrastructure in PHCs, CHCs and District hospitals- In order to
S^611
"9^t0 healtfl “f® campaign, a survey was conducted in Badwani and Jhabua
distnct by Jan Swasthya Samrti to document the situation of public health services in these areas. Here
based on the checklist information was collected through observation and discussion with PHC/CHC staff
Informaton was collected from a total of 31 PHCs, 5 CHCs and 1 District hospital. Secondary data available
at Distnct Health Departments were collected to supplement the field level data. Based on this information a
report was prepared which highlights the stated and actual provision of public health services in the districts.
thParTa S°.moblh^ P“ple fa"1 Jhabua <fetrict to participate in Jan Sunwai. Almost all active groups at
the area participated in this precess. Keeping in view to address this issue to middle class people, doctors
Sir £ eachei'S’
were also invited and were convinced by JSS people to participate in the
puuiiG ncanng.
1?^? ’
ST Th‘S ®nbLe Process culminated in the Jan Sunwai organised on 4” September 2003
qJrtS
n hhlCS KUnA 200 people ParticiPated- 11 was organised by Jan Swasthya Samiti
Dh
h0Sted by Adlvasi Mukti Sangathana, Sendhwa. A panel consisting of Dr Anan‘
RJhd?eq'bhea lh rCtiV'St fr°m Pune' Dr T Sundararaman, Health Advisor to Chattisgarh government. Dr'
3ic^i n
f .h'
1.1*
vra > The District Administration
Representatives of 9 blocks from BaX’ X^uJ^p^ thei? sZm^f pXeS
and hlpalth
nST? d tonis !n? expres^d tfleir
/ opinion about the issue. They recommended9 “The CMHO
needs to senously take note of these gross deficiencies and take up remedial measures". As follow-up this
report, the recommendations of the panel were submitted to District Administration & Health Department.
^bs®puenM has now been decided by Jan Swasthya Abhiyan, MP that such type of Jan Sunwais would
be held in different areas of the state. Like Madhya Pradesh in other states also public hearing were
organised as part of Jan Swasthya Abhiyan.
9
National Consultation on Health Can as Human right
rTPai9n' bOnJhe u
sep °3' a national worksh°P and nafonal * hearing of the
demal of health care were held in Mumbai, the latter in the presence of the chairperson of the National
Human Rights Commission (NHRC). It was attended by over 250 delegates from 16 states, dedicated to a
b^HlvZS.?
and V baS6d movemente- inc,udin9 rights for women, children, people affected
H dlsP|aced peopte. people in areas of conflicts, workers in the unorganized sector, as well as number
of academicians, policy analyst and other interested citizens.
The workshop included a series of presentation, which provided the background to the issue of health care
SreaTa humanriS. * ? elementS °f healtt’**9r°UpS m0St Vulnerabte t0 tbe violation of t,eattfl
In the Consultation, Justice Anand, Chairperson of NHRC mentioned in his inaugural speech that the
Supreme Court has taken a view that health care is a fundamental right At the end of his spShe stated
Moving towards a campaign on Right to beam and Health Care: Indian contM ■- Amutya NiOe
22
his clear position that "Obligation of the state to take care of primary health is paramount, total and
absolute. The state cannot avoid its constitutional obligation on account of financial constraints^6
Other Strategies:
Besides building a public opinion through the above strategy, the other approach adopted is initiating a
dialogue with a wide variety of professional associations like Indian Medical Associations, Medical Council of
India, universities and academic research institutions and networks. This is necessary to build up an ethos of
support to the campaign and would also help to counter the potential opposition of the medical industry or
those who see a threat in this campaign.
The other step that is adopted is to try and evolve and integrate other health care systems and traditions
would greatly enhance the demand and support base.
Jan Swasthya Abhiyan also organised a ‘Public Dialogue with political parties on Health Issues' on 12th
March 2004 in Delhi before the General Elections 2004. Around 300 JSA associated persons attended this
public dialogue. This event involved representatives from different political parties, representatives from the
media both print and electronic, expert panelists and speakers, and JSA related health activists from a
dozen states. Members of some political parties also promised that they would take up issues related to
health in their campaign and also in the assembly.
Besides these above mentioned national level initiatives, various state units of the JSA are also involved in
state level campaigns to make right to health a reality.
The concluding chapter would focus on the issues that needs to be addressed further and strategies that
need to be adopted to make “Right to Health and Health Care" a reality.
Jan Swasthay Abhiyan, ’Report erf the National Workshop on
Right", 5-6°' September, organised by CEHAT, (2003).
to Health Care and National Consultation on Health Care as Hunan
Moving towards a campaign on Right to Health and Health Care Indian context- Amutya Nidhi
23
VI.
CONCLUSIONS AND RECOMMENDATIONS
Like all rights, the right to health care could not be realized with judicial intervention alone, but require
tremendous action by civil society. The law was only a part of the social framework with which the right to
health care could oe realized. The other integral part is civil society, which now needs to be strengthened
through education, and a consciousness of the value of human life. The last few years has already
demonstrated the tremendous power of the civil society in trying to achieve health care rights. The right to
healthcare campaign is trying to bring into light the readiness at the community members to contribute
towards demanding health care as their fundamental rights. This needs to be strengthened further.
After independence the state gave emphasis on enactment of new laws, modification of the colonial law and
the judiciary developed case laws to consolidate people’s entitlement of health care and to an extent, the
rights. This development took place on the basis of numerous recommendations made by various
committees like the Shore Committee(1946) and Mudaliar committee(1961). The Shore Committee
recommended formulation of a Public Health Act, which was subsequently tried by Mudaliar committee to
formulate such an act. The Mudaliar committee drafted a Model Public Health Act, which was a very
comprehensive document29. This draft Act aimed at being the legislative counterpart to implement fully the
recommendations made by the Shore Committee and Environmental Hygiene Committee reports and has
envisaged a comprehensive and integrated health service covering all the essential fields. The Act therefore
laid down statutory obligations on the State to ensure the fulfillment of the objective30. The subsequent
committees failed to take their recommendations to logical conclusions. Recently the Bajaj Committee(1996)
after relooking at the act has also recommended uniform adoption of Public health act This needs to be
implemented soon.
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. To estaolish
right to health and healthcare with the above scenario certain essential steps will be necessary, which are
listed below:
• Implementation of different provision already given though different international treaty. Pressunzing
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.
• Lobbying with parliamentarians to demand justifiability of directive principles. The directive principles
gives full scope to the parliament to make right to health care a fundamental right Filing public
interest litigation (PIL) on right to healthcare to create a basis for constitutional amendment.
• Besides, in the absence of a will to make it a fundamental right, there is also scope for enacting a
simple but comprehensive legislation for making right to health care an effective practical reality.
Implementation of Model Public Health Act (if necessary with some modifications) in all states31. If
the public health system fails to deliver basic health services, it should be treated as a legal offence,
remedy for which can be sought in the courts of law.
• To establish a district and State level systems for People’s monitoring and accountability
mechanism to oversee the implementation of the various provisions.
• Generating a political commitment through consensus building on right to health care in civil society.
• Development of a strategy for pooling all financial resources deployed in the health sector
29 Amar Jesam 'Right to Health Care: Entitlement and Law", Laws and Health Can Providers, CEHAT, Mumbai (1996).
30 Mudaliar Committee. 'Appendx B-38, Salient features of the Draft Model Putfc Health Acf, Repot of the health Survey and Planning
Committee, Vol 2, Government of Inda, Ministry of Health and Family Welfare, (1961).
31 This Act after modfication was circulated to all states for its implementation in 1987. It was to be examined by all State health authorities and
local health authorities to suit local and national needs.
Moving towards a campaign on Right to Health and Health Care: Indian on'ext-Amulya Nidhi
24
The medical councils must be made accountable to assure that only licensed doctors are practicing
what they are trained for. 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.
• Strictly regulate the private health sector as per existing taws, 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.
•
The agenda for health reform is long, far-reaching and tortuous, arguing for rethink on the role of public
health sector and for restructuring of the private sector. To conclude, it is evident that the neglect of the
public healtti 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. Givai 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
rights-based approach. The opportunity exists in the form of constitutional provisions and discourse,
international laws to which India is a party, and the potential of mobdizing civil society and creating a socio
political consensus on right to health care. 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
health and healthcare. While the course and outcome of these efforts would depend on the much larger
political situation, the following slogan should continue till we achieve our goal of a more humane society.
Hearth for All - Now!
The Right to Health is a basic human right!
towtris a campaign on
to Hearth and HeM\ Gm: Mw contoxt - Amufya
25
I
BIBLIOGRAPHY
Articles
1. Abusaleh Shariff, India Human Development Report,’ New Delhi: Oxford University Press for the
National Council for Applied Economic Research (1999).
2. Amar Jesani, The law and right to health care in India, Medico friend circle bulletin,mar-june2000
3. Amulya Nidhi, A two-pronged programme, Health Action, April 2004.
4. Kinney, E.D. 2001. 'The International Human Right to Health: What does this mean for our Nation and
World?’, Indian Law Review, pp 1457-1475.
Papers
1 Abhay ShuHa Creating a cons ensus on the Right to Health Care, Paper presented at National Meetino
on Right to Health Care, Mumoai, February 14, 2004.
2. Abhay Shukla, The Right to Health Care Moving from Idea to Reality-, Paper presented In Media
Workshop on Key Issues of Health and Health Care, 21* February, Indian Social Institute, New Delhi
organised by CEHAT 2004.
3. AmarJesarU "Right to Health Care: Entitlement and Law-, Laws and Health Care Providers, CEHAT,
4. S.V. Joga Rao, ‘Fundamental Right to Health and Health Care-, Country Report on Status of Health
care, CEHAT, (unpublished).
Books.
1. Advocacy update,oct-dec2001,No-16,National centre for Advocacy studies, Pune.
2. CEHAT, Right to Health Care- Moving from Idea to Reality, Dec 2003.
3. Centre for Social Justice ‘Constitutional Provisions and Supreme Court Judgments on Right to Health’
Ahmedabad (unpublished)
4. P.M. Bakshi, The Constitution of India’, Delhi: Universal Law Pubfishing Co. Pvt Ltd. (2000
5. 25 Questions and Answers on health and human rights, Health & Human Rights publicatior. series
Issue Nol ,July2002.
6. Medico friends circle bulletin, Jan-feb 2001.
Reports
1. NSS.1987: Morbidity and Utilisation of Medical Services, 42"“ Round, Report No. 384, National Sample
Survey Organisation, New Delhi.
2. Jan Swasthaya Abhiyan, ’Report of the National Workshop on Right to Health Care and National
Consultation on Health Care as Human Right-, S-e* September, organised by CEHAT, (2003).
3. Mudaliar Committee, “Appendix B - 38, Salient features of the Draft Model Public Health Act-, Report of
the health Survey and Planning Committee, Vol 2, Government of India, Ministry of Health and Family
Welfare, (1961).
4. Compendium of recommendations of various committees on health developmentl 943-1975 central
bureau of health intelligence, Govt of India,1985.
5. Report of the expert committee on public health system, Ministry of health and family welfare Govt of
India, June 1996.
Movrng towarts a campagn on Right to Health anti Heath Cm: Indian context- Amulya Nldhl
26
WARD
( Registered under Indian Public Charitable Trust Act )
(Reg. 53/1993)
©
04632-261603
Cell: 98428 18957
email: awardngo@rediffmail.com
2, Rengaraman Complex,
Madurai Main Road,
KAYATHAR - 628 952
Tuticorin Dist.
Tamil Nadu. S. India.
- 3 fltW
Ref:
TO
Peoples Health Movement Secretariet
C/o Community Health Cell,#367-srinivasa Nilaya,
Jakkasandra I main,I block,Koramangala,
Bangalore,India-560034
Date...............................
Dear sir/Madam,
“Greetings from our AWARD”
AWARD is a Non-Governmental Voluntary Organisation based on Tuticorin District of
Tamilnadu Since last 12 years. We co-ordinating one NGOs Net work team in the name of “Southern
Collective for Strategic Development”[SCSD]This body is registerd one.The spread of HIV/AIDS all over
India poses a grave challenge in the areas of health,social and econamic development.The AWARD project
was created to tackle this menace in South Tamilnadu.
GOAL:
To reduce the sexual transmission of HIV/AIDS in Tamilnadu,as it is the majour mode of transmission
accounting for 90% of HIV infections.
STRATEGIES: AWARD has four fold strategy to achieve its goals.
. 1.Small NGO support and technical assistance[network based]
2.STD prevention and control
3. Condom promotion,
4. Behaviour Change Communication
STD PREVENTION AND CONTROL:
Sexually Transmitted Disease(STD) increases the risk of contracting HIV/AIDS.Therefore prevention of
STD is crucial.
CONDOM PROMOTION
Condoms are very effective in preventing the spread of HIV/AIDS through sexual means.And creating
more condom outlets(traditional and non-traditional)in the targer areas.
BEHAVIOUR CHANGE COMMUNICATION:
To bring about a change in the people towards safer behaviour, A WARD chalked out the following
strategies.
♦Community levl intervention to create a well informed environment.
♦Individual level communication to bring about behaviour change.
♦Technical assistance to improve communication skills of small NGOs.
♦Trained NGO staff to recruit peer educators to reach the target audience.
AWARD marked off priority areas to conduct its activities, where the chances of reaching the high risk
group are more.The priority areas are our working south Tamilnadu for following
* Highly Populated places,
* Industrial areas,
To
* Highways
7^
♦Tourist Centres,
RfO_______ ______________ __ ________ __
Rcgd. ()fffice : 35 Pudukottai, Panneerkulamc PO) Via : Kayaib.ar. Tuticorin Dist.. pin-628 952
’
4»
* Places of worship
As a result of AWARD sustained HIV/AIDS prevention activities in these places,studies reveal that there is
a marked difference in the behaviour of the people.such as
*a sharp decline in the non-regular sexual partners among truckers.
*a rapid increase in condom usage among women in prostitution and truckers.
OPERATING AREAS:
AWARD is a mothor NGO of SCSD network of 16 small Ngos in south Tamilnadu.We covering Five
districts like Tuticorin,TiruneIveli,Kanyakumari,Virudhunagar,and Sivagangai districts.Each district we
selected for 3 genuine organisations only. We clear about no any duplication areas of operating by
Tamilnadu state Aids control society,and APAC funding project areas.Only we covering out of covering
important new target places.
CORE PRINCIPLES AND VALUES:
*The value of peer education and community participation in disseminating crucial information about
HIV/AIDS prevention.
*The commitment to constant innovation and learning in response to challenges.
♦The principle of confidentiality in protecting records and information pertaining to target population.
♦The commitment to professionals standards in all areas of work.
♦The development of synergy between AWARD,affiliated small NGOs community members,government
agencies,and departments,
♦The commitment to capacity building and sustainability of technical strategies and community networks.
♦The development of consistent messages and support structures to aid populations in implementing
behaviour change.
PROJECT PERIOD:
We want support minimum three years,maximum five years.
BY END OF THE PROJECT AWARD HOPES TO HAVE ACHIVED THE FOLLOWING:
♦A network of small NGOs involved in AIDS prevention
♦Programms to build the capacity of NGOs to ensure quality intervention projects
♦Increased number of oeoole aware of STD/HIV/AIDS oreventive measures.
♦Promotion of Condom sales and use.
♦Identifying more PLWHA in these areas.
REQUEST:
Our south districts of Tamilnadu more affected peoples in HIV/AIDS.Now our state HIV/AIDs patients
are 52036(june-2005,NACO statistics)More childres are affected daily for semi and full orphan.But not
reach the awareness to village poors,Agriculture labourers,street vendors,industrial workers,hotel
workers,mehanic workers and somany groups.So,we want to your kind humanitarian support of HIV/AIDS
awarenss in our South Tamilnadu.Our India HIV/AIDS patients 1,10,856 (NACO-june2005).so,Tamilnadu
is a first state of India in HIV/AIDS affecting.This is very dangerous one.So,its emergency of to complete
aware of all sectors of the peoples.So,we kindly requested to you please support of your funding for fight
against HIV/AIDS in Tamilnadu.We kindly requested to you please send your Application form,GuideIines
for project proposal,model budget breakdown and other informative materials send as early as possible.
Thanking You,
Youi
inhere ly,
IStKARUPPASAMYI
DIRECTOR-AWARD
CHAIRMAN-SCSD[NETWORK]
Award Trust
KAYATHAR 628952,
Tuticorin District.
Ph; 04632-261603
INFOCAP INFORMATION SHEET
Past, Ongoing, and Planned Projects
Project Title:
Narrative Description of
Project:
~ give briefdescription ofwhat the study is all about
Classification
Please put an X on all that apply:
Awareness raising
General issues on capacity building
Data and information collection exchange
Education and human resource development
Hazard and Risk Assessment
Industry Sector-Specific
Legislation, Policies, Strategies
Planning and development
Risk Management/Prevention/Reduction
Technical Infrastructure
Category:
classification of the research,
you may choose more than one.
For example, it can be data
information on legislation,
policies and strategies so we
check both
Keywords:
Generation of field monitoring data
Human health
’ for the keywords, choose those
Environment
that will describe the research ____ Communication
____ Accidents/Emergency response
Chemical Registries and Databases
Chemical-specific
Data quality control
Enforcement
Informatics
’ ’
Institutional Mechanisms
Laboratory
Modelling
Obsolete chemicals and pesticides
• Public
Scientific management options
Workplace
Project Duration
Project Start:
________ Project End:
Document Submission
URL#1: (please put website address here)
Document#!:
(please attach project or organization-related
document if you are submitting one)
- ifyour research or study can be found m your
website, please place website address at LlRLrJ and 2.
J so on if it is posted in more than 1 website but ifnot
then please send us an electronic copy ofyour
document
Collaborating Partners:
(name of your NGO and other partner organizations)
Inis includes all other organizations involved
in the research project
Types of Assistance for the
Project:
Please put.an X on all that apply:
___ Financial
___ Technical
Others (please specify)
(in dollars)
. .
Total amount of assistance for
the Project (optional):
- this isfor the implementing organization or can be
the organization who facilitated the project (overall
guidance)
Key contact for further
information
Name of organization:
Type of organization: ___ Non-Government Organization (NGO)
___ Government Organization
___ Inter-governmental Organization (IGO)
Title:
Mr.
Ms.
Mrs.
Dr.
Family name:
First name:
Position:
Email:
Working language: ___ English
___ Spanish
___ French
Full mailing address:
City:
State:
Province:
Postal Code:
Country:
Telephone Number:
Fax number:
Donor organization information
Ms is the one who funded or supported the
project
the donor is differentfrom the collaborating
partner
Name of organization:
Type of organization: __ _Non-Government Organization (NGO)
___ Government Organization
___ Inter-governmental Organization (IGO)
Title:
Mr.
Ms.
Mrs.
Dr.
Family name:
First name:
Position:
Email:
Working language: ___ English
__ Spanish
French
Full mailing address:
City:
State:
Province:
Postal Code:
Country:
Telephone Number:
Fax number:
Recipient organization
information
- the one who received the funding support, the
implementing agency (usually is the same with the
organization of the key contact)
-sometimes the key contactfactIHates the fundingfor
the project (from the donor to the recipient) and the
recipient (example a people ’y organization)
implements it and this is the time when the contact
person and the recipient organization become
different
Name of organization:
Type of organization: __ _Non-Government Organization (NGO)
___ Government Organization
___ Inter-governmental Organization (IGO)
Title: ___ Mr.
___ Ms.
___ Mrs.
Dr.
Family name:
First name:
Position:
Email:
Working language: ___ English
___ Spanish
__ _ French
Full mailing address:
City:
State:
Province:
Postal Code:
Country:
Telephone Number:
Fax number:
Centre for
Communication
and Development
Studies
.......................................■;
8th October, 2005
Dear Reader,
We are happy to bring you the third issue of InfoChange Agenda.
InfoChange Agenda has been conceived as a quarterly dossier that informs civil society
on crucial issues of sustainable development and social justice. It is designed to
enable concerned citizens in India /South Asia to marshal salient information, facts,
figures, perspectives and reportage on issues that are, increasingly, being pushed into the
margins of mainstream media and public debate.
Agenda is put together every quarter by InfoChangelndia’s extensive network of
journalists, development analysts and activists. This network has collaborated over the
last few years to build InfoChange News & Features (www,infochangeindia.org), one of
India's most-visited online resource bases on development and rights issues.
The first issue of Agenda was on industrial pollution and hazards, 20 years after the
Bhopal gas tragedy. The second issue was on access to public healthcare in India, with
reports on the spiraling costs of public healthcare and shrinking government spending on
healthcare.
The third issue of Agenda focuses on the ‘Politics of Water’. The articles deal with
control of water resources, the worth of water today, and raise questions about those who
suffer and gain as a result of water scarcity.
If you’d like to continue receiving copies of InfoChange Agenda, please write in/email us
indicating your interest (for details including address to write to, see the inside front
cover of the journal).
We also welcome your feedback on the contents of this issue, and your ideas and
contributions for forthcoming issues of Agenda.
With best wishes
For Hutokshi Doctor & John Samuel
(Editors)
—
C/12, Gera Greens, NIBM Road, Kondhwa, Pune 411048. Tel:91 2026852845/25457371
e-mail:ccds@dishnetdsl.net/infochangeindia@dishnetdsl.net web: www.infochangeindia.org
Registered under the Bombay Public Trust Act 1950 (Registration No E-3657 [Pune])
31
Page 1 of2
Main Identity
From:
To:
Sent:
Attach:
Subject:
"Romeo Quijano" <romyquij@yahoo.com>
<pha-exchange@lists.kabissa.org >
Thursday, October 27, 2005 12:48 PM
INFOCAP INFORMATION SHEET -withexplanations.doc
PHA-Exchange> Invitation to participate in INFOCAP
October 27, 2005
Dear Colleague,
Greetings!
We are writing to invite your organization to
participate in the Information Exchange Network on
Capacity Building for the Sound Management of
Chemicals (INFOCAP), an information exchange mechanism
to enhance effective coordination and cooperation
among countries and organizations involved in
activities related to sound management of chemicals.
The INFOCAP project will strengthen the level of NGO
intervention in global and regional chemical safety
activities which have become especially important in
influencing emerging chemical safety policies and
regimes in various parts of the world, particularly in
developing countries. We are confident that through a
transparent and cooperative mechanism of information
exchange, we can contribute significantly, and become
beneficiaries as well, in improving and expanding
institutional capacities for the sound management of
chemicals in order to protect health and the
environment.
! k!
Health Alliance Against Toxics(HEAL Toxics)/Pesticide
Action Network(PAN) Philippines (Ms. Sampaguita
Quijano as Coordinator) has been designated to
coordinate the participation of Public Interest NGOs
in the INFOCAP. We will help in gathering and
promoting appropriate information and materials
pertaining to activities related to chemical safety
issues and in identifying specific areas of need that
may potentially find support through INFOCAP
facilitation. As such, we shall provide an interface
to public interest NGOs' contributions and access to
the INFOCAP services.
In line with this, we would like your organization to
please fill up the attached INFOCAP Information Sheet
and send the accomplished form to us via email. You
v
10/28/05
FULL TIMERS
COMMUNITY HEALTH CELL
Society for Community Health Awareness, Research and Action
No. 367, Srinivasa Nilaya, Jakkasandra I Main, Koramangala, Bangalore - 560 034
Month : DECEMBER, 2003
DR. RAVI NARAYAN
MR. D.G. SRINIDHI
MR. S.S. PRASANNA
Leaves Available
Leaves Available
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Date
CL
SL
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Sunday
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CHRISTMAS
CHRISTMAS
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CHRISTMAS
27 - 12 - 03
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28- 12-03
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08 - 12 - 03
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CL
Leaves Taken
Balance C/F
Leaves on Loss of Pay
Over time
SL
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Page 2 of 2
may choose any of your past, ongoing, or future
projects (e.g., environmental toxins and pollutants,
pesticide monitoring, chemicals poisoning, etc.) to
put in the information sheet. Once we receive the form
from you, we shall send it to the INFOCAP website
(www.infocapjnfo), where the information about your
project and your organization may be viewed by
potential funding organizations and other NGOs.
Alternatively, you may send us information about any
of your projects and we can fill up the information
sheet for you.
In turn, your organization may use INFOCAP as a
web-based tool to find out more about ongoing projects
in other organizations, get information about
potential funding agencies, and obtain training and
guidance documents that you may want to use. Please
visit www.infocap.info, or email us for more
information. Thank you very much!
Sincerely yours,
Dr. Romeo F. Quijano (Sgd.)
10/28/05
Page [2
<avi Narayan
> Coordinator
> >1 IM Secretariat (Global)
>c/oC11C
> No. 359 (old No. 367)
> Srinivasa Nilaya, Jakkasandra 1st Main
> 1st Block. Koramangala
> kmgalore - 560 034. India
> Tel: 00-91-80-51280009
> 'ax: 00-91-80-25525372
> anail: secretariat@phmovement.org
> Website: www.phmovement.org
Do You Yahoo!?
Ti cd of spam? Yahoo! Mail has the best spam protection around
h 11 p: //m a i 1. y a h o o. co m
9/8/05
2
Fw: 5>raft General Comment on art. 12 of tje ICESCR
’’Nashik-Vachan" <vachan@bom2.vsnl.net.in>,
"Pune-Alochana" <alochana@pn2.vsnl.net.in>, “Pune-BangalR” <rbangal@hotmail.com>,
’’Pune-IHMP-Nandita’’ <ihmp@vsnl.com>, ’’Pune-MasumOflfice” <masumfp@vsnl.com>,
”Pune-MiraSadgopal" <miradina@wmi.co.in> ’’Pune-PRAYAS" <prayas@vsnl.com>
"Pune-SujataP” <spatel@unipune.ernet.in>, "Punj-ManmohanS" <vhap@cha.i91.net.in>
"R'than-Vimala” <vimalar@jpl .dot.net.in>, "TN-AnandZ” <zachariah@cmcvellore.ac.in >
"Bom-VibhutiP” <laral984@bom5.vsnl.net.in>, ”Bom-AnilP" <anilpil@vsnl.com>,
’’Bom-PadmaP” <nprakash@bom3.vsnl.net.in> "Bom-RaviD" <raviduggal@vsnl.com>
"Nashik-Dhruv-l” <mankad@vsnl.com>, "Pune-Anant (H)" <amoljp@vsnl.com>,
”Pune-CEHAT-MohanDeshpande” <cehatpun@vsnl. com>,
"Pune-Manisha-Masum" <masum@vsnl.com>
Dear Friends,
For last few months there has been lots of discussion within the UN on
the question of right to health care. The UN special Repporteur for
the Committee on Economic, Social and Cultural Rights has/have
prepared a general comment on the right to health care for discussion
within the UN. A copy of it is attached herewith, He would like to
receive comments from all concerned on the draft, If you have any
comment, please send it directly to him. or to me.
With best wishes.
Amar
(Amar Jesani)
Dear all.
Please find attached documents, one of which is the draft General
Comment on the Right to Health written by the Special Rapporteur Elbe
Riedel of the Committee on Economic, Social and Cultural Rights. He
would appreciate any comments, if ready prior to the session, [22nd
CESCR session from 25 April to 12 May 2000] sent directly to him at
the following address
Mr. Elbe Riedel, Member, Committee on Economic, Social and Cultural
Rights
University of Mannheim
Schloss, WestflUgel
68131 Mannheim,Germany
Tel.: (0049)(621)-181-1417/8 (profess.)
Fax: (0049) (621)-181-1419
E-mail: riedel@j ura.uni-mannheim.de
Tel.: 0049-63-21-848-19 (private)
with a copy to the secretary of the Committee on Economic , Social and
Cultural Rights, Mr A.Tikhonov at the following address: "Alexandre
Tikhonov" <atikhonov.hchr@unog.ch>
Sorry about the short notice
best wishes
Peter Hall
2 of 3
n
4/11/00 9:43 AM
Fw: 9raft General Comment on art. 12 of the ICESCR
j [j2DraftGC.14.doc
[^|encap2.ond
3 of 3
Namme: 2DraftGC.14.doc
Types Winword File (application/msword)
Eimcodnniigs base64
Nanunes encap2.ond
|
Types Macintosh BinHex Archive (application/mac-binhex40);:
Eimcodlninigs 7bit
4/11/00 9:43 AM
Fw: praft General Comment on art. 12 of the ICESCR
Saabjects Fw: Draft Genwirall Cominraeinit omi artO of the ICESCR
Date: Sun, 9 Apr 2000 22:59:41 +0530
From: "Amar Jesani” <Iaral984@bom5.vsnl.net.in>
Repfly-To: "Amar Jesani" <jesani@vsnl.com>
To: "Mah-Dolke" <aaasn@nagpur.dot.net.in>,
"Ahd-Charul/Vinay-1" <abhigamc@wilnetonline.net>,
"Blore-Aditi" <aditiyer@yahoo.com>, "Blore-CHC" <sochara@blr.vsnl.net.in>,
"Blore-GitaS-IIM" <gita@iimb.emet.in>, "Bom-CEHAT-Sumita" <cehat@vsnl.com>,
"Bom-CHS-TISS" <chs@bol.net.in>,
"Bom-JayeshShah" <bomaaa97@giasbm01 .vsnl.net.in>,
"Bom-KalpanaSharma" <ksharma@vsnl.com>,
"Bom-Kannamma" <kannammaraman@hotmail.com>,
"Bom-LakshmiL" <laxmil@hotmail.com>, "Bom-LakshmiL=TISS" <lakshmil@tiss.edu>,
"Bom-NehaM" <wellite@bom5.vsnl.net.in >,
"Bom-RadhikaRam" <soctec@giasbm01 .vsnl.net.in>,
"Bom-SharitB" <sharitbhowmik@hotmail.com>, "Bom--SuklaSen" <suklasen@yahoo.com>,
"Bom-SunilNandraj-1" <snandraj@hotmail.com>,
"Bom-SurabhiS" <surabhi_sh@yahoo.com>, "Cal-CINI" <cini@cal.vsnl.net.in >,
"Cal-Kunal-Soma-l" <somalkunal@caltiger.com >,
"Cal-RoshmiG" <roshmi@cal.vsnl.net.in>, "Chen-MadhukarP" <madhukar@hotmail.com>,
"Chen-MadhuP" <madhupai@vsnl.com>, "Chen-Sundar" <arfi@vsnl.com>,
"Delhi-Ghanshyam" <gshaw@jnuniv.emet.in>, "Delhi-IFSHA" <seher@del3.vsnl.net.in>,
"Delhi-InduJ” <indira@giasdl01.vsnl.net.in>, "Delhi-Lester-1" <lester@vsnl.com>,
"Delhi-MacFound" <macarth@giasdl01 .vsnl.net.in>,
"Delhi-MagicL-Sarojini" <magiclf@giasdl01 .vsnl.net.in>,
"Delhi-MohanRao" <mohan@jnuniv.ernet. in>,
"Delhi-RakeshShukla" <grade@del6.vsnl.net.in>,
"Delhi-RituPriya" <ritupm@jnuniv.ernet.in>,
"Delhi-Sarojini" <samasaro@giasdl01 .vsnl.net.in>,
"Delhi-Tarshi" <tarshi@del3.vsnl.net.in >, "Delhi-Visaria-L-P" <visaria@vsnl.com>,
"Goa-Albertina" <alal@goal.dot.net.in>, "Goa-Vikram" <vpatel@vsnl.com>,
"Guj-ICS" <ics@lwbdq.lwbbs.net>, "Guj-Renu/Chinu" <chinu@wilnetonline.net>,
"Guj-Sridhar" <manju.sridhar@pmail.com>,
"Guj-Sridhar-MFC" <sridhar.mfc@softhome.net>,
"Guj-Surat-CSS" <social@bom6.vsnl.net.in>, "Hyd-AlexG" <alxgeorge@yahoo.com>,
"Hyd-KalpanaK" <kalpana@hdl .vsnl.net.in>,
"Hyd-Prakasamma-ANS " <dirans@hd2. dot. net. in>,
"Hyd-VeenaS" <vnakanis@satyam.net.in>, "Bom-AC ASH" <acashorg@vsnl.com>,
"Blore-SanjayP" <sjpai@vsnl.com>, "Bom-ArunBal-IME" <balarun@hotmail.com>,
"Bom-ManKamath" <kamath@bol.net.in>, "BOM-SandhyaS" <sandhya@bom3.vsnl.net.in>,
"Bom-SanjayN" <nagral@bom3.vsnl.net.in>, "Bom-SantoshK" <bjwhc@bom2.vsnl.net.in>,
"Bom-SunilP" <sunil@pandya.ilbom.ernet.in>,
"Bom-YashL" <yashlokhandwala@hotmail.com>,
"US-MamdaniM" <meenalm@mediaone.net>, "Kerala-SundariR" <ravindrans@usa.net>,
"Kerala-ThankappanKR" <thank@sctimst.ker.nic.in>, "Keral-Ekbal" <ekbal@vsnl.com>,
"Mah-Gadch-Search" <search@mah.nic.in>, "Mah-MMP" <ihmpp@bom4.vsnl.net.in>,
"Mau-Rajni-Home" <lalmel@bow.intnet.mu>, "MP-BiswajitS" <biswajit@lwl.vsnl.net.in>,
"MP-Ilina-Rupantar" <rupantar@gwaliorl .vsnl.net.in>,
"Nashik-Abhivyakti" <amdnsk@vsnl.com>,
"Nashik-Sham" <ashtekar@giasbm01 .vsnl.net.in>,
1 of 3
4/11/00 9:43 AM
Page 1 of3
CHC
From:
To:
Cc:
Sent:
Subject:
"Debabar Banerji" <nhpp@bol.net.in>
"Claudio" <claudio@.hcmc. netnam.vn>
"PHM" <secretariat@phmovement.org>; "pha" <pha-ncc@yahoogroups.com >
Saturday, October 02, 2004 11:36 AM
[pha-ncc] Re: PHA-Exchange> Food for reversing a faulty process of thought
Dgst Dr Shuften
Once again, you have raised an important issue. PHM has to take a stand on this.
Regards, D Banerji
XV
v
— Original Message —
From: Ciaudio
To: pha-exch
Sent: Saturday, October 02, 2004 7:33 AM
Subject: PHA-Exchange> Food for reversing a faulty process of thought
Human Rights Reader 81
ON NGOs AND THE RIGHTS OF WINNERS AND LOSERS
1. NGOs became players on the political and human (or people’s) rights stage
( HR) long ago -both at the national and the international level. As such players,
in the Third World, many of the Northern NGOs have unfortunately too-often-*
and-for-too-long worked with authoritarian regimes. Anyone who, too-often-andfor-too-long, backs the wrong partners without criticizing them creates her/his
own reputation. Only having a strong moral vision does not per-se result in having
moral influence.
2. Going back to their origins, many NGOs working on development issues were,
from the outset, linked to economic liberalism (perhaps also to feminism and
religion).
3. Coming from a moral-theological perspectivedthese civil society organizations
stand for securing ;civilized social contracts’; they thus further tolerance and
plurality in thought. Nothing wrong with thaj^ut perhaps the time is over for this
A
path, because, on the basis of existing socio-economic inequalities and widespread
HR violations, much of civil society itself contributes to the reproduction of these
inequalities and the persistence of these violations.
4. So. the question is whether, today, the NGO concept has the potential to deliver
the structural and HR changes needed under the current ‘conditions-ofGlobalization’. These conditions are destroying livelihoods. Globalization is
neither a natural process nor an inclusive one; it is rather a planned project, and
one of exclusion. More than anything, Globalization is completing a project of re
colonization. Growth through Globalization is importantly based on the theft of
10/4/04
1
Z- «LJ1
j people’s resources, knowledge and economies. In the Globalization paradigm, the
j protection of people and the protection of nature are replaced by corporate
I protectionism. The rules of this imposed market- competition-dogma simply
transform all aspects of life into markets. (V. Shiva) Moreover, social and
employment concerns are never brought to the forefront in the process of
Globalization. Globalization does not create jobs; as a matter of fact, it is a hotbed
of anti-union activity.
5. Under Globalization, change creates both (a few) winners and (an army of)
losers. It therefore behooves NGOs (now being euphemistically renamed civil
society organizations by the World Bank) to work on strategies to revert this
process and to find ways to work with the current losers in interventions that more
proactively distribute the benefits of change more equitably.
6. Because of this, there are those who now dissociate themselves from the NGO
concept and opt for a more radical and militant perspective: one of socialmobilization-cum-political-consciousness-raising (a-la-Paulo-Freire).
Where in this continuum would you place yourself?
Claudio Schuftan, Ho Chi Minh City
claudio@hcTyic.Tiehiani.vn
Mostly taken from the Cterman development journal D+C, 31:2, 2004 and from Poverty, Health and
Development, Health Cooperation Paper No. 17, AIFO, Bologna, Italy, 2003
O
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PHM-Secretariat
From:
To:
Sent:
Attach:
Subject:
"Abhay Seema” <abhayseema@vsnl.com>
<pha-ncc@yahoogroups.com>
Monday, August 02, 2004 7:31 PM
The Right to Health approach MFC paper.doc
[pha-ncc] Article on the Rights based approach to Health Care
Dear Friends,
.
I am attaching an article on exploring the 'Rights based approach' towards strengthening peoples access to
health care which has been published in the recent issue of the MFC bulletin. Some of the pitfalls and cautions
we may keep in mind while adopting the Rights based approach are outlined in this article. I look forward to your
critical comments and ideas.
With regards,
Abhay
**************************************************************************************************************************
Abhay Shukla
B-1 Nilgiri Apartments, Karvenagar, Pune 411052
Maharashtra, India
Phone:020-2546 5936
Visit the Jan Swasthya Abhiyan and People's Health Movement websites:
www.phmovement.org/india and www.phmovementorg
-
aJ
8/3/04
Exploring the ‘Rights Based Approach* for a Renewal of Public Health
- Abhay Shukla
Among most health activists, there is a broad consensus about the need for strengthening
public health, and for greater accountability of the public health system. However, how to
practically move towards this goal in the real situation, at local, state and national levels is a
matter that needs to be worked out in practice. This is both a question of strategy, and also
relates to our broader perspective about processes for social change.
I would like to suggest that adopting a ‘Rights based approach’, in the form of building
initiatives for the ‘Right to Health and Health Care’ should be seriously explored for its
potential to increase popular awareness about entitlements in the health sector. Such an
approach can put pressure on the public health system to perform better, and to make it
accountable. We can use the Rights framework to also address the issue of quality of care and
social regulation of the private medical sector. Such an approach can also have wider social
implications and linkages. But along with the possible strengths of such an approach, some of
its limitations and pitfalls have also been discussed in this article, with the aim of trying to
clarify ideas and to refine strategies for the health movement in the coming period.
Our approach - Right to Health; one major strategy - Right to Health Care
It need not be reiterated that achieving better health for any population is dependent not
only on quality health care, but equally importantly, on assured food security and nutrition^
safe water supply, sanitation, healthy housing, safe occupational and environmental
conditions and other conditions necessary for healthy living. Keeping this in mind it is
necessary to define and distinguish between the ‘Right to Health’ and the Right to Health
Care’.
Let us start by specifying that when we talk ot the ‘Right to Health’ we actually mean
not the‘Right to be healthy’but rather
‘the Right to a variety offacilities and conditions necessary for the realisation of the
highest attainable standard ofhealth (ICESCR, General comment 14).
another similar definition of ‘Right to Health’ may be
‘The right to the highest attainable standard ofhealth in international human rights law
is a claim to a set of social arrangements - norms, institutions, laws, an enabling
environment - that can best secure the enjoyment of this right (WHO)
It is clear that achieving a decent standard of health for all would require a range of far
reaching social, economic, environmental and health system changes. There is a need to bring
about broad transformations both within and beyond the health care sector, which would
ensure an adequate standard of health. So to promote the Right to Health would require
action on two related fronts:
• Promoting the Right to underlying determinants of health
• Promoting the Right to Health Care
The first, the Right to Health determinants (to use a short term) is in effect a spectrum
of Rights, a set of rather diverse Rights to various services and conditions necessary for
health Many of these services and conditions (such as education or housing or environment)
are not particularly amenable to direct actions by actors in the health sector (because of their
lack of expertise and mandate), despite their undoubted importance for health. Agencies
'
engaged in the health sector may not be able to deal with most of these issues on their own,
but they could highlight the need for better services and conditions, from a health perspective.
Thus the role of health sector organisations in addressing such determinants may be to
strengthen and substantiate demands, to advocate and support other agencies working directly
in these areas, to help bring about relevant improvements.
Regarding the second, the Right to Health Care, we would accept that given the gross
and unacceptable inequities in access to health care and inadequate state of health services
today, we need to work to ensure access to appropriate, rational 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 the issue of Right to Health
Care lies primarily with agencies working in the health sector, though efforts in this direction
would surely be supported by a broad spectrum of society.
With this understanding, I would argue that the overall approach of health activists might
be the ‘Right to Health Approach'. Within this framework, establishing the Right to health
care appears as one major strategy and an imminent task, to be taken up by organisations in
the health sector, within the broader context outlined above. Simultaneously, health activists
should seek to link with movements for allied Rights such as Right to food, water, housing,
employment - ultimately leading to a widely and strongly felt demand for an alternative
system, which could satisfy all these rights more effectively.
In the remaining part of this paper, I will focus on the Right to Health Care, to be
considered within the framework of the broader understanding of a Right to Health
approach.
The Rights based approach - attitude towards pubiic health system and
private medical sector
In this paper, I have not dealt with the detailed content of the ‘Right to Health Care’
since this has been dealt with to some extent in my paper ‘Right to Health Care - moving
from idea to reality’. However, it seems important to make one clarification here. When
health care rights are taken up as a form of resistance to weakening of the public health
system, naturally the demands would be focussed on the public health system, especially in
the initial phase. The framework and demands we raise would relate to strengthening the
Public health system, under peoples monitoring. It is from the Public health system that we
can demand a set of comprehensive health services, since it runs on taxpayer s money and is
accountable to all of us. There are comparatively clear population based norms, mandated
levels of facilities and at least a nominal goal of universal coverage. So as we press for the
legal and social right to certain basic health services, the Government would be pressurised to
strengthen and reorient the public health system, in order to deliver these services.
However the repeated experience is that when we make some general complaints about
lack of proper health services, the standard response from Government officials is that ‘our
systems are fine, we are giving all the services, and if there is some minor issue we will solve
it’. We are handed out some statistics about number of PHCs and immunisation coverage etc.
etc. This hides the fact that the public health system is being weakened day by day, and
people are often not getting even bare minimum services of adequate quality. So if we are to
effectively challenge this situation from a Rights-based approach and even get legal support
for our argument if necessaiy, we have to document various actual cases where people have
been denied required health services from the public health system, and present this as a
widespread, serious human rights violation. This building of pressure would of course always
be accompanied by the demand for strengthening and accountability of public health services.
Notwithstanding the fact that we would sharply point out weaknesses in the public
health system, this does not mean that we exonerate the private medical sector, or that we
promote privatisation of health services. In fact we do need to assert that citizens have certain
rights concerning private medical services; to start with we should demand regulation of the
quality and standards of private care, and care according to standard treatment guidelines.
Regulation of costs of care is a more complex issue, which may be taken up as a subsequent
step. New laws and regulatory mechanisms are required for this (for example in Maharashtra
due to prolonged efforts by health activists, along with a favourable attitude of the
Government, a modified act to regulate clinical establishments has been drafted.) We need to
think of appropriate strategies to raise the issue of people’s rights concerning the private
medical sector in the coming period, and link this with specific demands tor regulation.
Another related issue concerns irrational or unnecessary health care, including public
health interventions that are unjustified from a socio-epidemiological perspective (such as the
proposed universal Hepatitis-B vaccination). The Right to health care obviously implies the
right to rational health care, and not the promotion of medical consumerism or overuse of
medical resources. In fact it would encompass the right to freedom from irrational or
unnecessaiy medical procedures. As we specify the concrete content of the Right to Health
Care, we may keep these issues in mind.
In short, raising the issue of Right to Health Care would imply as the first step,
demanding quality health services from a significantly strengthened and more accountable
public health system, combined with effective regulation of the private medical sector. This
should subsequently lead to the Right to Health Care becoming a fundamental right, and the
operationalisation of a system for Universal access to Health Care over a period of time. The
detailed content, mechanisms for operationalising the Right to Health Care and universal
access systems are issues that require detailed discussion and working out, which could take
place in MFC or broader platforms like Jan Swasthya Abhiyan.
Stages In development of the health rights approach
The utility of the Rights based approach changes with the level and stage of any
movement. I would suggest that the movement for health rights might develop through three
'successive (though overlapping) stages:
o Today, the fight for Health care Rights is primarily a form of resistance against
withdrawal and weakening of public health services. Demanding the Right to Health care can
form the basis for struggles at various levels, against denial of health care and user fees which
form a barrier to accessing care. Asserting rights can help people to protest against poor
quality of care and to oppose various forms of discrimination related to health services.
Along with many others, the SATHI team of CEHAT has been regularly collaborating with
people's organisations to develop such processes, as a part of various initiatives across the
country.
o Gradually, the Rights framework should also form the basis for a comprehensive
policy critique, exposing neo-liberal health policies. We can demonstrate how these policies
are responsible for moving from a welfare state to a market driven health system, and hence
are responsible for denial of an entire range of health rights. Asserting the Right to Health
care as an overall approach can become the logical basis for demanding a system of
Universal access to health care.
o Further, we may want to use the Rights approach as the basis for counter-hegemony,
challenging the entire dominant conception of the ‘Market oriented approach’ to health care.
Building counter hegemony is a process by which oppressed groups or classes not only
challenge the dominant social framework, but also concretely develop and offer an alternative
system to reorganise society. Let us examine this in some more detail below.
Counter hegemonic action: Rooted in the present, reaching towards the future
In the era of globalisation-liberalisation, ideas like ‘leave it to the market’, ‘the
government cannot be expected to do everything’, ‘the private sector is more efficient’ etc.
are emerging as dominant ideas. These ideas, centred on the ‘Market oriented approach’ can
be considered as part of the ruling class hegemonic framework, and are accepted even by a
large section of die middle class and intelligentsia. To counter this, and to win over an
increasingly large section of society to the idea of a different, equitable and just social
system, we can take the basis of the ‘Rights based approach \ as a form of counter
hegemony. In other words, one way of countering the ideological dominance of the market,
may be to publicise the need for the establishment of various rights.
Counter hegemonic action may consist of asking for changes that are viewed by the
majority of people as justified, even mandated by the Constitution etc. but might not often be
implemented in practice. Such demands can gather strong popular support, and shift the onus
of non-performance onto the system. Even if such demands are partially fulfilled, the
continuous expansion of the sphere of Rights throws up ever-newer demands and continues
the movement. Such action builds upon a component of people’s present consciousness,
namely the widely held belief that certain basic rights are justified, but can reach far into the
future, by strengthening the movement for an alternative society.
In this context, we can start from entitlements in the existing system, which are
universally recognised as being ‘justified’, such as the Right to Life which implies the Right
to Health Care. We can ask, why these are not being fulfilled, and can suggest how these
rights can be fulfilled if systems are organised in an alternative way. For example, asking for
a system for Universal access to health care, (along with Health Care being made a
fundamental right) is an idea, which would be generally regarded as justified by most
ordinary people. We can build a campaign based on such a counter-hegemonic demand,
which may command broad support, even from a section of health care workers and
professionals. Such a campaign may achieve concrete gains for people, and may also expose
the system in certain other respects. If certain political forces oppose such a proposition, the
real character of such forces standing for the ‘Market centred system’ becomes exposed, and
people can mobilise for change. However, if the demand is accepted in part, this opens the
space for some concrete improvements in people’s lives and at the same time, through
monitoring and accountability mechanisms, can give people greater power locally. Hence
counter-hegemonic demands can form a bridge between a seemingly hopeless present and a
projected, detached ‘ideal’ future that may be viewed by people as a good idea, but
unrealistic. Being able to fight for and achieve real changes, here and now, enables people to
shake off pessimism (“nothing will change”) and can provide hope, while opening the way
for more far-reaching transformation.
Usually, the state would not deny the demand for such a Right directly, but may seek to
dilute, water down, appease such demands or even try to satisfy them in a pseudo
progressive’ form by retaining the words but taking out the substance. In such a situation, we
should work for appreciable improvements in the form of achieving certain rights, expose
3rd August, 2004
illusory programmes, and keep emphasising the larger aim and move towards a progressive
expansion of rights. With each step forward, if people become more capable of asking for
their rights, of monitoring the system and understanding the need for further changes, then we
may consider this to be moving ahead.
Some potential shortcomings of the Rights approach to Health
The Rights based approach has certain obvious pitfalls, which should be recognised and
as far as possible avoided, whenever such an approach is adopted.
• If the struggle for health care rights is limited to specific local rights (such as the
availability of certain services, medicines etc.), this may pit people against the local providers
(e.g. the PHC doctor or ANM) but may leave the state and national level policy makers and
the global actors unscathed. Keeping this in mind, moving from resistance to comprehensive
policy critique is important. Continuously pointing out the larger links and generalising the
demand for health care rights beyond just local demands would increasingly bring the main
decision makers into focus. Also, we may attempt to build bridges with the lower level
functionaries in the public health system, and document the obstacles they face in providing
services, to avoid targeting them and to raise our ‘gun sights’ towards the real decision
makers.
• A narrow interpretation of the Rights based approach may be viewed as a ‘non
political’ approach if confined to a limited interpretation of a single Right (“All we are saying
is give health a chance”). People may interpret it as the demand for specific improvements in
one sector, while leaving the overall socio-political system intact. Here again, moving
towards a counter hegemonic process where struggles for various rights converge and
strengthen each other, and begin to question the system from various angles, is a process that
should be attempted and should emerge over a period of time.
• As mentioned above, the demand for rights may be partly met by introducing certain
reforms, and an attempt may be made to co-opt this demand as ‘good governance’. Even an
international agency like the World Bank may support certain limited, local ‘rights’ in the
form of increasing accountability, checking gross corruption and so on. The coalition which
has been built up to demand a certain right may be divided about whether to accept certain
partial, at times even tokenistic measures being implemented by the Government. Here again,
judiciously accepting genuine implementation of rights, while exposing tokenism and
continuously pushing for more extensive changes is a matter of strategy, which needs to be
debated and worked out in each particular situation.
Some strengths of a Rights based approach to Health
Despite these potential pitfalls, there are a number of strengths in the Rights based
approach, which can make it an effective tool for the health movement, to ensure people’s
access to health related entitlements. Some of these features are:
• A simple slogan like ‘Right to Health Care’ can be comprehended, at a basic level, by
anyone - from an ordinary ‘person in the street’ to a WHO official. The rights language has a
strong universal appeal, and can help a much larger mass of people, beyond health experts
and activists, to relate to the basic issue and get involved. The rights approach can help us
link somewhat complex issues of health policy with a demand that can be taken up by people
anywhere, and considerably broaden and strengthen the health movement.
• The health rights approach empowers individuals, communities and organisations,
enabling them to demand in a specific way, particular health services and facilities. Once
grasped in its essentials, this approach can be wielded by any person or collective, and
becomes a source of strength and bargaining power.
• The health rights approach focuses on functional outcomes, and measures all policy
changes or declarations in terms of what people actually receive in terms of real entitlements.
The rights approach can effectively challenge the claims of the health officials that “we have
so many health centres, we are spending so much money, we have good policies” etc. by
pointing out the violations of health rights as long as they continue to occur.
• When the idiom of health rights becomes part of the overall discourse, automatically
health services become understood as important public goods, to be universally accessible,
distinct from commercial goods or services to be purchased in the market. This is an
important paradigm shift, helping to push back the dominance of the market approach to
health care.
• Rights lend themselves to expansion and universalisation. Once certain rights
become established, they become a precedent for other groups or marginalised sections to
demand similar rights. The rights approach naturally strengthens the claims of the most
disadvantaged and vulnerable sections of society, and helps us both to challenge
discrimination and to ask for attention to the most deprived.
• Rights once granted cannot be easily reversed. While policies and programmes may
be changed by new governments, sometimes leading to weakening of services, once the Right
to certain services or facilities is established, it would be very difficult to take away this right.
• The rights approach talks in terms of obligations and violations, thus placing the
responsibility to deliver on the system. The beneficiaries are transformed from ‘supplicants’
to ‘claim holders’. When a right becomes a legal entitlement, any individual or group that has
been denied their right can institute legal action, and even a few such actions have a much
wider effect, in ensuring that all facilities deliver the services.
Some pointers we could keep in mind while adopting the Rights approach
Finally, given the potential pitfalls and limitations of the Rights approach, we could keep
in mind some of these pointers:
• The Right to Health Care would be realised in phases, and perhaps only to certain
extent in today’s social system. However, we need to work for a progressive expansion and
deepening of this right over time, rather than being content with partial reforms. We should
continuously establish linkages with the systemic, structural and policy issues that underlie
the violation of the Right to health care. This could pave the way for demanding systemic
changes, and not just ‘making the existing system work’.
• We may adopt the rights-based approach to continuously push for improvements, but
should try to steer clear of reformism. The difference between reformism and a radical
approach, based on popular pressure and pro-people advocacy, is the question of where
power, initiative and decision making lies. Since ‘Reforms are changes introduced by the
powerful’ (Chomsky) as a top-down process, what is given from above may never reach
below, it may reach in a much diluted or distorted form, or if given today may be taken back
tomorrow. On the other hand, when changes take place due to popular mobilisation and the
pressure of public opinion, and where people are aware of their rights and actively demand
these, the changes are more likely to be actually implemented, sustained and thoroughgoing.
Ultimately, one of the major strengths of the rights approach is that it takes the debate out of
the circle of ‘experts’ (even if the debate is between official versus pro-people experts) who
may continue to argue about policies, and places ordinary people, who can relate to certain
♦
rights and demand them, on the stage. The touchstone of change is no longer who ‘wins’ the
debate, but whether the change leads to real improvements in people’s lives by ensuring them
certain entitlements, which they can ultimately fight for, even without support from experts.
• In this context, any changes that we seek to bring about should strengthen the power
of communities and people’s organisations in being able to demand accountability of health
services, and in being able to negotiate for services as a right. In the process of a campaign,
even if some representatives of the movement might be involved in lobbying and developing
a framework for alternative intervention, the larger mass of activists and people should retain
their freedom to ‘criticise from outside’ and to act as a strong pressure group to push for more
thorough changes and to ensure effective implementation.
• Finally, uhile demanding health rights, we should remain aware of the context of our
dependent capitalist system, in the larger setting of globalisation - liberalisation processes.
Over a decade of virtually untrammelled liberalisation has pushed the social sector in this
country to the wall. Yet paradoxically, the very weakening of the social sector has raised the
awareness of social sector rights, since ‘when policies weaken, the demand for rights gets
strengthened’. And fortunately, the ordinary people of India are once again teaching their
rulers a lesson - that the needs of common people cannot be indefinitely ignored. Through
many events large and small, the apparently invincible tide of liberalisation may be turning,
even if only a little. Against the mighty Goliath of globalisation, David may be standing up at
last.
And so the way ahead is difficult, but the outlines can be seen - the struggle for the Right
to Health and Health care has to be strengthened, and linked up with the struggles for various
other basic rights. The struggle for health rights would develop as part of a spectrum of
movements for various rights, which together point the way towards the goal of social
transformation. Because, despite the proclamations of certain worthy scholars, there is no
‘End of history’. Though we have many more lessons to learn, and many more struggles to
wage, we can look forward to a time when history will be made once again.
About the KFHR
(Korean Federation of Medical Groups for Health Rights)
The KFHR (Korean Federation of Medical Groups for Health Rights) is a
joint organization of 6 NGOs representing 40,000 hospital workers,
about 2,500 various medical professionals, and activists for
workers' health right.
The NGOs forming the KFHR are organized in 1987, the period
of Korean renaissance of social movement, The KFHR have
struggled for the reform of the national health insurance system,
organized social movements against privatization of public health
system, demanded people's right to the accessibility to essential
medicines, and actively participated in anti-war movement.
& In year 2003, the KFHR sent a medical aid team to Iraq from
May to July, and held the Asian Health Forum 2003 ’People's Health
Right against WTO/Globallzation in September.
& We are preparing two testimonies in the IHF 2004, which are
'The Medical Situation of Baghdad, Iraq', and 'Gleevec Campaign
against Novartis, a pharmaceutical TNC'.
& As a program of the WSF 2004, the KFHR is preparing a
workshop with the title 'The Impact of the U.S. Military Bases and
People's Struggle Against If. S. Korea, the Philippines, Japan, and
Iraq’. It will be held at room A-14 at 9:00-12:00A.M., January 19.
To contact us, please mail us, call us, and
slte(though the contents are written in Korean).
visit
Address
110-500
Phone noJ
Homepage’.
E-mail :
Jongro-gu Yiwha-dong 26-1, 3rd -Floor
Seoul, Korea.
82-2-3675-1987
http://www.KFHR.org/
heaithright@korea.com
cur web
The U.S. operate a vast array of foreign bases manifesting many social and
environmental problems. After watching the gross injustices taking place in
the Philippines, Vieques, Japan, and Panama, and now we have faced people's
sufferings and resistance against US army in Afghanistan and Iraq.
As American military hegemony continues to grow like a cancer across the
globe, there will be more and more places in need of international solidarity
while dealing with U.S. base issues.
We will have reports from the damage by a firing range in Maehyangri,
Korea, the US base in Okinawa, Japan, and Subic, the Philippines. In addition,
KFHR report about the Iraq survey result which was done May to July 2003.
Asia, as a most threatened region by U.S unilateral militarism after
September 11, we would like share our pain, urgency and furthermore
solidairy and hope. We need stop the U.S and Koreans look forward to being
a part of such efforts.
Date: January 19, 2004
Time: 9:00-12:00
Place: a-14
Organized by KFHR(Korean Federation of Medicai Groups for Health Rights)
KFHR is a joint organization of 6 NGOs representing 40,000 laborers of hospitals,
and about 2,500 various medical professionals, and activists for workers' health
right.
The NGOs forming KFHR are organized in 1987, the period of Korean renaissance
of social movement. KFHR have struggled for the reform of the national health
insurance system, organized social movements against privatization of public health
system, demand the people's right to the accessibility to essential medicines, and
actively participated in anti-war movement. Recently. KFHR sent medical aid team
to Iraq in last May-July 2003, and held the Asian Health Forum 'People's Health
Right against WTO/Globalization' in last September.
The Medical Situation in Baghdad Under War, Based on the Experience of the KEHR
1. Background
From April to July 2003, the KFHR provided medical aid in New Baghdad area, but
this was not a project made by the KFHR alone. Just after the start of the violence in
Iraq, South Korea was sizzling with anti-war demonstrations and campaigns to raise
,1
money for the Iraqi people. In spite of these activities, the S. Korean government was
planning to send army to Iraq. To lead the public opinion against sending army and to
help the Iraqi people, the Hangyore Newspaper and the KFHR decided to send medical
aid team to Iraq.
2. The situation in Iraq
Iraq had had quite effective public health care system until the early 1980s. But with
a series of wars and economic sanctions for 13 years, the social infrastructure of Iraq
crumbled down. After 1991, the budget for medicine fell to 1/4, neonatal death rate rose
in a steep curve, chronic shortage of medicine and medical equipments, and leakage of
medical professionals to other countries all led to the instability of medical system. The
invasion of coalition force was a large blow on this fragile system.
3. Medical aid
Before the end of war. the main task was to supply intravenous fluids and anesthetics
to the hospitals of Baghdad and gathering information of the medical status.
In May, the war ceased and we focused to rebuild primary health care centers in Al
Mashtel area. Medical team provided medical care to about 200-300 patients every day,
and medicine was supplied to several health care centers in this area.
4. Survey
The purpose of our activity was not only to provide medical aid, but also to work as a
part of anti-war activity. We’ve conducted some survey to evaluate the nutritional
status and the psychiatric stress on children who’ve suffered two wars and long lasting
economic sanctions.
By the survey on psychiatric stress, it became obvious that even though children
seemed cheerful and smiling, they were suffering from serious stress. More than 80%
of children replied that they feel lonely and unhappy; about 90% of children were
fearing of death of their families or themselves; 85% of children felt safety only when
!1
1
they were with adults; and 80% replied that they think something bad would happen and
feel unsafe if they are at unfamiliar places. It has become impossible to expect Iraqi
children of childlike curiosity and adventurous spirit any more.
5. Remaining Issues
Hi
Hh :
; i '. ‘ M' 1 Vi* I
In the standpoint of scale and effectiveness, the activity of KFHR i<IS I obviously
■ij
i i
ill
1
insignificant. We think our effort was just pouring a bucket of water on a dry desert.
However, we would like to find some meaning on our activity.
First, instead of just delivering medicine and doctors, we tripd to he’n Irani neonle ho’n
themselves and tried to draw an up-to-date picture of the medical system.
Second, many Korean anti-war activists and other local activists helped the KFHR in
Iraq, and thanks to their effort, we could settle many strategies that the KFHR would
follow in the future activities.
Third, according to our evaluation, while major hospitals were filled with staffs and
medicines, local primary health centers had difficulty to find medical staffs and
medicines. We concluded that reconstruction of the primary health care center would be
the most urgent task to improve the health status of Iraqi people.
As a conclusion, providing medical aid AFTER war is not sufficient. The more important
thing is to PREVENT war. Therefore, we concluded that while providing medical aid to
the people in need, we should try to gather information of the impact of war on people’s
health and provide it as an evidence of anti-war movement, to prevent the war in the
future.
j
1
II1'
i'l
"Gleevec campaign against Novartis"
1. From Asking for Drug
1) About Gleevec
Gleevec(STI571)
is the
iiM ni
only known
effective therapeutic agent for CMLfchronic
myelocytic leukemia) except for BMT(bone marrow transplantation). As BMT is available
• ■...> la..: t.-.kJ. ’
Ih
for only a small portion of CML patients, Gleevec is the only effective oral medicine that
CML patients can depend on.
’2) Patients Start to Organize
In December 2000, the news about a miraculous drug called Gleevec reached to the
CML patients through the Internet. Patients pleaded for early approval and marketing of
this medicine. In July 2001, Novartis launched Gleevec in S. Korean market.
Patients waited for its emergence in the market with hope, but this hope turned into
despair when they found out the price of Gleevec was about 19 USD for each capsule.
An ordinary CML patient have to take 4 to 6 capsules each day, which costs about 76 to
114 USD every day, 2280-3420 USD every month to survive.
This ignited the leukemia patients to unite and they formed the ‘Korean Association of
Leukemia Patients(KALP). The KALP and the KADAG1 asked Novartis to reduce the price
of Gleevec. asked the S. Korean government for more coverage of National Health
Insurance(NHI) for cancer treatment, and also for approving compulsive license to
produce Gleevec.
As a result of struggle that lasted two years, the patients received the promise of more
coverage of the NHL including more coverage for the medicine, and more indication for
applying the NHL On the other hand. Novartis didn’t step back even one step to uphold
the ‘Worldwide-Single-Price Policy’.
2. I o consideration of so many aspects
During the struggle and arguments, ihe members of KALP and KADAG encountered
many facts about the development of medicine, the unreasonable process of pricing, and
rethinking of priority in right to health vs patent right.
1) Policy on Pricing
The target markets of pharmaceutical TNCs are the highly developed countries which
occupy 80-90% of all drug markets. As a result, the price is based on the affordability of
those countries, but this is too expensive for people of all the other countries.
I
I i
■I
'dll
II
I
Especially for a newly developed medicine like Gleevec. the global single price is so
high that even British and Australian government hesitated to approve insurance coverage
for Gleevec. In the case of S. Korea, the price of Gleevec is based on the average price
of seven leading countries: the USA, Britain, Germany. France, Swiss, Japan, and Italia,
whose GDPs are several times more than S. Korea.
Ji'
According to the Novartis’ website, in year 2002, Gleevec's sales topped 615 million
USD. making it Novartis’ fifth biggest product in the second year of its market
emergence.
In desperate effort to get the medicine, Korean patients found a generic brand named
‘Veenat produced by Nalco pharma Ltd., an Indian pharmaceutical company. All were
stunned by the fact that the price of Veenat was only two dollars per capsule!
2) Patent Right vs Right to Health
Xovarlis and many other pharmaceutic TNCs claim that they have invested a lot of
money to develop such medicines. But in case of Gleevec, it was issued as an orphan
product, the company was benefited by reduction of tax, shortened clinical test period
and approval for sale because patients pleaded the government to shorten the trial
period.
As we see in the Novartis’ website, Novartis has already regained the money they’ve
invested to develop Gleevec. The cost price of Gleevec is not so expensive as we see
the price of Veenat, and Novartis still has the global exclusive patent for 13 more years.
In March 2002. the KALP and KADAG submitted a petition to the National Human
Rights Committee claiming that the National Health Insurance(NHI) system is
discriminating CML patients by several reasons, and therefore infringing on their right to
health. This was the first appeal in S. Korea that patients claimed for their health as a
human right.
In the struggle over Gleevec, the patients are not asking the pharmaceutical
companies to give up. They are just asking for a more reasonable price.
'There are many other desperate patients in the world who are suffering from various'"
diseases and expensive medicines. Especially, the medicine for Malaria, Tuberculosis,
and HIV/AIDS are of main concern.
If we don’t reconsider the policy on pricing and if we don’t focus on the accessibility
to essential medicine as a basic human right, this list of desperate patients will grow
longer and longer.
i
‘
!
11 'h ly
r'
’’
'
1 (
1
Stop Oppressing
the Poor in the
Name of Beggary
Prevention
Withdraw Draconian, Anti-Poor
Beggary laws
• Bharat Dogra
VOICES
"The society which cannot provide for social se
curity ensuring satisfaction of minimum needs has no
moral authority to arrest persons for begging out of
sheer helplessness."
- Bombay High Court (Commission on Beggars Act, 1990)
Massachusetts's highest court has held that to
prohibit begging is to prohibit individuals from "engag
ing with fellow human beings with the hope of receiv
ing aid and compassion."
(424 Mass 918-1997)
(1)
A widely recited doha of Kabir implores people never
to torment those who are already weak and distressed.
In present times, India's beggary prevention laws and
their implementation provide one of the worst examples
of tormenting the poorest, most vulnerable people.
Despite the ancient tradition of charity and alms giving in India which created conditions in which some
of the most venerated saints chose to obtain their
subsistence by asking for alms, it is strange that the
modern Indian legal system has gone to the other
extreme of criminalising not only begging but even the
mere suggestion of begging. For example the Bombay
Prevention of Begging Act (1959) defines begging in such
a broad way that any poor and homeless person can
be listed as a beggar, and this listing in turn can lead
to imprisonment for a long time in the most difficult
conditions imaginable.
It is bad enough for law to criminalise all forms of
begging, it is perhaps even worse that even those who
do not beg are also arrested under these laws in large
numbers. What is more, the custodial institutions built
around these laws are generally run in such a way as to
inflict the worst suffering, humiliation and in many cases
even torture on their inmates. Infact violation of basic
human rights is seen at almost all stages of these
anti-beggary acts.
It was therefore a case of a long-felt need being
fulfilled when a 'National Consultation on Urban Poor
With Special Focus on Beggary and Vagrancy Laws' was
organised on July 15 and 16 in Delhi. Ashray Adhikar
Abhiyan, an organisation working for homeless people
in Delhi (which has achieved much in a short time)
(2)
teamed up with Action Aid and Indian Social Institute to
organise this much needed consultation.
A particularly moving aspect of this consultation was
the testimony of several persons who had actually
suffered due to the highly distorted anti-beggar laws and
their equally arbitrary implementation.
Gaur Nisha was rushing on a New Delhi Road to
fetch medicine for her daughter who was prone to
having fits. Two other children accompanied her.
Suddenly a group of policewomen swooped on her and
pushed her into a waiting van. Nisha shouted again and
again that her sick daughter is waiting, but her cries were
ignored and the van drove away.
Just a few metres away Zainam waited endlessly
for her mother to come. The minutes turned into hours
and hours into days but mummy did not come. She
wandered aimlessly here and there, her fits troubling her
but probably also protecting her from persons with wrong
intentions.
Meanwhile Nisha was taken to a place which she
learnt later was a beggars home. Here whatever little
money she had was snatched away and she was given
a heavy work load. She also saw a woman being beaten
in the most cruel way and so she did not dare to protest.
When she finally managed to send a message of
her confinement to a friend and efforts were made to
bail her out, she rushed to find her daughter. For once
luck was on the side of the troubled mother as she was
able to find her daughter - in a bad shape with several
layers of dust and dirt but safe otherwise.
Anoop was selling garlands in a Delhi market when
(3)
a policemen asked him to take one garland to a waiting
van. As the unsuspecting youth, a newcomer to Delhi
from Faizabad approached the van to give a garland, he
was asked instead to step into the van. His garlands
were thrown away and he was driven away.
When he did not return till late evening his parents
set out in search for him. Some shopkeepers told them
that their son had been taken to Seva Kutir after being
accused of being a beggar. This poor household had to
incur a heavy debt to get their son out on bail.
Social workers working with homeless people and
lawyers providing legal aid at beggars' homes have
hundreds of examples of people who have been treated
very harshly and unjustly under the existing beggary
prevention laws in Delhi and elsewhere. Human rights
are violated at every stage. Generally poor helpless
people picked up arbitrarily are not informed where they
are being taken.They may be imprisoned for one to three
years (or even more if they have been brought a second
or third time) for the supposed 'crime' - real or false, of
begging. The places where they have to live out this
sentence are deprived of the most basic needs. Inmates
are beaten up frequently and given huge workloads.
Women face the additional hazards of sexual
exploitation. Many of them are unable to contact their
families in far-away villages. Their families live in
constant tension of what may have happened to them.
Some of them become so depressed that they lose the
will to communicate with outsiders. When they emerge
from their dismal sentences, many of them cannot
continue whatever precarious livelihood they pursued
earlier and do not have the heart to tell family and friends
that they had been confined all the time to a beggars'
Mg®
(4)
home.
After hearing the testimonies of people who have
actually suffered under the anti-beggary laws and the
views of several legal luminaries and social activists, this
national consultation concluded firmly that anti-poor
beggary laws should be scrapped. The only aspects of
begging which need to be curbed relate to the various
types of forced begging in which children or even adults
may be kidnapped and/or injuries may be inflicted on
them and they are then forced to beg to bring profits to
gangsters. Strict actions against such forced begging
rackets can be taken under I.P.C. Similarly any other
aspects of forced begging/extortion can be taken care
of by other legal provisions. There is absolutely no need
for separate beggary prevention laws, particularly of the
kind which criminalise all begging, (as distinguished
from a small part of forced begging). These anti-poor
laws should be scrapped along with the custodial
infrastructure mainly beggar homes (Delhi has nearly a
dozen of these) they have needlessly created. These
wasted efforts and funds should instead be channelised
to providing better health service to homeless and
destitute people as well as to beggars. Several aspects
of such an effort including better mental health service
and a humane approach to care of leprosy patients were
discussed at this national consultation.
To have a better understanding of this muchdistorted issue, it may be helpful to examine it in three
parts - (i) the real condition of beggars and begging in
the context of urban India (ii) the elitist perception of this
issue as also reflected in the policies of the government
and (iii) suggestions on how government policies should
be changed to tackle the real issues in such a way
(5)
that most vulnerable people get real help and the
involvement of the people can be obtained in such an
effort.
I - Understanding the Real
Condition of Beggars
Even according to government's own statistics,
crores of people live below the poverty line. Even if we
ignore the non-official estimates (which are on the higher
side) and go strictly by official estimates, 260 million
people in our country do not have incomes to access a
minimal consumption basket which defines the poverty
line. India has 22 percent of the world's poor. Every third
child born in India is under-weight. Around half of the
pre-school children suffer from under-nutrition. More than
half of India's women and children are anaemic. During
the last 10 to 15 years there were cutbacks in some of
those schemes which the government regards as the
most crucial planks of its poverty alleviation effort.
The fragile subsistence of poor people can be
shattered by the all-too-numerous (and increasing)
calamities like floods, droughts and accidents. The
incidence of occupational accidents and diseases is
known to be very high. The number of people suffering
from diseases which render the body incapable of any
hard work is very high in India. The plight of widows and
deserted women is very bad. Aged persons, particularly
when they are diseased or disabled, face increasing
neglect from their families. The number of physically and
mentally challenged people is known to be much higher
than the official estimates. The overwhelming majority
of poor people are deprived of even minimum provisions
(6)
for social security. Keeping in view this situation should
it surprise anyone if millions of people have no other
choice but to appeal to the compassion of more
fortunate fellow human beings to meet their subsistence
needs?
Recently Action Aid conducted a study to
understand the real condition of beggars. This study was
based on interviews with 1248 beggars, 50 officials and
28 alms-givers. This study was conducted in 9 cities of
four states. - These cities are Jaipur and Ajmer
(Rajasthan), Chennai and Madurai (Tamil Nadu), Patna
and Gaya (Bihar) Allahabad, Lucknow and Varanasi
(Ultra Pradesh).
According to a presentation
of this study by Subrata De, this data shows that almost
every beggar (99% among men and 97% among women)
get into beggary due to poverty. Almost all the beggars
(85%) used to have an earning below the poverty line
annual family income (less than Rs. 8000-9000) before
getting into this practice. Out of that 25% people got into
beggary because of poverty along with disability,
disease, old age etc.; and 15% faced family problems
due to poverty.
None of these people had agricultural land or
assured income from sharecropping. Inability to sustain
the family system led quite a large majority of people
(more than 75%) to leave the rural livelihood and come
to urban areas. Considerable portion of people could
not do manual work due to disability, physical and
mental, (76% among men & 55% among women) and
old age (52% among men & 43% among women). Only
one-fourth (27%) people were literate. Out of that only
16% people had gone to school. Within the school going
group more than 70% dropped out soon after getting
(7)
into secondary level. Little more than 1% passed class
10.
This study found the daily income of beggars ranges
from Rs. 2 to Rs. 50. Average income is Rs. 26 for ablebodied men and 30 for able-bodied women. Moreover
28% women and 36% men earn less than Rs. 20 per
day. Disabled and diseased people earn more, Rs. 45
for women and 31 for men.
People cannot take bath for weeks or wash clothes
for months together. All of them have developed some
health problem due to such unhealthy living. 25% money
is spent on an average for toilet, bath and washing clothes
and 5% for drinking water. The medical expense is very
high (average 20%, but at times it goes up to more than
35% since Govt, hospitals generally do not treat them).
Beggars end up paying a considerable portion of their
income to police, which is included in expenditure for
place of stay. Amount under this head at times go up to
50%. Almost all the beggars (94%) are forced to remain
on street without shelter. More than 80% beggars have
opined that police beat them unnecessarily. 32%
beggars felt that beating is used for extracting money
from them.
It is clear from this study that most of the beggars
are genuinely needy people who have suffered much
from the ravages of hunger and poverty. From a
common sense point of view, there is absolutely nothing
criminal about the effort of a hungry or badly deprived
person to meet his or her basic needs (as well as the
needs of their dependants) by appealing to the
compassion of fellow human beings and obtaining small
amounts of money or food from them. The criminal
aspect of begging is confined to only a very small
(8)
section of beggars where gangsters force children or
adults to beg for them.
II - Elitist perception of beggary
and government
policies based on this perception
Unfortunately eliist opinion frequently fails to
recognise this real situation of beggars. This is part of a
larger tendency of elitist opinion to be unsympathetic
towards urban poor. For example, elitist opinion frequently
opposes the housing rights of slum-dwellers and
pressurises the government to demolish slums, or to shift
slum-dwellers to the outskirts of the city. Elitist opinion is
even less tolerant towards beggars who are described
as a menace and the government is asked to somehow
remove them away from the sight of local elites and
tourists. Elitist opinion encourages the impression of
beggars as idle people trained to earn easy money from
others. This opinion also greatly exaggerates the
presence of criminals in begging, while ignoring the
obvious reality of millions who genuinely needs alms for
sheer survival.
It is unfortunately this elitist opinion which has been
accepted by the government as the central plank of its
policies towards beggars and beggary. Most of the
legislation on this subject regards all begging as a crime,
instead of confining the stigma of crime to only a small
section of forced begging. This amounts to needlessly
tormenting millions of already distressed people. Due to
the unjust socio-economic conditions of the country,
extreme inequalities as well as the additional burden of
calamities and accidents, millions of people are reduced
0)
to a situation that they resort to begging in cities and
towns. It is completely unjust and irrational to regard them
as criminals. At a time when a shortage of police force is
frequently cited as an excuse for the government's
inability to curb serious crime, where is the justification
for using the police to chase poor helpless people?
Social welfare officials are paid to promote the welfare
of weaker sections. Where is the justification of using
them to arrest poor helpless people?
Infact the existing laws (and their implementation)
are even worse than this. In reality these are being used
to arrest not only beggars but even other helpless, mostly
homeless people who have never begged. This happens
also in the normal course of the implementation of these
laws but this is stepped up particularly at the time of
special anti-begging drives when the anti-begging
squads are under pressure to 'capture' a large number
of beggars.
A highly unjust aspect of the existing anti-begging
effort is that in many cities a huge infrastructure has
been created around the implementation of beggary
prevention laws. For example in Delhi there are nearly a
dozen beggars homes. This is a highly corrupt system
and to keep this corrupt system running a steady stream
of beggars and alleged beggars are needed in these
custodial institutions. Hence powerful persons develop
a vested interest in the perpetuation of a highly unjust
and cruel system.
At present there are about 12 beggary prevention
laws in operation in the country, many of them going
back to colonial times. These laws include the following
- The West Bengal Vagrancy Act, 1943, the Mysore
laaaaaaaaaaaaaaaaaw
(10)
Prevention of Begging Act, 1944; the Madras
Prevention of Begging Act, 1945; the Bihar Prevention
of Begging Act, 1951; the Bombay Prevention of
Begging Act, 1959; the Jammu and Kashmir Prevention
of Begging Act, 1960; the Andhra Pradesh Prevention
of Begging Act, 1964; the Haryana Prevention of
Begging Act, 1971; the Punjab Prevention of Begging
Act, 1971; the Goa, Daman & Diu Prevention of
Begging Act, 1972; the Cochin Vagrancy Act, 1974; the
Uttar Pradesh Prohibition of Begging Act, 1975;
Some of these acts apply to a wider area than what
is suggested by the titles. For example the Bombay
Prevention of Begging Act (BPBA) was extended to Delhi
in 1960-61 after adding some rules for Delhi.
While these laws may differ in detail, by and large
the tendency is to regard beggars as criminals and
thereby to call for the elimination of beggary - including
begging that takes place for very genuine subsistence
needs in the absence of alternative means of
subsistence. Here we examine particularly one such law
which applies to two of India's most important cities (Delhi
and Mumbai).
The BPBA has a very wide definition of begging a) soliciting or receiving alms in a public place, whether or not
under any pretence such as singing, dancing, fortune telling,
performing or offering any article for sale;
b) entering on any private premises for the purpose of
soliciting or receiving alms;
4
c) exposing or exhibiting, with the object of obtaining or
extorting alms any sore, wound, injury, deformity or disease whether
of a human being or animal;
d) having no visible means of subsistence and wandering
about or remaining in a public place in such a condition or manner,
^3|§g|gg|gg|g^gg|
(11)
as makes it likely that the person doing so exists by soliciting or
receiving alms.
Any poor, unemployed, homeless person can be
picked up under this law. In practice this law has been
interpreted even more widely by officials bent on
fulfilling their target of 'capturing1 a certain number of
'beggars'. According to this Act, any police officer may
arrest without a warrant any person who is found
begging. This power may also be extended to any other
person (such as official of Social Welfare Department)
in accordance with the rules. The police department
has created a special anti-begging squad which is
attached with the Department of Social Welfare at its
Reception-cum-Classification Centre.
Now let's see what happens in practice when such
wide powers are given to arrest beggars or supposed
beggars as though they were criminals?
In the year 2000 eight inmates of Lampur Beggars
Home died and 114 suffered from gastroenteritis. When
news reports appeared to this effect, the Delhi High Court
asked a lawyer Mr. Rakesh Saini to prepare a report on
beggars' homes in Delhi and related issues. This is what
he wrote in his well-documented report "My conscious is shocked... to learn that for a
simple and unfortunate so-called offence of begging, a
citizen of the country, who is a victim of circumstance for
the creation of which the state and society are also
responsible to some extent, can be deprived of his
personal liberty and freedom and detained for a long
period of 2-3 years, merely by a summary trial and thrown
into a Beggars homes only to be beaten up and tortured
there, taken advantage of and exploited and exposed to
the risk of disease and a horrible death there.
aaiaaaaaaaaaaaaaaai
(12)
I
"In most of theses institutions, a number of
persons complained that they were innocent and not
professional beggars and were forcibly picked up from
various places in Delhi while going their way, taken to
remand and classification centre at Kingsway Camp
where they told the probation officer about themselves
who assured them of help and redressal but did not
do so. Instead, they were beaten up and tortured and
thereafter produced before the magistrate. The
magistrate also did not listen to them and sent them to
the Beggars Home to be kept there for 1 -2 years."
-R. K. Saini in the High Court Committee (HCC) Report
on Beggars Homes
In another official report 'Beggar Institutions Lampur, Narela - An Assessment report (Commissioned
by the Government of NCT of Delhi, March 2001) a
senior official G. D. Badgaiyan confirmed that many
innocent people are arrested. Many indiscriminate
arrests are due to the emphasis on fulfilling 'targets'
or 'quotas' particularly during anti-begging and
beautification drives. The accused are taken to the
Beggars Court or Poor House Court. This report
criticised the lack of legal aid in the court and the fact
that the Magistrate was acting as defence lawyer,
prosecutor and judge. As this report pointed out, each
trial lasted two minutes on average and only five people
were acquitted in 2000.
However many of the arrested people could get
relief once a legal aid system was introduced at the
Beggars Court and also to help the inmates of the
Beggars' Homes. In recent times a large number of
arbitrarily arrested persons have escaped harsh
imprisonments due to the dedicated efforts of a handful
(13)
SESSBHBniHBHBBEHBESBBsHEllSiEBsS
of highly committed lawyers providing legal aid in very
difficult conditions and having to overcome a lot of
resistance and many hindrances. In Delhi this legal aid
system for beggars and alleged beggars is in place due
to the effort of a Delhi Legal Service Authority (DLSA),
Legal Aid Clinic (Faculty of Law, Delhi University),
Human Rights Law Network and Ashray Adhikar
Abhiyan. Social activists and public spirited lawyers in
other parts of the country can benefit much from the
recent experiences of these dedicated lawyers, legal
experts and social activists in Delhi to take legal aid to
the poorest of the poor in Delhi.
Even though these lawyers are able to help
several distressed people almost every day, they still feel
strongly all the time that this is only a temporary relief
and the real solution lies in repealing the anti-poor,
draconian beggary prevention laws.
Recent surveys by Ashray Adhikar Abhiyan
conducted with the help of lawyers and social activists
have revealed that alarming violations of human rights
continue in the existing system of arrest and
confinement under BPBA in Delhi. For more than 90
percent of the arrested persons, the manner of arrest
had elements of coercion, deception, false promise,
abuse and violence. Generally they were not told where
and why they were being taken against their will, 78
percent said they were not aware of reason behind
arrest. Asked about activity at the time of arrest, only 11
percent described it as begging or receiving alms. Clearly,
all this cannot be tolerated in any society that values
human rights. This injustice to the poorest has
continued for too long. It must go - the sooner the better.
(14)
III - Alternative Policy Framework
I
Therefore it is proposed that
(i)
the existing beggary prevention laws and the
supporting infrastructure of beggars' homes etc. should
be scrapped along with funding for the same.
(ii) These funds should be diverted to providing health
care to beggars, destitutes and homeless people, with a
special emphasis on mental health and leprosy. This
should be a partnership of government and citizens'
groups who are keen to help these poorest of the poor
in our cities.
(iii) Whenever any traces of organised begging
gangsters who kidnap and maim for forced begging are
found, strict action should be taken under provisions of
I.P.C. Similar existing legal provisions can be used to
prevent any extortion.
(iv) Ordinary begging activities should be free from the
stigma of crime throughout the country.
V
Year of Publication : 2005
____________________ Price : Rs. 8.00____________________
This book is published by Bharat Dogra, C-27, Raksha Kunj, Paschim
Vihar, New Delhi-110063, Ph. 25255303 and printed by Kulshrestha
Printers, A-11, Tyagi Vihar, Delhi-110041, Ph. 25472648
(15)
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Phone : 25255303
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(16)
1
The Right to Health Care is a Basic Human Right!
Towards attaining the Right to Health Care...
The Government of India has been unable to fulfill it’s commitment of ‘Health for All by 2000 A.D.’ till
now. In fact, primary health care services are becoming more and more difficult to obtain especially
for people living in urban slums, villages or remote tribal regions. The condition of government
hospitals is worsening day by day. Nowadays, in most of the government hospitals there is
inadequate staff, the supply of medicines is insufficient and the infrastructure is also inadequate. The
facilities for safe deliveries or abortions are also very inadequate. Given the fact that women do not
even get adequate treatment for minor illnesses such as anaemia, services for problems such as the
health effects of domestic violence remain almost completely unavailable. At the village level, there is
no resident health care provider to treat illnesses or implement preventive measures. All hospitals are
located in cities, and here too public hospitals are increasingly starved of funds and facilities. Thus
there is lack of availability of government health care services on one hand and the exorbitant cost of
private health services on the other. This often leaves common people in rural areas with no other
option but to resort to treatment from quack doctors who often practice irrationally. Thus most of the
population is being deprived of the basic Right to Health Care, which is essential for healthy living.
The Indian Constitution has granted the ‘Right to Life’ as a basic human right to every citizen of India
under article 21. In article 47 of the Directive Principles of the Indian Constitution, the Government’s
responsibility concerning public health has also been laid down. Yet the Government is backtracking
from fulfilling this responsibility. This is obvious from the fact that the Government’s proportion of
expenditure on public health services has been declining every successive year.
What can be done in the near future to establish the Right to Health Care?
The year 2003 was the silver jubilee year of the ‘Health for AH’ declaration. On this occasion, Jan
Swasthya Abhiyan launched a nationwide campaign to establish the Right to Health Care as a basic
human right. Some of the following activities are being taken up as part of this campaign:
•
•
•
•
Documentation of individual case studies involving denial of health care. Information is being
collected in a specific format with the help of questionnaires. The cases where denial of health
services has led to the loss of life, physical damage or severe financial loss of the patient are
being emphasised. These case studies will be presented to the National Human Rights
Commission. It is hoped that they would help us to depict the real status of provision of the
primary health services by the government and strengthen our demand for improving public
health services as well as help us in dialoguing with the public health system.
Similarly, situations of structural denial of health care, where Primary Health Centres,
Community Health Centres or public hospitals are regularly denying basic health services to
people are being documented. Questionnaires have been prepared to help in such
documentation, based on which the demand for adequate services and facilities may be raised.
Jan Sunwais on the Right to Health Care are being organised at the local, district and state level.
JSA linked organisations can organise such Jan Sunwais to highlight the state of public health
services, and instances of denial of health care / structural denial of health care can be presented
in these programmes.
The National Human Rights Commission, in collaboration with Jan Swasthya Abhiyan, is
organising Public Hearings on Health and Human Rights in various regions of the country from
mid-2004 onwards. These regional hearings would be followed by a national public hearing. JSA
linked organizations and individuals can present case studies during these public hearings and
ask for effective action by state health authorities and investigation by the NHRC.
These are some of the steps being planned to move towards establishing the Right to Health Care.
Let us join this campaign and strengthen the movement to achieve health care and Health for All!
Jan Swasthya Abhiyan - People’s Health Movement India
For more information visit www.phmovement.org/india or contact:
Jan Swasthya Abhiyan Secretariat, Address: C/o CEHAT ,3&4, Aman Terrace, Plot no. 140, Dhahanukar Colony,
Kothrud, Pune-411029 India; Phone. + 91-20-25451413/25452325; E-mail: cehatpun@vsnl.com
LA'
Jan
Arogya
Abhiyan
I
=
i
I
Patient’s
Kights
Campaign
in
Maharashtra
i
I
Jan
Arogya
Abhiyan’s
Actions
for
Change
■
For long private sector regulation as an agenda, remained
confined to the policy makers and the medical professionals.
=
Patients and ordinary citizens, who are mainly affected by the
behavior of the private medical sector, were outside the realm
W This is
of regulatory deliberations. The dominant narrative on the
a story of
1 private sector was always from the perspective of the powerful
Jan Arogya
medical lobby.
L Abhiyan,
j This situation is slowly changing. People are getting mobilized.
There is a popular narrative shaping up, arising out of people's
L, Maharashtra.
kLrii
^■1
lived experience. This document is an attempt to capture the
L
spirit and the hands-on feeling of actions that arose from the
real-life efforts of patients, community, and activists.
r
Stories of people who have been denied health care, or were exploited by the very hospitals
and doctors in whom they have confided are not uncommon in India. Some remain untold,
and some are so striking that they. Here are some true stories® On 4th June 2018, Radhika Chavan, who gave birth to a child a week ago, committed
suicide in a toilet of the Government Medical College, Latur. To treat a new born child,
she and her husband were asked to purchase medicine from outside which they could
not afford. Radhika was so demoralized that she decided to end her life in the hospital.
Ironically, this was a Government facility; and by definition, all medicines are expected
to be available free of cost.
® Sixty-two years old Chandrashekhar Kulkarnifrom Mulund, Mumbai, was operated in a
big private hospital for non-existing cancer. Part of his intestine was removed. Crippled
for life with different complications, Mr. Kulkarni spent 20 lacs on the surgery, and
when he consulted another doctor for a second opinion, he came to know that he never
had cancer. He is today fighting a lone battle with the medical establishment, starting
from approaching Consumer Forum to redress gross medical negligence, to
Maharashtra Medical Council- which is expected to take punitive action in cases ur
breach of medicalethics.
® Pranju Dange was admitted with a brain hemorrhage, in the C11 MS Hospital which is a
charitable trust hospital in Nagpur, on 5th July 2017. Inspite of all the documentary
evidence to prove that she belongs to economically poor section of the society, and
deserves free treatment as mentioned in the government rule, Cl I MS denied her free
treatment. Moreover, even when the Chief Minister's office ordered Cl I MS to treat her
free of costthe hospital refused to oblige. Herfamilywasforcedtoselltheiragricultural
land- only source of family income, to take care of the hospital expenses. A due
complaint was lodged in the Nagpur Charity Commissioner' Office, however there is no
action so far.
The pain in these lines is real, and people in these stories decided to make their grievance
visible and public. On the backdrop of despair, people in these stories, along with activists,
are fighting back against injustice. This document is an attempt to give glimpse into Jan
Arogya Abhiyan' struggle for patient's rights. It tells what we won and what remains to be
own it says smallvictories matter; and remembering them matterstoo.
What are «ur
grounds for hope
for ensuring
patients’ rights?
L •
I
No private health providerand institution can oppose patient's rights in principle. Every healthcare institution has to wearan
apparent mask of protecting patient's rights. However, in a stark contradiction, when it comes to enactment of the Clinical
Establishment Act- which effectively can safeguard patient's rights and regulate the private sector, opposition from the
united private medical sector is fierce. In contrast, patients and communities are not organized to question the unethical
and exploitative practices in the private health sector. People require a forum to get together, to share stories, build
solidarity, and turn it into a campaign. We perceived this need and started to work on patient's rights.
First strategy was to use an idiom that people know, and to establish a narrative on patient’s rights. So, what did we do?
i
■ Voting for patient's rights- Voting for better health care
Under the broad heading of "Patient's Voice, Citizen’s Initiative Campaign,” we organized voting for patient's rights in
different parts of Pune District, from 15th June to 30th June 2017. Each ballot paper reflected what people want; it was an
exercise that gave us a glimpse of how strongly people feel about patient' rights in both public & private healthcare sector,
and the exploitation in the private sector, and how much they aspire for better public health services. Here is a snapshot of
thevoting® 21351 votes were cast.
® Thevotingwasconducted at more than 80 placesin Punedistrict.
® 670 people voted online.
® People from various residential societies, slums, villages, companies, colleges, self-help groups participated a very wide
cross-section of society voted- there were government employees, doctors, nurses, IT professionals, unorganized sector
workers, waste pickers, farmers, farm labourers, sex workers, people belonging to nomadic tribe community, truck
drivers; all voted with fervor.
® In this voting exercise, three questions were asked. Should Maharashtra Government regulate and standardize private
hospitals to check commercialization? Should Maharashtra Government take concrete steps to improve quality of care in
public hospitals? Should Government immediately enact legislation to protect patient's rights?
® Out of the 21351 people who voted, an overwhelming 21067 (98.7%) voted in favour of bringing private hospitals under
regulatory framework while 21247 (99.5%) agreed that government should take concrete measures to improve quality of
care in public hospitals. 21225 (99.4%) people demanded the enactment of a legislation to protect patient's rights. This
indicates that people from all walks of life are dissatisfied with current healthcare options and they strongly demand
reforms in the healthcare system.
The context of voting, the sheer number of
people who voted, underscored the
importance of engaging with ordinary
people. The campaign culminated into a
public event, and the results of the voting
were announced on 1st July 2017 (Doctor’s
Day). Noted theater personalities like Atul
Pethe, activists like Poornima Chikarmane,
and people from all walks of life participated
in this event. The uniqueness ofthis event did
not go unnoticed, almost all leading
newspapers and electronic media reported
about voting and results.
© Many people who voted, were not just there to cast a vote, but shared personal
stories of denial, negligence, and exploitation.
© Voting as an idiom had struck a chord with people. They found agency and meaning
in the voting and came out in large numbers. In a process, we also got a sense about
the magnitude of discontent regarding existing status of healthcare services in
both public health system and private health sector.,
© This social churning did not go unnoticed; media covered details regarding the
voting and the public event in great detail.
This campaign gave us confidence that people' power is with us. We also knew that
dreamsand reality are contrasting, but actions synthesizethem.
What
have
we
learnt?
Knocking the door of decision-makers: Actions for change Making discontent visible and public is often a first step in remedying it, the experience of voting reinforced our advocacy efforts.
14th December 2017- A rally for patient's rights and enactment of
the Maharashtra Clinical Establishment ActThe unexpected success of the voting inspired us to move forward, and we realized that time had come to engage with the
ruling government and the other elected representatives to assert our demand for the patient' rights. Street protest is many
times a tactic of last resort when more conventional advocacy actions fail to open up policy space. It was a time for the rally.
The place was Nagpur, and the occasion wasthe winter session of the Maharashtra Assembly.
This was not the first time that JAA organized such a rally during the winter session of the Assembly. In December 2012, a
similar campaign was organized by JAA, and follow-up protest was also held in 2013. Both these campaigns, and sustained
advocacy resulted in formation of the Drafting Committee, in which Jan Arogya Abhiyan got representation, which came up
with a draft bill of Maharashtra Clinical Establishment Act, in June 2014. With specific elaboration on the charter of patient's
rights, district level grievance redressal mechanism, enhanced representation to civil society organizations in the various
official bodies/forums, provision of dedicated human resources for implementation of the legislation in the form of
Directorate of Clinical Establishment were proposed in this draft by Jan Arogya Abhiyan and included in the bill. This draft bill
was significantly improved and more pro-people than the model Clinical Establishment Act passed by the parliament of
India. Jan Arogya Abhiyan also insisted upon removal of non-practicaland seemingly harsh provisions from the point of view
of any rational, ethical doctor. Those changes were also accepted. Following endorsement from the Directorate of health
services, it was accepted by the Health Minister. However, with the new government in power in 2014, and with the changed
political priorities, the draft Maharashtra CEA was not adopted. Tellingly, the rally on 14th December, was also to remind
governmentabout previous commitmentsand the need forimplementation.
Communicating through
Pamphlets, Posters,
and Slogansf
?
Dr. Deepak Sawant @dr... 15 Dec 17 s.
The State Government is enacting an
Act on the lines of Central Government’s
Clinical Establishment Act to keep
control over private hospitals
overcharging the patients. #ShivSena
@AUThackeray
Protesters at the front of the rally flashed a big placard with an
unmissable cartoon of the Health Minister, with a prominent and
provocative message - "Health Minister Wake Up." Over the years JAA
has realized that slogans are powerful; they persuade people to think,
and messages in slogans travel quickly. The rally in Nagpur was no
exception. Activists and ordinary people came to join the rally. The rally
culminated just before the entrance of Maharashtra legislature.
A delegation of JAA met the Health Minister of Maharashtra, Minister
of the State- Health, Leader of the Opposition, and 18 Members of
Legislative Assembly(MLAs).
Main demands that we put forth to elected representatives and the Minister were® Reverse budget cut (500 crores) in the allocation for Public Health and Family Welfare Department and demanded
increase in the public health budget substantially from 12,000 Crto 20,000 Cr
® Start 'Free Medicines and Free Investigation^scheme' in Maharashtra on the lines of Rajasthan and Delhi Government
© Enact Maharashtra Clinical Establishment Bill along with provisions for rate transparency, rate standardization, charter
of patient's rights and grievance redressal mechanism
© Direct transfer of untied funds in the accounts of Rogi Kalyan Samiti and Village Health, Nutrition, water supply, sanitation
Committee to avoid delay and corruption
This rally was an attempt to fortify CSOs on the issue of patient's rights, win popular support of the people, and gain entry into
the political space of policy change.
The rally achieved two things. The rally gave much visibility to the issue of patient's rights and the coverage by the media was
good. Additionally, we were successful in meeting face-to-face with many decision makers and pursue them to support
patient's rights. Opening up the government arena was important for the success of our campaign.
On 15th December 2017, the Health Minister of the Maharashtra State announced in the Assembly that to curb excessive
charging and exploitation by the private hospitals, the Clinical Establishment Act will be passed in Maharashtra too.
However, besides getting visibility to other issues and assurances from the ruling government, there was no tangible result
in terms of the policy-change regarding demands otherthan MCEA.
J
Claiming space on the table- Struggle for patient's rights in the policy space:
After the announcement made by Health Minister of the Maharashtra State regarding enactment of the Clinical
Establishment Act, Maharashtra Government constituted a committee chaired by Dr Mohan Jadhav, from the Directorate of
Health Services, Mumbai, in January 2018, to give 'frank feedback' on the provisions in the proposed Maharashtra Clinical
Establishment Bill 2014 before it gets moved to the next level.
Although this was a positive development, the process of committee formation was exclusionary and was heavily skewed in
favor of the private health sector. The committee included representatives from the Indian Medical Association, Vidarbha
Hospital Association, Pathology laboratories, Hinduja Hospital, Nanavati Hospital, Ruby Hospital, SRL Diagnostics, etc. This
committee which predominantly represented the private sector interest was to provide 'frank feedback' on provisions
mentioned in the Maharashtra Clinical Establishment Bill 2014, by 5th February 2018. JAA strongly objected to this move on
the following grounds© Drafting Committee for the bill in 2014 included representatives from different associations of doctors in a majority.
Then, why the Government felt the need to take their 'frank feedback' once again?
© Why does this committee not include a single representative from civil society organisations wor^ng on patient's rights
issues?
© Committee has one-third members from Corporate Sector! In the 12-member committee, four members are from
Corporate Sectorand big hospitals (Hinduja Hospital, Nanavati Hospital, RubyClinic, SRL Diagnostics)
It was surprising to see that no civil society
organization got representation in the
committee. Following stiff resistance from
JAA, two JAA representatives were invited
to be a part of deliberation in this
committee. The committee accepted some
of their suggestions regarding the patient's
rights, however, their dissenting voice was
largely ignored by the committee members.
This was not surprising. In spite of limited
progress through this committee, JAA
managed to get the attention of the policy
I
*
makers and the private sector alike. That
paved the way forfurtheradvocacy.
■
_
T
® Gains made by Jan Arogya Abhiyan in Maharashtra Clinical Establishment Bill
2014 were retained. So, the provisions for charter of patient's rights, district level
grievance redressal mechanism, enhanced representation to civil society
organizations in the various official bodies/forums, provision of dedicated human
resources for implementation of the legislation in the form of Directorate of
Clinical Establishment were retained.
® Transparency in rates of the hospitals was included in the final draft. However, it
will be only for the general ward in the hospitals. This is a significant exclusion, and
JAA still fighting to make transparency in rates as a universal clause for hospital
services.
® Provision for rate standardization, capping profitability of hospitals in medicines
and consumables was included in the draft bill.
What we I
s.
won
what
remained
undone?
Following .ey provisions suggested by Jan Arogya Abhiyan have not been included so far.
® Display of charter of patient's rightsand responsibilities at prominent place in the clinical establishment
® Patient's right to get itemized bill.
® Display of rates of facilities, services, packages on the website of the clinical establishment, if hospital has its website.
® Display of information related to all registered clinical establishments including their rates on the Government website
® Compliance with self-declared rates of facilities and services by the clinical establishments; Penalty for irrational
overcharging compared to declared rates and returning back 'extra charged amount' to patients if hospital found to be
guilty of irrationally overcharging compared to theirown declared rates.
® Penaltyfordenialofgivingphotocopyofclinicalrecordstotheconcernedpatient.
® Penalty for keeping body of the deceased patient has a hostage for payment of the bill.
Although JAA intervened in the policy-making arena, success was limited. We were determined to make the government
see the reason. It was a time to plan a follow-up action. We decided to protest. The place was again Nagpur, but this time
during the monsoon session of the assembly. A newaddition in ourstrugglewere people who suffered because of the denial
and negligence of the medical sector.
These people gave a new meaning to our struggle by sharing their stories and thereby creating a compelling case for the
regulation of the private health sector, strengthening of the public health system, and the respect of the patient's rights.
Ordinary people showed extraordinary courage to come all the way to Nagpur. They came with an intent to share their story.
12th July 2018- Rugna Satyagrah Patients’ Campaign for (Insistence on Truth) We want to tell our story
UV-*9<?r
" Many stories matter. Stories have been
used to dispossess and to malign. But
stories can also be used to empowerand
humanize. Stories can break the dignity
of a people. But stories can also repair
the broken dignity"
- Chimamanda Aichie
Three real stories mentioned at the start of this document are a testament to how badly the private sector needs regulation
and underscores the need for the strengthening of the public health system. Above cases, and others that are not included in
this document, needed a remedy and healing touch. Stories of individuals in these cases are lived experiences; it was a time
to integrate theirvoices with our collective demand for better health care.
Many people who suffered at the hands of the public and the private health establishments participated in "Rugna
Satyagraha” (Patient’s Campaign for Insistence on Truth) on 12th July 2018, in Nagpur. They, along with JAA activists,
campaigned to submit a memorandum to the Chief Minister, Health Minister, and various leaders of the opposition. Among
multiple demands, central demand was to enact credible Clinical Establishment Act to regulate the private sector. Since
people who suffered were physically present in the campaign, the decision-makers were forced to respond. The Health
Minister, along with high-level officials met JAA delegates and promised to expedite the process of implementing CEA.
I
I
5
Key demands in the memorandum were:
© Improve medic:ne availability in the public health system, and take measures to establish medicine procurement
corporations LikeTamilNadu and Rajasthan.
© Pass the Maharashtra Clinical Establishment Act, which should include patients’ oriented recommendations given by
JAA.
© Establish responsive grievance redressal mechanism regarding denial of mandatory free care to poor patients in the
charitable trust hospitals.
© All the low income people who were forced to take treatment from the private hospitals because of the inadequacies in
the public health system should get reimbursements of the money spent.
© Patient's whose testimonies are included in the memorandum should be addressed immediately, and punitive action
should be initiated against the erring officials, and the public and private health institutions.
© Delegate recruitment rights to District Collectors for speedy induction of doctors into the public health system.
© Start Village Child Development Centers immediately to tackle child malnourishment problem. These centers were shut
down by the current Government
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Reimagining Change- Our Key Leanings:
© Struggle to regulate the private health sector will require a longer time horizon. The power of the private sector is
enormous, and their cheerleaders- including some parliamentarians and bureaucrats, etc. are occupying key positions
in the decision-making arena. We understand that this deeply entrenched power of the private sector in the policymaking spaces is hard to tackle by a single street protest or campaign activity. We will require a series of events and
innovative methods to protect patient’s rights and regulate the private sector.
© Private sector is more organized whereas patients and communities are not. Patients often lack agency. They are not
organized like the private sector, neither they are heavily resourced like the private sector. However, campaigns can
think of creating community spaces to share experiences of denial of healthcare, give visibility to these issues. Voting as a
tactic was immensely useful because patients and people could relate to the idea of patient's rights.
© “There is no agony like bearing an untold story inside of you”. People don't have cases they have stories, and they want
to share it too. Our campaign gave that space to people. Individual testimonies not only give a glimpse into the widespread
dissatisfaction regarding the medical practice but also reinforce collective spirit for social action. Moreover, testimonies
are hard evidence. It cannot be refuted very easily.
© The middle class of the society is an important constituency in the struggle for the patient's rights. Looking at the
pattern of voting during the campaign, we realise that discontent among middle class regarding the private health sector
is enormous. One of the highlights of the voting campaign was the overwhelming participation of the middle-class
population. The middle class doesn't just respond to public opinion; they shape it. Hence, the middle class is a vital
constituency, and their significant participation in voting opened other possibilities of the campaign.
© The term “Patient's Rights” was far more effective than the abstract language of "Private Sector Regulation.” In a
campaign, we realized that the term patient's rights, as a unit of information and allegory, not just resonated with people
but they intuitively understood what it would mean to them and their family. How we frame the message is important for
the success of the campaign.
® Good Public Health System is in itself a natural regulator for the private medical sector. It would be a folly to
understand the public health system and private healthcare sectoras completely isolated entities in a developing country
like India which is affected by Mixed Health System's Syndrome. Any advocacy for regulation of private medical sector
should be accompanied with advocacy for more budget to public healthcare services, improvement in quality,
transparency and accountability of public health services. Strong Public Health System is a natural regulator of the
private medical sector. Weaker the Public Health System and more entrenched the private medical sector makes the
task of regulation more difficult.
II
CQ^plusion
Oftenttt|jK5, Wien- private health sector regulation as an issue is discussed in policy-forums, this is
framers if politicians, corporate executives, and their interests have all the power but thq rest of usthe people, don't. This is common control mythology that normalizes existing power dynamics and
makes them appear unchangeable. JAA's campaign is an attempt to develop a counter-narrative to this
dominant thinking and the hegemony of the private sector. In spite of significant way to go and small
victories, we can definitely say, we are no longer accepting the things we can not change...we are
changing the things we can not accept.
Memorandum given to Minister of Finance & Planning
I'
Memorandum given to Health Minister
Ki ’
■ 1
Memorandum given to Member of Legislative Assembly
from ruling party
Memorandum given to Ex-C
.. Chief Minister
4=
i
2018-7-11 15:5‘
Memorandum given to Ex- Deputy Chief Minister
Memorandum given to Member of Legislative Assembly
from opposition
Report prepared by Dr. Dhananjay Kakade
Design and Layout by Sandeep Deshpande
Published by Jan Arogya Abhiyan
Contact:
s
Jan Arogya Abhiyan
c/o Dr. Anant Phadke, 8, Ameya Ashish,
Near Hotel Konkan Express, Kothrud, Pune 38
janarogyaabhiyan@gmail.com
www.facebook.com/janarogya
4
i
MOVING TOWARDS A CAMPAIGN ON RIGHT TO HEALTH AND HEALTH CARE ■
INDIANCONTEXT
Analysis of cases related to Access to Health Care
Project Assignment
Interface of Law, Health and Medicine
Submitted by
Amulya Nidhi
ID No. ML&E521/2002
2002-2004
r
NATIiONAL LAW SCHOOL OF INDIA UNIVERSITY
BANGALORE
JUNE 2004
Moving towards a campaign on Right to Heafth and Health Care: Indian contoxt - Arnufya NJdhi
u-tL
i
ACKNOWLEDGEMENT
My inspiration to work in the area of Right to health has developed while
interacting with several groups across the country through Jan Swasthya
Abhiiyan. I am grateful to them for channelising my efforts in a proper
direction. I would like to deeply acknowledge the contribution of Ms. 5helley
Saha, who provided valuable inputs m conceptualizing and for spec/f/c response
to various drafts. I am also thankful to Dr. Abhay Shukla Dr. Anant Phadke for
his time and feedback given for this project.
I would also like to acknowledge the libraries of Centre for Enquiry into Health
and Allied Themes (CEHA T), Mumbai, Pune, Indore and National Centre of
Advocacy Studies, Pune. In addition I would like to thank my colleague Kaja!
Jain for providing me time so as to complete this project. I recognize the
financial and organisational support provided to me by CEHA T for pursuing this
course.
Moving towards a campaign on Right to Health and Health Care: Indian context- Amulya Nidhi
2
table of contents
Abbreviations
I.
Health in todays context
Right to heallh and UealU1 c31®" Conceptual Iramework
Legal provisions rotated to RlOht to health and health care
5
8
12
16
iv Denial Of Right 10 health care
V.' ways ahead - Building a Campaign on too Right'o health and health oote
20
VI. conclusions and Recommendations
References
*
5A:
■
$
■1r.
V
$
&
i
I.
■■'a
L
3
ABBREVIATIONS
: Adivasi Mukti Sanghthan
: Convention on the Elimination of All Forms of Racial Discrimination
: Centre For Enquiry into Health and Allied Themes
: Consumer Protection Act
: Expanded programme on immunization
: Growth, Oral rehydration, Breast feeding, Immunization Female literacy,
Family planning and Food supplements
: International Covenant on Civil and Political Rights
ICCPR
: International Covenant of Economic, Social and Cultural Right
ICESCR
: Infant Mortality Rate
IMR
: Jan Swasthya Abhiyan
JSA
: Multi Purpose Worker
MPW
: National Family Health Survey
NFHS
:
Non-Governmental Organisations
NGO
: National Health Policy
NHP
: National Human Rights Commission
NHRC
: Primary Health Care
PHC
: Public Interest Litigation
PIL
I
SPHC : Selected Primary Health Care
: Universal Declaration of Human Rights
UDHR
: United Nations International Children's Emergency Fund
UNICEF
: World Health Organisation
WHO
AMS
CEDAW
CEHAT
CPA
EPI
GOBIFFF
Moving towards a campaign on Right to Health and Health Care: Indian context - Amulya Nidhi
I
4
I.
HEALTH IN TODAY’S CONTEXT
INTERNATIONAL SCENARIO:
In 1978, at Alma Ata the World Health Organisation (WHO) and the UNICEF presented a radical new
strategy as a part of the target of achieving 'health for all by the year 2000'. Important principle of the Alma
Ata declaration is that health for all can be achieved through primary health care (PHC). It says, “that
primary health care is the key to attaining this target. It is essential health care based on practical,
scientifically sound and socially acceptable methods and technology made universally accessible to
individuals and families in the community through their full participation"1. Tne central message of the PHC
strategy was a call for equity and social justice.
Such a radical strategy was bou.id to have Its opponents. Within a year of signing the declaration, an
alternative approach to PHC, the selected primary health care (SPHC) was being widely disseminated. This
approach argued that PHC is not cost-effective, in fact it was too expensive. A more effective method of
decreasing mortality and morbidity lay in the selection and prioritisation of selected number of diseases2.
This approach quickly gained acceptance among donors. UNICEF introduced the growth, oral rehydration,
breast feeding, immunization female literacy, family planning anf food supplements (GOBIFFF). The
expanded programme on immunization (EPI) was given considerable support by multi-national donors.
These selective programmes are, as Rifkin and Walt have argued, a departure from the key principles of
PHC3. Its approach Is efficiency rather than equity; the market rather than social justice; the disease rather
* than social, economic and political development. The WHO’s Strategy of 'Health for All for the 2181 Century’
is a benign neglect for those who cant afford to be part of the market4. For the poor, of both South and
North, health for all for the 2181 century will not lead to a world where health will be a fundamental human
right - a state of complete physical, mental and social well-being and not just the absence of disease and
infirmity.
NATIONAL CONTEXT
Health Policy
In the first two Five-year Plans following India’s independence there appeared to be a commitment to
address the health needs of the populations comprehensively - with preventive, promotive and curative care
provided through a wide network of community based health centres, in tune with the recommendations of
the Bhore Committee. But in the years that followed, the health sector was driven by technological forces
and has become physician centred, reducing the pursuit of health to the provision of medical care, ignoring
the broader determinants of health5.
Despite significant strides in eradicating communicable diseases and smallpox and in containing malaria and
tuberculosis, the health status of vast majority of the people are far from satisfactory. Even though the
country had aimed at attaining health for all by year 2000 it has become a distant dream even in the
beginning of 2181 century. The 1903 National Health Policy (NHP) was meant to arrive at *an integrated,
comprehensive approach towards the future development of medical education, research and health
services
to serve the actual health needs and priorities of the country"6. Critical of the curative model of
International Conference on Primary Health Care, Alma Ata, USSR, 6-12 September, (1978).
J.A.. Walsh and K.S. warren, 'Selective Primary Health Care’, 301 (18) New England Journal ofMedidne, 967-74 (1979).
3 S.B. Rifkin and G. Walt, "Why Health improves: Defining the issues concerning Primary Health care etkI Selective Primay Health Cae’ 23(6)
Sodal Science and Medicine (1988).
4 WHO ‘Investigating in Heallh Research and Devdopmenf, World Health Organisation (1996).
5 S, Saha and TKS Ravindran, 'Gender gaps in Research on Health Services in India’, 4 (2) Journal of Health Management, 185-214 (2002).
6 Government of India, 'Statement on National Heallh Potic/, Ministry of Health and Family Welfare, New Delhi, (1982).
Moving towards a campaign on Right to Health and Health Care: Indian context-Amulya Ndhi
5
health care, it emphasised a primary health care approach to prevent illness and promote good health. The
next decade saw the rural health infrastructure develop with a massive expansion of primary health care
facilities. However, this effort was sabotaged by a combination of poor quality facilities, inadequate supplies,
ineffective managerial skills, poor planning, monitoring and evaluation. The private health sector has grown
phenomenally since, thanks to state subsidies in the form of medical education, soft loans to set up medical
practice, etc. accounting for 70-80 percent of all primary care sought, and over 40 percent of all hospital
care, in a country where over three-fourths of the population lives below subsistence level. In fact the Draft
National Health Policy released by the Ministry of Health and Family Welfare in 2001 further legitimized
these trends. It completely omits the very concept of comprehensive and universal health care. The Draft
departs from the fundamental concept of the NHP1983 and the Alma Ata Declaration. The draft, for all the
rhetoric on community participation, is replete with “top down” prescriptions. While admitting the wastage
involved in running centrally sponsored vertical programmes, it goes on to recommend that we would need
to retain many of them!7 The draft legitimizes further privatization of the heath sector.
Therefore today wo find that the private sector has virtual monopoly of ambulatory curative services in both
rural and urban areas and over half of hospital care. The health care market is based on a supply-induced
demand and leading to an increase of the cost of health services. Thus India today has a large, unregulated,
poor quality, expensive and dominant private health sector, and an inadequately resourced, selectively
focused and declining public health sector.
Besides not formulating people’s friendly health policy, the State’s insufficient commitment to provide health
care for its citizens is reflected in the inadequacy of the health infrastructure, low levels of financing and also
in declining support to various health care demands of the people. Under structural adjustment since 1991
there has been further compression in government spending in its eTorts to bring down the fiscal deficit to
the level as desired by the World Bank. This global pressure on the Indian State is evident through its
policies of focusing on selective services, for instance RCH and AIDS receive overriding support over
primary health care or basic referral services. Another trend that further reduces access is the increased
corporate control of health care. New medical technologies have helped complete the commodification of
health care.
Given the above context, it is natural that health status of the Indian population would be unsatisfactory.
There is no dearth of evidence to show that India’s health indicators are one of the worst in the world. India’s
population is characterised by high levels of mcrbidity especially among Infants and children, women, and
the elderly; and high incidence of communicable diseases associated with low levels of sanitation, public
hygiene and poor quality of drinking water8, infact the latest Human Development Report shows a downward
trend in India’s global ranking9. For millions of people the enjoyment of the right to health remains a distant
goal.
Health Infrastructure
India has a vast health sector, which is broadly divided into the public sector, the private sector and the
household. The publiu sector is comprised of the health care facilities set up by central and the state
governments, municipal and local bodies. The private sector consists of private physicians and a range of
other practitioners including those practicing non-allopathic systems of medicine, health facilities and
corporate hospitals operating for profit and non-governmental organisations (NGOs) operating as non-profit
enterprises. Households or self-medication provide first level care in many settings as in many places as
health services are unavailable or unaffordable to a large section of the population. Various national level
7 Response of the National Coord nation Committee of the Jan Swa^thya Abhiyan to Draft National Health Policy, 2001 (unpublished).
*.
8 Abusaleh Shariff, India Human Development Report,' New Delhi: Oxford University Press for the National Council for Applied Economic
Research (1999).
9 UNDP Human Development Report (2000).
Moving towards a campaign on Right to Health and Health Care: Indian context - Amulya Nidhi
6
Pe*S utilisation of health «re is falled by ta> aMily „
w W1 by
SsUS inSi?a£(?n7Js SarT'^e^’^
methodology
Purpose of the research
Focus of research
■ rar a. are
,„i#ate to|
Research methodology
Thls research is an analysis of
secondary materials. Primary data is
also used for analysis.
Mo^to^^paignonRlghttoHealth
Health Care. Indian context - Amulya Nidhi
7
II.
RIGHT TO HEALTH AND HEALTH CARE - CONCEPTUAL FRAMEWORK
Human rights are legally guaranteed by human rights law, protecting individuals and groups against actions
that interfere with fundamental freedoms and human dignity. They exist to protect individuals from abuses of
state power and obligate states to piovide the conditions necessary for prospenty and well being. This does
not mean that human rights apply exclusively to the relations between the state and the individuals; they,
and the principles underlying them, also inform and structure relationship among individuals, particularly
where tliere are power inequalities among those involved (eg between health care provider and patient)10.
Human rights empower the poor by granting them rights that are legally guaranteed, while at the same time
imposing obligations on governments and public bodies such as international organizations. Because
human rights are generally legally binding, these bodies arc accountable for ensuring that these entitlements
cannot be reduced to mere privileges or luxuries or left to the whim of markets.
Every human being has the right to the highest attainable standard ofphysical and mental health (referred to
as “right to health"), conducive to living a life in dignity was first reflected in the WHO constitution (1946) and
then reiterated in the 1978 Declaration of Alma Ata and in the World Health Declaration adopted by the
World Health Assembly in 1998. According to the General Comment 14 of the International Covenant on
Economic, Social and Cultural Rights ‘The right to health must be understood as a right to the enjoyment of
a variety of facilities, goods, services and conditions necessary for the realization of the highest attainable
standard of health'11. This right is one of the fundamental human rights and is closely related to and
dependent upon the realization of other human rights which are the underlying determinants of health, that is
access to safe and potable water, adequate food, nutrition, housing, work and education and on provision of
health care service.
The Right to health care as a component of the Right to Health
Looking af 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 incident. It constitutes the
daily denial of a healthy life because of profound structural injustice, within and beyond the health sector.
The denial needs to be addressed in a rights-based framework that has gathered momentum in the late
90’s, by systematically establishing the right of every citizen to a healthy life. Right to Health is a part of the
Right to Life -, the Right to Life with dignity and right to livelihood. Right to health care means having
appropriate, accessible end quality health services for all people. According to WHO, to promote the right to
health, action is required on two related fronts as depicted in figure 1.
Figi
THE RIGHT TO HEALTH
Underlying
Determinants
Health care
In May 2000, the Committee on Economic, Social and Cultural Rights, which monitor the International
Covenant of Economic, Social and Cultural Right, adopted a General Comment on the right to health.
10 National Centre for Advocacy Studies, ’Right to Health’, 3(5) Advocacy Internet, sept-oct (2001).
11 General Comment 14, CESCR, E/C. 12/2000/4. Twenty second session Geneva, 25April -12 May (2000).
Moving towards a campaign on Right to Health and Health Care: Indian context - Amulya Nidhi
8
General Comment applies to nations that have ratified ICESCR and India is one of the states to ratify it. It
addresses the content of right to health and the implementation and enforcement of the right to health.
According to that the following criteria was set to evaluate the right to health a) Availability - adequate number of functioning public health and health care facilities, goods and
services.
b) Accessibility - health facilities should be accessible and affordable to everyone without any
discrimination.
c) Acceptability - all health facilities should be appropriate and sensitive.
d) Quality - health facilities must be scientifically and medically appropriate and of good quality12.
General Comment 14 reaffirms that several “core” obligations have been established in prior human rights
instruments: These core obligations, as well as additional obligat ons are presented in Figure 213.
Figure 2
'
GENERAL COMMENT 14
OBLIGATIONS REGARDING THE HUMAN RIGHT TO HEALTH
Core Obligations Established In Prior International Human Rights Instruments:
To ensure the right of access to health facilities, goods and services on a non-discriminatory basis,
especially for vulnerable or marginalized groups:
To ensure access to the minimum essential food which is nutritionally adequate and safe, to ensure freedom
from hunger to everyone;
To ensure access to basic shelter, housing and sanitation, and an adequate supply of safe and potable
water;
To provide essential drugs, as from time to time defined under the WHO Action Programme on Essential
I Drugs;
To ensure equitable distribution of all health facilities, goods and services;
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 all vulnerable or marginalized groups.
Obligations of Comparable Priority:
To ensure reproductive, maternal (pre-natal as well as post-natal) and child health care;
To provide immunization against the major infectious diseases occurring in the community;
To take measures to prevent, treat and control epidemic and endemic diseases;
To provide education and access to information concerning the main health problems in the community
including methods of preventing and controlling them;
To provide appropriate training for health personnel, including education on health and human rights.
1475nney' ED’ 2001 ’ 71)6 ,nte^nationa, Human
to Hoa,th:
d065
mean for our Nation and World?', Indian Law Review, pp 1457-
13 General Comment 14, CESCR, E/C. 12/2000/4. Twenty second session Geneva, 25April -12 May (2000).
Moving towards a campaign on Right to Health and Health Care: Indian context - Amulya Nidhi
9
A rights-based approach to health entails recognizing the individual characteristics of the population groups
concerned. In the 70s and 80s in India there was an initiative to move from health care centred health
service delivery to community based health worker programmes, trying to provide affordable and rational
care to the villages. The same period also saw the emergence of specific campaigns related to drug policy,
hazardous contraceptives, etc. This approach received a set back at the turn of the nineties when resource
commitments in the public health sector declined.
This is reflected at one level in slowing down of improvements in health outcomes and the widening ruralurban gap of these outcomes. And at another level the public health care facilities are getting incapacitated
because the necessary inputs that are needed to run these facilities are not being adequately provided for.
The 2002 National Health Policy unashamedly acknowledges that the public health care system is grossly
short of defined requirements, functioning is far from satisfactory, that morbidity and mortality due to easily
curable diseases continues to be unacceptably high, and resource allocations generally insufficient
(MOHFW14). The evidence for this is clearly brought out in the changes one sees across the 42nd and 52nd
Round National Sample Surveys'5, when over this decade utilisation of private health services, especially In
the hospital sector, increased substantially, out-of pocket spending galloped, indebtedness due to health
care affected half the users and the proportion of non-utilisation also increased.
Therefore besides having poor health indicators, India also has the dubious distinction of being among the
most inequitous countries of the world, as far as health status of the poor compared to the rich is concerned.
What is even more serious is the fact that these inequities, instead of decreasing over time, are increasing.
Some striking facts in this regard are16• Infant mortality among the economically lowest 20 percent of the population is 109, which is 2.5 times
the infant mortality rate (IMR) among the top 20 percent population of the country.
• Under-five mortality among the economic bottom 20 percent of the population is 155, which is not only
unacceptably high but is also 2.8 times the rate of the top 20 percent.
• Child mortality (1-5yrs age) among children from the 'Low standard of living index' group is 3.9 times
tnat tor those from tire 'High s^ndara of living index' group according to recent NFHS data.
• Tribals, who account for only 8% of India's population, bear the burden of 60 percent of malarial deaths
in the country.
Such gross inequalities are of course morally unacceptable and are a serious social and economic issue,
and also exemplify the impact of globalisation-liberalisation policies in widening the gap between the rich
and the poor. In addition, such a situation may also be considered a gross violation of the rights of the
deprived sections of society, an Invisible daily Holocaust. This becomes even more serious when viewed in
the context of gross disparities in access to health care17• The richest quintile of the population, despite overall better health status, is six times more likely to
access hospitalisation than the poorest quintile of the population. 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 accounts for 38.5 percent of inpatient days, while the poorest quintile accounts for
just 6.6 percent, out of the total hospitalisation days for the population.
M, Government of Incfia, ‘National Health Policy 2002*, Ministry of Health and Family Welfare, New Delhi, (2002).
’5NSS-1987:Morbkfty and Utilisation of Medcal Services, 42^ Round, Report No. 384, National Sample Survey Organisation, New Delhi; and
NSS-1996:Report No. 441, 52nd Round. NSSO, New Delhi, 2000
18 Abhay Shukla Creating a consensus on the Right to Hedth Care, Paper presenlort at National Meeting on Right to Health Care, Mumbai,
February 14, (2002).
17 Abhay Shukla Creating a consensus on the Right to Health Care, Paper presented at National Meeting on Right to Health Care, Mumbai,
Fefcruay 14. (2002).
Moving towards a campaign on Right to Health and Health Care: Indian context - Amulya Nidhi
10
As high of 82 percent of outpatient care is accessed from the private sector, which is met almost e
y
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-f°ur^
he
government. This ofen pushes the aiready vulnerable poor into indebtedness, and in over 40 percent
hospitalisation episodes, the costs are met by either sale of assets or taking loans.
.
id Health Care’ is being raised today. The next chapter
It is at this context the issue of 'Right to Health am
would highlight how this right can be addressed.
Moving towards a campaign on Right to Health and Health Care: Indian context - Amulya Nidhi
11
III. LEGAL PROVISIONS RELATED TO RIGHT TO HEALTH AND HEALTH CARE
We can view the justification for this right at three levels - human rights issue, constitutional-legal and socio
economic issue.
Human rights justification
The right to health is solidly embedded in international human rights law. It is explicit in Article 25 of the
Universal Declaration of Human Rights (UDHR), adopteo by the United Nations (UN) General Assembly in
1948 (WHO). It is not a treaty but a statement of policy and a call to action much like the Declaration of
independence. It affirmatively states a human right to health18:
"Everyone has the right to a standard of living adequate for the health and well-being of Irmself and of
his family, including...medical care...and the right to security in the event of ...sickness, disability..."
Numerous subsequent international and regional human rights treaties have given further definition to the
right to health. In the 1960's the UN sponsored the development of two international covenants that
articulate the human rights recognized In the Universal Declaration of Human Rights. Those two covenants
are the International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on
Economic, Social and Cultural Rights (ICESCR).
The International Covenant on Economic, Social and Cultural Rights (ICESCR)-the so-called Economic
Covenant-is the most important in terms of the right to health. Article 12 of ICESCR states that the right to
health includes “the enjoyment of the highest attainable standard of physical and mental health19." The
relevant provisions of this covenant are presented in Figure 3.
Figure 3
The International Covenant on Economic, Social and Cultural Rights (ICESCR)
Article 12
1. The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the
highest attainable standard of physical and men tai 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.
v. .
A human right to health is also recognized in numerous other international human rights authorities that
establish prohibitions against government conduct that is detrimental to health. Such treaties include the
International Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) of
1979, Convention on the Elimination of All Forms of Racial Discrimination, and the Convention on the Rights
of the Child of 1989. Figure 4 presents the health contexts of these conventions:
10 Universal Declaration of Human Rights, Adopted by the UN General Assembly Resolution 217 A (III) of 10 December 1948.
19 International Covenant on Economic, Social and Cultural Rights, Adopted by UN General Assembly Resolution 2200 A (XXI) of 16
December (1966). Enforced on SJanuary 1976 in accordance with Article 27.
Moving towards a campaign on Right to Health and Heath Care: Indian context-Amulya Nidhi
12
Figure 4
A,
♦ States shall
ensure to (women)
access to specific educational information to help to
ensure the health and well-being of families, including information and advice on family
planning..... States shall........ eliminate discrimination against women in
health care
to
ensure, on a basis of equality of men and women, access to health care services
; ensure.....
appropriate services in connection with pregnancy
States shall
ensure
that [women
in rural areas]...... have access to adequate health care facilities, including information counseling,
and services in family planning............ (Convention on the Elimination of All Forms of
Discrimination Against Women, Articles 10,12 and 14)
♦ States undertake to
eliminate racial discrimination
and to guarantee the right of
everyone the right of everyone, without distinction as to race, colour or national or equality before
law......... the right to public health, medical care, social security and social services......
(Convention on the Elimination of All Forms of Racial Discrimination, Articles 5)
♦ States recognize the right of the child to the enjoyment of the highest attainable standard of health
and to facilities for the treatment of illnesses and rehabilitation of health
(Convention on th/
Rights of the Child, Articles 2420)
J/
Also of interest, is the 1993 Vienna Declaration and Programme of Action emphasizes the fundamental inter
relatedness of political and civil human rights and economic social and cultural human rights. The Vienna
Declaration specifically provides:
“All human rights are universal, indivisible and interdependent and interrelated. The international
community must treat human rights globally in a fair and equal manner, on the same footing, and with
the same emphasis. While the significance of national and regional particularities and various historical,
cultural and religious backgrounds must be borne in mind, it is the duty of States, regardless of their
political, economic and cultural systems, to promote and protect all human rights and fundamental
freedoms.”
The Vienna Declaration has become a crucial principle in international human rights law recognizing the
irreducible truth that all human rights must be recognized if specific human nghts are to have concrete
meaning21.
Reference can be made to other similar international conventions, wherein Government of India has
committed itself to provide services related to right to health, for instance the Alma Ata Declaration. National
Human Rights Commission (NHRC) has also concerned itself with this issue of right to health.
Constitutional and Legal Justification
The issue is, how far these international obligations, agreements, treaties and covenants bind the Indian
state and Nationals? Unfortunately, in the Indian Constitution, health is not a fundamental right of citizens,
but has to be inferred from the broader parameters of social and economic justice. For instance, the
Preamble of the Constitution of India directs the State to initiate measures aiming at improving, the health of
the people. The same logic can be stretched to the Fundamental Right - Protection of Life and Personal
Liberty.
Only in the Directive Principles is it categorically stated about State's responsibility to health of its citizens
and regarding provision of health care. Article 39 states that
United Nations Convention on the Rights of the Child, 1989, Adopted by UN General Assembly Resolution 44725 of 20 November (1989).
E.D. Kinney. The Intematic'al Human Right to Health: What does this mean for our Nation and World?', Indian Law Review, 1457-1475,
(2001).
Moving towards a campaign on Right to Health and Health C^e: Indian context - Amulya Nidhi
13
The state shall, in particular, direct its policy towards securing; that the health and strength of
workers, men and women, the tender age of children be not abused and that citizens are not forced
by economic necessity to enter a vocation unsuited to their age or strength’.
Article 4T22 of the Constitution states that
“The State snail regard tl.e 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...... ’
Thus, the article 47 of the constitution under the directive principles of state policies define health both in
mahSh"?’35 r T3 and sPecifical|yin terms of health care. Conceptually, this is a great advantage, as
the healthy living is not construed only to medical care but also of good nutrition and living standards This
provides a wider scope for legislating on the issue of health and health care.
an.d health C3re h3S not been exPress|y incorporated in the Constitution as a
nf9h ’ buldU,e ?
Pl0neerin9 and progressive judgments, right to health has acquired that
in
such a kind of interpretation has created by the important judgment of the Supreme Court
in the Paschim Banga Khet Mazdoor Samiti and others V. State of West Bengal and other, 1996, while
interpreting Article 21 the Supreme Court has indisputably held that providing adequate medical facilities for
the people is an essential part of the obligations undertaken by the Government in a welfare state. Similarly
in the cases Bandhua Mukti Morcha v. Union of India and others, 1982 concerning bonded labourers the
Supreme Court gave orders interpreting Article 21 as mandating the right to medical facilities for’ the
workers In another landmark judgment in 1995, the Supreme Court stated that right to health and medical
hi
S^TS a"d‘heureafter-is a fundamental right*. Similar judgments by Supreme Court
by interpreting Article 21 has established right to treatment in emergency situation, worker’s right to clean
“5 “S “iS?*as 3
tea"h
an<l
o,her
Other Constitutional obligations related to health are that Public health and Sanitation is a state subject as
given in the Seventh Schedule, Article 246, list II-6 of the Indian Constitution. This provision assumes
importance as this means that without changing any constitutional provisions, the states can make
provisions for improving public health. The 73rd and 74,f, Constitutional Amendments Act, 1992 provide for
SSii01 Panchayatl
institutions and Na9ar Palikas in all developmental programmes including
The Consumer Protection Act (CPA) addresses the aspect of medical negligence in the country. But many
times GPA acts as a hindrance to provision of emergency medical care as doctors are scared that if the
condition of the patient detonates they may be charged for medical negligence.
The social and economic justification
Heelth as a basic human right should be viewed holistically and its positive aspect, that is well-being should
be acknowledged which would lead to achievement of a socially and economically productive life. The right
Wlth‘n itSelf the r'9ht t0 a poor patient t0 get ade<iuate treatment from the state
Hiuopeciivc ot ine cost.
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
23 P'M-
The Constitution of Inda’, Delhi: Universal Law Publishing Co. Pvt Ltd (2000)
Moving towanis a campaign on Right to Health and Health Can: Indian context- Amulya Nidhi
]4
ETcb °f 'fcconomic 9rowth above a11' may d0 wel1 to heed the words of the Nobel Laureate economist
'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 Sodal
Opportunity by Jean Dreze and Amartya Sen)
This chapter briefly dealt with relevant constitutional provisions and legal enactments regarding health. It is
In his enforcement of these obligations that the Courts can play an effective role In safeguarding the rights
of the citizens. Supreme Court has upheld right to health through some progressive judgments but It should
“xsxx’s’at Tx““n8 cha* ”uM
Moving towards a campaign on Right to Health and Health Care: Indian context-Amufya Nidhi
,o a"<'
15
IV.
DENIAL OF RIGHT TO HEALTH CARE
In this chapter I would present selected cases where people’s right to health care has been violated. These
cases are from Barwani and Jhabua districts of Madhya Pradesh and Thane District of Maharashtra, which
were presented in a Public hearing in Sendhwa on 4th september2003 organised by Adivasi mukti
Sanghatan and Mokhada on 9th January 2004 organised by Shoshit Jan Andolan. In the public hearing26 the
relatives or the patients themselves narrated their suffering of denial of primary health care in public health
care faciPies. These public hearing were organised as part of Right to health care campaign initiated by Jan
Swasthya Abhiyan. These cases were collected by volunteer/staff of CEHAT, activists of Adivasi Mukti
Sanghatana, Khedut Mazdoor Chetna Sanghatana/Narmada Bachao Andolan and activists associated with
Shoshit Jan Andolan.
Case Study 1
Mr. N, a poor adivasi, was residing with his family of 6 members in J village of a blocx of Barwani district In
the night of 23rd June, 2003 his son K had a severe problem of vomiting and loose motions. Next day the
Multi Purpose Worker (MPW) gave him an ORS packet. When no improvement was observed in the child’s
condition, it was suggested that he be taken to the nearest Primary Health Centre (PHC), where the medical
officer treated him. But, after sometime bleeding started from inside the mouth and nose of the child. At
another doctor’s suggestion, Mr. N had to shift his child to Sendhwa PHC. Due to lack of money he had to
bring the critically sick child in a brick loaded truck. The earlier PHC didn't have ambulance for this
emergency situation.
In Sendhwa PHC too, he had to purchase injections and syringes worth over hundred rupees. Later when
the condition became more serious, it was suggested that he take the child to Barwani district hospital. But
Mr. N, a poor adivasi, did not have money for the transport and further treatment and ultimately decided to
come back to home. On the way back home his child died.
"This oaso study demonsbates hew a PHC is not able to provide essentia' health services, not even an
ambulance in an emergency condition, to save the life of an ill child. This case shows violation of Right to a
set of basic health services which is guaranteed to us by Article 21 of the Indian Constitution and also Article
24 of the Convention on the Rights of the Child.
Case Study 2:
Mr. D is a 90 year old man of K village of a block in Barwani district. Sometime ago he was not being able to
pass urine and was suffering from acute urinary retention. Due to this problem he was taken to Sendhwa
PHC for treatment, where the doctor checked him and referred the patient to Karuna Hospital (Private) by
saying that he is not able to give him treatment here. Urinary retention is an acute surgical emergency and is
simply treated by catherisation, which means a tube has to be inserted to drain the urine from the urinary
bladder. This simple facility should be available at the PHC level.
In this emergency condition, the family had to take the patient to Karuna Hospital where the doctor was
surprised that catherisation which is easy treatment, could not be given to this old man in the PHC. Hence
the person had to suffer and had to spend Rs. 1200/- on treatment, which could have been freely available.
This case shows violation of Right to emergency medical care, and right to essential drugs at an affordable
cost. This case shows that these violations amount to violation of Article 21 of the Indian Constitution,
26 The process of Jan Sunwai is presented in the next chapter.
Moving towanfc a campaign on Right to Health and Health Care: Indian context - Amulya Nidhi
16
°"EmiCi Social aKI c"“ *'s als°
25 °,,i'e
Case study 3 ®
v The only family planning service that is mosUy provided in the PHC is tubectomy. It is generally conducted in
^2nfally b/the 9t°hveTenl at the PHCs-The main aim of doctors and ANMs in
these camps is to fulfill the set target and therefore the operations are often done insensitively and in
from tSnf?ndltlHnS- N° atympt ,is made t0 explain t0 the women what is being done to them. Often women
from the interior villages are forced to walk long distances to get home the same day.
hetoSSh^Sr ■
? 3a° year°ld WOmen fro,T1 K Vlllage’ wentt0 thefami|y Planning camp
a
PHCIn ^ndhwa block. After her operation, which was conducted in overcrowded conditions
nn th
h n
cnme day. A week later she went to the PHC to get the stitches removed and returned’
I?"10 dayu Tw°ldayS latcr sh0 dovel°Pcd severe abdominal pain and was admitted to the cS
n tha hosn^ Xd’ h6'6 h h3S d?9hn0Sed With lelanus and was also told that treatment wil1 nd be possible
SfilitoSTnAnd691'9^06 the. government health facility and reflects the over-keenness of its personnel
S: whiner 9 ?. JJ?!96?raUier han provide quality teatth services. Also there is extreme insensitivity
moral resSb^oKSp" 'r‘>m
,t'ey "h”*«»sofa.
Sh°WS thl v'olation ofR'9ht to monitoring and accountability mechanisms and the Right to privacy
a d the provisions that was specially provided to women under various articles of CEDAW.
Case Study 4
patient to Mokhada Rural hospital and left the premises. The woman then went to the residences of the three
resident nurses and begged them to treat her husband. They refused saying that they were ndion duty and
to thet^^nHh? y Wh U attend tOrhim'The nurse on ni9ht Cluty never turned UP 50 once again she went
nafi»nf an n' f
r®slden. Purses' Finally one nurse Ms. Z took pity and came to the PHC. She gave the
pat ent an injection and administered a bottle of saline. The nurse told them they could not stay in the PHC as
XteXtor^ KinSdS?^' Hnd Shf6 T'd nOt Stay any l0n9er- Finally the PaBent was taken to a
£OT<’* s”a'M
Moving towards a campaign on Right to Health and Health Care: Indian context-Amulya Nidhi
17
Case Study 5
Mr. M, age 44 years, resident of Taluka Mokhada, fell from a tree on 15th November 2003. He was brought to
the Mokhada Rural hospital immediately. The doctor admitted him and asked the relatives of the patient to
purchase two bottles of saline, which were administered to him. They then asked them to shift the patient to
Nashik Civil Hospital and informed them to hire a private vehicle as no ambulance was available. The next day
the patient was taken to Nashik Civil hospital where he was admitted. The doctors there advised the relatives
to take him to a private hospital for a C.T. scan as the equipment in the Civil hospital was out of order. The
relatives could not afford a C.T. scan so the patient was discharged after fourteen days and has now become
crippled due to lack of proper treatment.
A taluka level Rural Hospital there was no ambulance available to transport such a needy patient. The Civil
Hospital in a large city like Nashik could not provide the CT scan facility, resulting in a person becoming
permanently disabled due to denial of health care. This case shows the violation of Right to a set of basic
public health services, Article 12 of the International Covenant on Economic, Social and Cultural Rights, which
says that everyone has the right to the enjoyment of highest attainable standard of physical and mental health
and also the interpretation of Article 21 of the Constitution as mandating the right to treatment in emergency
situation.
Case Study 6
Mr. G, age 2 years, was suffering from diarrohea and vomiting. He was taken to the Tokavda PHC by his
mother on the morning of December 25,2003. The doctor did not examine the child and gave only a packet of
ORS. A couple of hours later the mother informed the doctoi that the child was running temperature. The
doctor did not examine the child but wrote out a prescription for medicine, injection and disposable syringe, all
to be purchased from outside. The child was administered the medicines purchased from the private medical
store and sent home. The next day the mother returned with the child and she was once again asked to
purchase medicines from outside. On the third day the mother did not return with the child as she had no more
money to purchase medicines.
Adequate treatment for diarrhoea, one the simplest and commoner illnesses, could not be given by the PHO.
This case shows the violation of Right to essential drugs at an affordable cost, which is guaranteed to us by
Article 21 of the Indian Constitution and also Article 24 of the Convention on the Rights of the Child.
Case Study 7
4
Mr. J, age 62 years, resident of Dahanu taluka, was suffering from continuous cough and breathlessness for
some time. He approached the Multi Purpose Worker (MPW) of his village working through Kasa PHC for help.
The MPW did not give him any assistance so he came to the Cottage Hospital in Dahanu where an X-ray was
taken, they examined his blood and sputum and directed him to go to the Kasa PHC to get his treatment for
T.B. under the DOTS programme. He was told that the MPW would come to his house and give him his tablets
daily, which he was supnosed to consume in the presence of the MPW. After a few visits from the MPW, he
went on leave for 15 days and the treatment stopped. The patient went to the MPWs house to ask for the
tablets but he refused to give them to him and said that he would personally administer them to him at his
house. After repeated requests to the MPW, the patient complained to the doctor about the abrupt stoppage of
his treatment. The MPW made only one visit gave him tablets for a few days after which the treatment was
stopped till today.
Movii.g t wards a campaign 01 Right to Health :nd H akh Care: inoian context-AmuHa Nidhi
18
Regular treatment for a case of tuberculosis, the core activity of the National TB Control Programme, was
denied despite his^ taking repeated initiative to obtain treatment ano the patient being enrolled under the muchpublicised ‘DOTS' programme. This case shows the violation of Right to a set of basic public health services.
This is a violation of the International Covenant on Economic, Social and Cultural Rights and also the
provisions guaranteed by the constitution.
Case Study 8
Ms. U, age 12 years, resident of Jawhar taluka went to school on 27th November 2003 as usual, after an early
lunch at about 10.00 a.m. She vomited three times in school and then came home. She continued vomiting a
number of times. At about 7.00 p.m. when her parents returned from work they rushed her to the Jawhar
Cottage Hospital. She was admitted in the hospital, given one injection and some tablets but her vomiting did
not stop. Her father requested the nurse on duty to attend to her but she did not pay any heed instead she
scolded the parents, saying that the girl was dirtying the hospital. The parents were asked to give her glucose
water orally which they administered the whole night. The girl could not sleep, she had high fever and she was
crying incessantly, however no medical staff came to see her despite several requests. At about 6.00 a.m. the
next day the girl’s stomach become distended. Even then no medical staff on duty attended the patient. At
11.00 a.m. the doctor came on his routine round, examined her pulse and moved on. The parents requested
the doctor to give the child intravenous saline, since she was not able to swallow the glucose water but he did
not pay any heed. At about 12 noon the child became unconscious. The father rushed to the doctor who was
on duty at Jawhar cottage hospital, informed him. The doctor asked him to bring the patient to his chamber. By
the time they brought the patient to the chamber, she had expired.
While in the Cottage hospital, the child was in severe distress for more than 12 hours, but was not given
adequate attention required to diagnose or treat the underlying problem. The cnild died, and adequate medical
attention not being given in time was a likely contributory cause. This case shows the violation of Right to a set
of basic public health services. This is r violation of the lnternat!on?l Covenant on Economic, Social and
Cultural Rights, the Right io life, guaranteed by the constitution and the right of the child recongnised by the
Convention on the Rights of the Child.
The above cases show that the existing situation is very dismal and the changing political economy does not
show too much promise of change for the betterment of health, unless of course there is a radical
transformation in the political commitment. For this to happen the support of civil society pressures and
demands for a transformation of the healthcare and rehabilitation dispensation will be needed. We need to
move towards the objective of establishing health care a Fundamental Right in the Indian Constitution. This
would be a prolonged and challenging process, and would involve political mobilization and widespread public
awareness besides other things. The time has come to begin asking as to how the human rights related
commitments and concerns will be translated into action in a realistic, time bound and accountable framework.
The following chapter would present the efforts undertaken so far in this direction.
Moving towards a campaign on Right to Health and Health Care: Indian context-Amulya Nidhi
19
V.
WAYS AHEAD- BUILDING A CAMPAIGN ON THE RIGHT TO HEALTH AND HEALTH CARE
Right to health and healthcare is a fundamental social and economic right recognised by the International
Covenant. But such a demand is not on the political agenda in India. This massive health care deprivation
amidst potentially adequate health care resources needs to be addressed by establishing the right to every
citizen to basic health care, accompanied by operationalising a system, which would ensure universal
access to health care. The first step towards this direction was taken in the International Conference on
Primary Health Care, meeting in Alma Ata in 1978. The Conference reaffirmed that health is a fundamental
human right and that the attainment of the highest possible level of health is a most important worldwide
social goal27. It says that governments have a responsibility for the health of their people, which can be
fulfilled only by the provision of adequate social measures.
For building an effective campaign for right to health the central task must necessarily be the task of
mobilizing those who are personally facing the brunt of the anti-people policies. Any movement that Is not
based on the mobilization of this section is seriously limited. Though the slogan Is 'People’s health In
People’s hand', it is yet to be placed in people’s hand because most organisations and networks currently
focusing on right to health come from middle class backgrounds. Though even with this limitation certain
demands like increase in budgetary allocation and expansion of public health services form a ground for
action - but they are not adequate to form a movement.
For mobilizing this section, two approaches are useful. One is the articulation of comprehensive radical
critiques, if possible with alternatives, for making out the correct political position. Another approach is to
engage in lobbying and advocacy for policy changes and shaping of a public opinion. One way to generate a
public debate is to take the formal judicial route, filing of Public Interest Litigation (PIL), which would draw
media attention and would put pressure on the political sphere. This could lead to short term gains and this
can help in sustaining mass action. But to build a larger public campaign for the 'right to health and health
care’ - a nation wide initiative Jan Swasthya Abhiyan (People’s Health Movement- India) was Initiated. Jan
Swasthya Abhiyan is a campaign platform that has emerged from the People’s Health Assembly process in
India in 2000. It forms the Indian regional circle of the global People’s Health Movement, and is a coalition of
20 National networks and several hundred organisations from all over the country working in the area of
health, people’s science, women’s issues and development
Jan Swasthya Abhiyan (JSA) in India has voiced a demand to make health care a right, but this requires a
widespread awareness campaign and participation of many more civil society groups. This chapter would
describe the various initiatives that are undertaken in the country by JSA in the direction of maWng health
care a right
In India to achieve right to health and health care two parallel process Is needed, firstly by demanding from
the Government, amendments in law and secondly by building pressure from people. As at present asking
right from the formal judiciary is a long way process and it is expensive for a common man to fight with the
system individually, therefore a parallel Judicial System was initiated, which is accessible and affordable to a
layperson. It was known as people court. In ancient time also in villages there was a system of panch
system, which solved day-to-day crime and conflicts in villages. Still in some parts of Rural India this system
is functioning.
27 International Conference on Primary Health Care, Alma Ala, USSR, 6-12 September, (1978).
Moving towards a campaign on Right to Health and Health Care: Indian context-Amulya Mdhi
20
Public hearing as a means for creating public discourse and people's mobilization
In India, Jun sunwai as an innovative advocacy strategy was initiated by Mazdoor Kisan Shakti Sanghatana
(MKSS), Rajasthan. It was initiated as part of Right to information campaign. After this in several parts of
country Public hearing was organised on different social issues.
Jan Swasthya Abhiyan has emerged as a premier national level platform in India with a clear Rights-based
approach to health. State and national level activities have included facilitation of‘People’s Health Enquiries’
in over 200 districts all over the country. In continuation with its pursuance of health rights, JSA organised
Public hearings {Jan Sunwai) in various parts of the country. Here I am going to present the process of
conducting Public Hearings.
Meaning of Jan Sunwai“Jan Sunwai is a process in which any issues related to social sector is addressed to a panel of
experts from related field". In past few years Jan Sunwai (Public hearing)- as a model has become very
popular in which experts from related field act as a judge and activist as a lawyer and government
representative as a third party. In public hearing public officials and representative are invited to defend
themselves in these hearings. This strategy encourages people to speak out fearlessly and give evidence
against the misdeeds of the administration. Like in court, common people are allowed to listen to the
judgments, in the same way the Public hearings is not limited only to the people actually suffered, but
lawyers, intellectuals, academicians, and journalists can also be a part of the process. The judge or panel
gives recommendations after listening to people’s voices for immediate action so as to make relevant
changes in the policy. In public hearing villagers/ common people are informed in advance about place,
date and others details to be discussed. A large number of people from all walks of life participate in the
hearings.
The strength of public nearing is it is being organised in local language. This encourages the poor, who are
otherwise unheard of to express their negative encounters with the government system. Public hearing was
not only effective as an advocacy strategy, bet as a means to give the poor an opportunity to voice their
dissent. It helped to increased the strength and bargaining power of people in relation to state machinery.
The well planned public hearing not only serve as a means to create mass mobilization and grassroots
mobilization, but also created a lot of news value in the media. So public hearing had multiple strategic
functions. Here I would present few instances of Jan Sunwai held in the country in the last one year on the
issue of health care.
Regional level - Jan Sunwai-Sendhwa, Madhya Pradesh
Jan Swasthya samiti, Sendhwa, Madhya pradesh had organised a public hearing, which was hosted by
Adivasi mukti Sanghatana, Sendhwa on the issue of peoples right to health on 4th September 2003. The
idea of organising a Jan Sunwai was initiated in a meeting of Adivasi Mukti Sangathana at Niwali
in July 2003. The process details of this important step forward in the health movement in Western
Madhya Pradesh (MP) are as follows.
*
Organisational groundwork: In this process at first village meetings were held and specific cases of denial of
health services, which led to either loss of life or endangered life were documented. Activists of POs,
Volunteer MSW fieldwork students and staff associated with CEHAT and Ashagram, documented these
cases. Simultaneously a meeting was organised in the month of August in Sendhwa by the Jan Swasthya
Samiti, Sendhwa to discuss the present situation of public health services after 25 years of Alma Ata
Declaration. In that meeting it was felt that these findings should be discussed with the people to make a
wider impact.
Moving towards a campaign on Right to Health and Health Care: Indian context - Amulya Nidhi
21
district by Jan Swasthya Samiti to doXSt th!ft ’
'"PHCs'CHCs arci D“ * i"
f
/ W!S
*>
in Badwani and Jhabua
with PHC/CHC staff
at District Health Departments were collected to supnlmSiHhl
I1??1* Secon<ia,V dala available
report was prepared which hWts the stated and^taai proSXS^
=s2Ess=eis=
Sendhwa and hosted by Adivasi MukH S?' e . organised by Jan Swasthya Samiti,
Phadke, health activist from pJn
Sundalaram!!3^^ !h
COnSiSting Of Dr Anant
Rahul Sharma, Convenor of BGVS Gwalio ISSt? ?
t0 Chattis9arh government, Dr.
and Health dept were also invited fnr thk
hr sent for the Jan Sunwai. The District Administration
RepresentatlX?^
“
did
“™ tor th, hearing.
a~:a-s ex se ••-i ■'->“—“xs;
=~s=ss^g=S=
“hXX'nVa^SKte"
organised as part of Jan Swasthya Abhiyan.
Y
3
In ° hef StateS alS0 pubhc heann9 were
National Consultation on Health Care as Human right
d^nto^hS SS h“ld to MpXX^h^’T'M
»' «>a
ssssessss—
Of academicians, pS anaX eZ'SXX"’e “OrSa"M
aS
Moving towaris a campaign on Right to Health and Health c^ . Indian
22
his clear position that "Obligation of the state to take care of primary health is paramount, total and
absolute. The state cannot avoid its constitutional obligation on account of financial constraints923.
Other Strategies:
Besides building a public opinion through the above strategy, the other approach adopted is initiating a
dialogue with a wide variety of professional associations like Indian Medical Associations, Medical Council of
India, universities and academic research institutions and networks. This is necessary to build up an ethos of
support to the campaign and would also help to counter the potential opposition of the medical industry or
those who see a threat in this campaign.
The other step that is adopted is to try and evolve and integrate other health care systems and traditions
would greatly enhance the demand and support base.
Jan Swasthya Abhiyan also organised a ‘Public Dialogue with political parties on Health Issues’ on 12th
March 2004 in Delhi before the General Elections 2004. Around 300 JSA associated persons attended this
public dialogue. This event Involved representatives from different political parties, representatives from the
media both print and electronic, expert panelists and speakers, and JSA related health activists from a
dozen states. Members of some political parties also promised that they would take up issues related to
health in their campaign and also in the assembly.
Besides these above mentioned national level initiatives, various state units of the JSA are also involved in
state level campaigns to make right to health a reality.
The concluding chapter would focus on the issues that needs to be addressed further and strategies that
need to be adopted to make “Right to Health and Health Care” a reality.
k
i
28
Jan Swasthay Abhiyan, 'Report of ti»e National Wocksbop on Right to Health Care and National Consultation on Health Care as Humai
Right",
September, organised by CEHAT, (2003).
Moving towards a campaign on Right to Health and Health Care: Indian context - Amulya Nidhi
23
VI.
CONCLUSIONS AND RECOMMENDATIONS
tLrLmoanHn9htS’rhe
•? healtfl
not 66 realized with judidal intervention alone but reouire
hMtm
3C wn by a? S0Ciety' The law was only a part of the social framework with which the riqht to
health care cou d oe realized. The other integral part is civil society, which now needs to be strenothpnpd
SL6 U±"; and a ^^ness of the value of human life. TeTast few
emonstreted the tremendous power of the civil society in trying to achieve health care rights The rioht to
healthcare campaign is trying to bring into light the readiness at the community members to contribute
towards demanding health care as their fundamental rights. This needs to be strengthened further.
th! State 9ave emPhasis on enactment of new laws, modification of the colonial law and
riohkd Thk h!V8 Of>ed T 'tWS ,0 conso,idate People's entitlement of health care and to an extent the
commits? lipV?h°f "rk1 °? P'aCe °n ’he baS'S °f numerous recommendations made by various
committees like the Shore Committee(1946) and Mudaliar committee(1961) The Shore Committpp
Spr^^tfai ^ State tdeirrecommendatons to logical conclusions. Recently the Bajaj CommitteSe)
frnplemi^n
recommended uniform ad°Ption of
health ait This needs to be
mvolvemen s which will be needed to build a consensus and struggle for right to healthcare To establish
listed belo? and hea'thCare With the above scenan'°
essential staPS will be necessary, which are
i'nWnS!?^01 dil?re^OSSiOn already 9iven ttl0U9h different international treaty. Pressurizing
Ncwfn dn S lke T0, ^mittee of ESCR, UNCHR, as well as national bodies like NHRC
CW to do effective monitoring of India’s state obligations and demand accountability
’ oSTn
Padiarnentarians to demand justifiability of directive principles. The directive prindples
gives fu scope o he parliament to make right to health care a fundamental right Ring pubhc
. RpS 1 '9 m'°n L On /9ht t0 hea,thcare t0 create a basis for constitutional amendment9 P
’
4^^
hT XTrf h50de! ^UbhC Health Act (if necessary with some modifications) in all states3' If
i
29
M
Car°Pmviders’CEHAT' “ t1996)-
comm/ttee, Vol 2, Government ol India, Ministry of HeX id FamTyWe^re^et^'^
°'
Surmyand P'annin0
,Or ilS im^enlen,at'on ln ^9®^'" was r0'56 examined by all State health authorities and
Moving towards a campagn on Right to Headh and Health Care: Indian context - Amulya Nidhi
24
The medical councils must be made accountable to assure that only licensed doctors are practicing
what they are trained for. Further continuing medical education must be implemented strictly by the
hou^and^rttot000'S aT l,CenS^ |^jUld nOt renewed (as per existin9 ,aw) if trie required
•
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.
The agenda for health reform is long, far-reaching and tortuous, arguing for rethink on the role of public
health sector and for restructuring of the private sector. 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 poMcal 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
o the economy (which directly benefit capital accumulation) is more urgent (from the business perspective)
man 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
nghts-based 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 health care. 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
health and healthcare. While the course and outcome of these efforts would depend on the much larger
political situation, the following slogan should continue till we achieve our goal of a more humane society.
Health for All - Now!
The Right to Health is a basic human right'
Moving towards a campaign on Ri&t to Health and Health Care: Indian context-Amulya Nidhi
25
BIBLIOGRAPHY
Articles
1. Abusaleh Shariff, India Human Development Report,' New Delhi: Oxford University Press for the
National Council for Applied Economic Research (1999).
2. Amar Jesani, The law and right to health care in India, Medico friend circle bulletin,mar-june2000.
3. Amulya Nidhi, A two-pronged programme, Health Action, April 2004.
4. Kinney, E.D. 2001. ‘The International Human Right to Health: What does this mean for our Nation and
World?’, Indian Law Review, pp 1457-1475.
Papers
1. Abhay Shukla Creating a consensus on the Right to Health Care, Paper presented at National Meeting
on Right to Health Caro, Mumoal, February 14, 2004.
2. Abhay Shukla, "The Right to Health Care Moving from Idea to Reality”, Paper presented In Media
Workshop on Key Issues of Health and Health Care, 21ot February, Indian Social Institute, New Delhi,
organised by CEHAT 2004.
3. Amar Jesani, “Right to Health Care: Entitlement and Law”, Laws and Health Care Providers, CEHAT,
Mumbai 1996.
4. S.V. Joga Rao, “Fundamental Right to Health and Health Care”, Country Report on Status of Health
care, CEHAT, (unpublished).
Books.
1. Advocacy update,oct-dec2001,No-16,National centre for Advocacy studies, Pune.
2. CEHAT, Right to Health Care- Moving from Idea to Reality, Dec 2003.
3. Centre for Social Justice “Constitutional Provisions and Supreme Court Judgments on Right to Health",
Ahmedabad (unpublished)
4. P.M. Bakshi, ‘The Constitution of India’, Delhi: Universal Law Publishing Co. Pvt Ltd. (2000
5. 25 Questions and Answers on health and human rights, Health & Human Rights publication series,
Issue No1,July2002.
6. Medico friends circle bulletin, Jan-feb 2001.
1
Reports
1. NSSJ987: Morbidity and Utilisation of Medical Services, 42nd Round, Report No. 384, National Sample
Survey Organisation, New Delhi.
2. Jan Swasthaya Abhiyan, “Report of the National Workshop on Right to Health Care and National
Consultation on Health Care as Human Right", 5-6^ September, organised by CEHAT, (2003).
3. Mudaliar Committee, “Appendix B - 38, Salient features of the Draft Model Public Health Act", Report of
the health Survey and Planning Committee, Vol 2, Government of India, Ministry of Health and Family
Welfare, (1961).
4. Compendium of recommendations of various committees on health development! 943-1975, central
bureau of health intelligence, Govt of India, 1985.
5. Report of the expert committee on public health system, Ministry of health and family welfare, Govt of
India, June 1996.
Moving towards a campaign on Right to Hearth and Hearth Cere: Indian context - Amulya Nidhi
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- Media
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