Today across India, people continue to suffer and die unnecessarily due to poor access to affordable and effective health care and due to a range of social and economic determinants that promote ill-health and disease. Approximately 1.83 million children under five years of age die each year in India. This is the highest number anywhere in the world. One-third of all malnourished children live in India. The cost of health care is a leading cause of poverty. National Sample Survey Organisation’s (NSSO) recent morbidity, healthcare survey, estimates that around 63.22 million individuals or 11.88 million households were pushed to BPL due to healthcare expenditure. Paradoxically, all these are happening at a time when India has the resources, knowledge and skills to usher in real change. Given this context, Jan Swasthya Abhiyan proposes below a set of clear policy proposals. We would like to request all political parties to commit themselves to these proposals, and if elected to power, to deliver upon them. We are confident that these measures would be found to be extremely popular among ordinary people, and parties which publicly commit themselves to carrying out these measures would enjoy widespread public support.
Manifesto to Promote Health and Healthcare
The right to health is a fundamental and universal right of all citizens and this will need to be respected and realized within a time frame. The Right to Health needs also to be located in the underlying determinants of health such as access to safe water and sanitation, adequate food and nutrition, housing, and secure livelihoods. Above all social inequities – based on disparities along gender, caste, class and other lines – have a profound impact on the health of the poorest and the most marginalized. At the same time the right to comprehensive quality health care services is an important part of the Right to Health. To ensure the fulfillment of this right, the public health system needs to be much better resourced, expanded and made accountable so that it can provide free and health care services that are comprehensive, of good quality and accessible to all. The proliferation of an increasingly commercialized and exploitative private medical sector is a major cause for concern and urgent measures are required to reverse this trend and strictly regulate the cost, quality and ethical norms of services that the private sector provides. The following concrete proposals are designed to reverse the present – entirely unacceptable — situation in the health sector, and to secure conditions of living and health care services that promote health in all its dimensions.
1. Act on the Social Determinants of Health:
This would include promotion of food security by universalisation and expansion of the Public Distribution System (to also provide local cereals, pulses and oil); a national policy on Child Health and nutrition and universalisation of ICDS with expansion of staff and services to effectively cover under-3 children; ensure universal availability of safe water in each village and habitation; and universal access to safe hygienic toilets in all habitations.
2. Address the Gender dimensions of Health:
Guarantee comprehensive, accessible, quality health services for all women and transgender persons for all their health needs which includes but is not limited to maternal care. Abolish all coercive laws, policies and practices that violate the reproductive, sexual and democratic rights of women; and regulate use of invasive reproductive technologies. Recognize gender based violence as a public health issue and ensure access to comprehensive health care (physical as well as psychosocial), screening, documentation, referrals, as well as coordinated, ethical medico-legal processes for survivors. Guarantee comprehensive, quality, accessible, adolescent-friendly health care, including for their reproductive and sexual health needs.
3.Immediately reverse Caste Based Discrimination:
Take immediate and effective steps to entirely reverse all forms of caste based discrimination, which is one of the most important social determinants of ill health. Immediate ban on manual scavenging. In the health care sector, special measures to promote priority access to discriminated sections of society.
4. Enact a Right to Health Act
An act which assures universal access to good quality and comprehensive health care for all the entire range of primary, secondary and tertiary services, and that makes denial or non-availability for reasons of access, affordability or quality a justiciable offence.
5. Increase Public Expenditure on Health:
Increase Public Expenditure on Health to 3.6% of GDP annually (Rs 3000/- per capita at current rates) with the central government’s contribution being at least 1% of GDP (Rs 1000/- per capita). All public health expenditure to be tax financed. Public health spending to be increased to 5% of GDP in medium term.
6. Ensure Quality and Assured Availability of Health Care:
Quality of care to be ensured in all health facilities, which would mean health care that is effective, safe and non-exploitative, provided with due dignity and respect to patient rights, and which aims at patients’ comfort and satisfaction. Quality norms and standards shall not mean conforming to infrastructure or other standards, which favor large corporate hospitals, or worse medical tourism, and make it impossible to provide low cost, rational and effective care. Every public health care facility would be required to provide guaranteed health services appropriate to their level in assured manner. Public health facilities to be entirely free of user fees and the entire range of services to be provided directly by government run facilities and not through Public Private Partnerships(PPPs).
7. Stop both Active and Passive Privatization of Health Care Services:
Necessary measures to stop active privatization in the form of transfer of public resources or assets to private entities that provide services on a commercial basis. Measures to stop passive privatization by increasing investment in public health facilities, increasing number of beds and facilities in the public sector, and by expanding range of services available in public facilities. Public facilities to provide comprehensive health care services, not limited only to reproductive health care, immunization and care for a few diseases of national importance.
8. Training of Health Workforce:
Increase public investment in education and training of the entire range of health personnel. Ensure that government run colleges to train a range of health workers, nurses and doctors are located in areas where they are needed most. Training to be reoriented to impart skills that address the health needs of local communities. The trend of commercialization of higher education in medical and allied.
9.Well Governed, Adequate Public Health Workforce:
Create adequate posts for the entire range of health personnel in the public health system. Regularize contractual employees and provide ASHAs, ANMs and all levels of public health system staff with adequate skills, salaries, and decent working conditions. The health and safety of workers, particularly of women to be assured. Act on available evidence from many states which show that the problem of the lack of doctors in rural areas is more a result of administrative incompetence and political failure than a matter of professional culture. Creation of a cadre of doctors, nurses and other paramedical workers who have training in primary health care, public health and in working as a team.
10. Secure access to quality assured essential medicines and diagnostic services in all public health facilities, free of charge.
This would be achieved by developing autonomous and transparent procurement and demand driven distribution mechanism (on the lines of Tamil Nadu, Kerala and Rajasthan). For chronic illness it would mean ensuring such access throughout the year from a distribution point most accessible to patients. Generic prescriptions to be made compulsory in all health facilities.
11. Participatory Planning, Community Participation and Community Based Monitoring of health services to ensure accountability and responsiveness of services.
Community Based Monitoring and Planning will be generalized and made a core component of all public health programmes and health care services, to help effective delivery of services and ensure accountability and transparency.
12. Eliminate Corruption in the Public Health System through transparent policies for appointments, promotions, transfers, procurement of goods and services and infrastructure development – all of which are legislated through a Transparency Act (as in Tamil Nadu for procurement and Karnataka for transfers). Institution of robust grievance redressal systems, which are adequately financed and managed with some degree of autonomy from the management.
13. Reverse Exploitation by private hospitals and protect ethical private non commercial private providers: The national Clinical Establishment Act would have provisions for: observance of patient’s rights in all clinical establishments; regulation of the rates of various services; elimination of kickbacks for prescriptions, diagnostics and referrals; and establishment of government supervised independent grievance redressal mechanisms for patients. Standards would be designed in a manner that would prevent corporatization of health care. This would promote genuine not-for-profit and ethical health care providers and would contain costs of care in the private sector.
14. Absorb, over a period, existing publicly funded health insurance schemes (RSBY and different state health insurance schemes) into an expanded public health system publicly financed through general taxation. All entitlements available under these schemes would be made available through the public health system, suitably expanded and adequately resourced. This should include a comprehensive system for health care protection of unorganized and organized sector workers (providing primary, secondary and tertiary health care), linked with expansion and rejuvenation of the ESI.
15. Eliminate the role of multi-lateral and bilateral financing agencies from all areas of technical assistance or health policy formulation. Eliminate the influence of agencies — such as the World Bank, USAID and Gates Foundation, as well as consultancy organizations such as Deloitte and McKinsey — informulation of national priorities and approaches to health care provisioning and financing. Build international collaboration for generation and sharing of knowledge resources, especially with other developing countries. Exert pressure at the governmental level to free WHO, UNICEF and other UN agencies from dependence on corporate financing and influence. Critically examine the offer of advise and expertise from such agencies till such time as they continue to be influenced by corporations and private foundations.
16. Build National and State level Capacity for Health Research and Development:
The government would invest at least 5% of its public health budget on health research including health systems research. The government, for the purpose of promoting health systems research and research for domestic priorities, would develop institutions and strengthen existing institutions that are financed through public funds.
17. Ensure Access to Essential and Safe Drugs & Devices:
Cost-based price-control of all medicines, measures to ensure drug and device safety, banning of irrational medicines and irrational combinations, opening of generic medicine outlets in adequate numbers, mandatory provision for doctors to write generic names of medicines, use of the public health safeguards in the Indian Patent Act to promote access to medicines, and active promotion of indigenous manufacture of most drugs and devices.
18. Regulation of Clinical Trials and Ethics in Biomedical Research:
Develop a clear framework for the ethical conduct of clinical trials in India, combined with the regulation of all those that are involved — sponsors of trials, CROs, ethics committees etc. Ensured that the CDSCO and the ICMR monitor the conduct of clinical trials at the trial sites and only permit trials at sites which are equipped to handle emergencies and adverse events. Fair compensation norms for trial participants who suffer from adverse events to be expeditiously developed and implemented. A charter of rights of clinical trial participantsto be developed and made justiciable.
19. Ensure access to treatment and care of persons with mental illness (PWMI) through integration of the revised District Mental Health Program with the National Health Mission. The rights of PWMI need to be protected by adoption of the Mental Health Act and action on the draft mental health policy.
Jan Swasthya Abhiyan Health for All – Now! Health is a Basic Human Right!
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