JAN SWASTHYA ABHIYAN
Statement
on Universal Health Care
On
the occasion of World Health Day – April 7th 2012
BACKGROUND
Over the past
year there has been a lot of interest in and visibility of the concept of
Universal Health Care. The Planning commission had set up the High Level Expert
Group (HLEG) on Universal Health Care (UHC) in October 2011 to inform the 12th
plan which was being finalized. Similarly the Prime Minister during his address
to the nation on the occasion of Republic Day 2012 also mentioned that like the
11th plan was focussed on education, the 12th plan would
be focussed on health.
The JSA
discussed the HLEG report on UHC as well as the Report of the Steering Group on
Health with its proposals for UHC during a two day workshop in Delhi on the 21st
and 22nd of March 2012. This statement is based on the emerging
understanding of the concept as well as the concerns expressed during that
meeting and discussions both before and on going.
While JSA
welcomes this interest and commitment to health by the government of India, on
the occasion of World Health Day it would like to set out clearly its views on
the issue as well as express very serious concern with the direction in which
the discourse on Universal Health Care seems to be going.
JSA's
STARTING PRINCIPLES
JSA believes and
reiterates that Health is a fundamental human right, that the government is
responsible for the provision of health care as well as an enabling environment
for the realization of this right to health which includes the right to control
over the social determinants of health. As noted by the Special Rapporteur
for the Right to Health, the Right to
health includes the Right of people to participate in all decisions related to
health, the implementation of these policies as well as their monitoring and
evaluation.
Our starting
principles continue to be the Right to Health and the Social Determinants of
Health, and equally the principles of Comprehensive Primary Health Care as
enunciated in Alma Ata.
We believe and reiterate
that Health Care is only one of the many determinants of health. Mere access to
health care even if universal will have no meaning unless these larger social
determinants of health are squarely addressed and issues of caste, class and
gender are engaged with as a society. JSA
believes that the goal of Health for ALL! Will definitely be furthered
significantly with the introduction of Universal Health Care, however we
believe that what needs to be universalized needs to be reflected
upon. We do not believe that a mere expansion of access to the present
technology and industry driven, commodified, irrational and impersonal form of
medicine that is dominant in today's world is the answer. In fact we fear that
a superficial and hurried attempt at universalizing an “essential health
package” in the present un-regulated situation in which there is absolutely no
accountability of the system to the people it purports to serve will only
increase the problems people face and increase inequity. What is required is a
complete re-think of medicine as it is practiced, starting with people and
looking at all resources available for health including the AYUSH, folk
medicine and self – care at the family and community level.
THE HLEG AND
STEERING COMMITTEE REPORTS
The JSA welcomes
a number of key aspects of the HLEG report. Most importantly we appreciate:
·
The emphasis of the
report on the concept of “universal” over the earlier dominant “selective” or
“cost- effective” package. .
·
The complete rejection of
user fees in the health system.
· Bringing focus to the critical issue of human resources to the
center of the table.
· Clear statement against the private insurance route to health
financing.
· Defining the need and urgency of private sector regulation.
· Bringing Community based accountability mechanisms to the center
stage. .
· The suggestion of a redressal mechanism.
It is indeed surprising that an issue of
such critical importance to the country be crippled by such un realistic time
lines. In this situation some of the crucial gaps we see in the HLEG report
include,
·
The fact that the report has
failed to undertake a more wide and deep consultation with all levels and
groups of stake-holders in the health system.
·
That the report has failed to
engage with the reality of the present context of development of the health
system.
·
The report has also failed to
question the present commodified nature of health and health care which is
indeed one of the main reasons for both continuing preventable ill health as
well as inequity.
·
There is a lack of detailing
and operational suggestions in a number of critical aspects which pre-disposes
to easy re- and mis-interpretation of the suggestions in a way that will
further weaken the public sector.
·
The report suggests a number of
new institutions, however we believe that what is needed is a new way of
looking at health and the health system and making the current set of
institutions more people centric rather than another slew of “expert” driven
bodies with complicated lines of accountability to the people.
More recently the Steering Group of the
Planning commission on health finalized its report which is available on the
website of the planning commission. This report which incorporates (interprets)
the findings of the HLEG into the Planning Commission process. The Steering
committee report and its “interpretation” of the HLEG report have many
concerning issues that are likely in our opinion to completely defeat the
purpose and spirit behind any evolving process of Universal Health Care.
·
The reduction of the
comprehensive Essential Health Package suggested by the HLEG into RCH and
National Health Programs shows the very contracted nature of the vision of our
health planners. This in no way can be considered as a Universal health
package.
·
The concept of financial and
operational autonomy of the public health facilities is also very problematic.
While autonomy in operational terms is necessary for any health facility within
the overall regulatory and accountability frameworks, financial autonomy is
concept that needs to be defined further. If it means leaving the public sector
to “fend for themselves” in the present environment, it will merely mean the
death knell of this system and putting paid to any hopes for a Universal System.
·
The concept of “provider
choice” is also problematic in the present situation of a historically
neglected and dilapidated public health system and a private sector which has
received encouragement and absolutely un regulated growth, enabling it to reap huge
and obscene levels of profit and increasing inequity.
·
The designation of the District
Health Society as the key player for empanelment and regulation without any
allusion to the way in which these are functioning at present points out to the
lack of engagement with reality.
·
Further more the suggestion
that cost escalation will be contained by sticking to Standard treatment
guidelines without questioning the basic commodification of health care again
questions the vision of this report.
·
It suggests that one district
in each state pilot this concept in the first year of the plan. We would
strongly suggest that the unit of pilot should logically be the state, and more
over that such pilots be initiated only after full discussion and public
debate.
BROAD PRINCIPLES OF JSA
Health Care provisioning:
We firmly believe that the public health
system has to be the back bone of any universal health system. In its present
state it definitely cannot be so. The public health system has suffered years
of neglect due to lack of funding, poor governance and active encouragement of
the private sector.
It is also true that in order to cover the
complete population for all the services the involvement of the private
providers in some form may be necessary. However we hasten to add that the
degree, form and content of the engagement needs to be decided after three
critical steps:
·
Strengthening the primary level
of care with more Health workers and encouraging and building up the capacity
of self-care, and especially preventive and promotive care.
·
Bringing the public sector up
to its full functional capacity and expanding it up to the level at which it is
supposed to be including population norms and infrastructure at least upto the
IPHS standards, before providing public monies to the private sector.
·
A detailed mapping and
assessment be done for each district of the actual need of curative health care
at each of primary, secondary and tertiary care after taking into account a
fully strengthened primary level (including curative, preventive and
promotive).
The private sector needs to be brought in
only on the terms of public good. The integration of the public and private
sector is not seen only in terms of provision and financing but most crucially
in terms of an integration of the “logic” of the health system, with corporate
profit not being allowed to lead or define health provision. The health system
has to be strictly and transparently regulated with its primary goal being the
people's welfare rather than private profit. It is only under such
circumstances that we can develop a system that will truly serve the needs of
the people equitably.
Financing:
There seems little doubt that the most
widely successful way is through single pool, non-commercial, tax based financing.
This needs to be in an environment of strict regulation. While a number of
countries have provided models worth studying, India needs to chart out her own
course. One thing for sure however is that what we are aiming for is health
security and universal coverage and NOT the currently fashionable and
politically convenient “insurance schemes for tertiary illnesses” of the
Arogyashri type or the limited hospital based coverage of the RSBY type.
Governance:
Whatever the provisioning and the financing
mechanisms, unless the governance of the whole system is firmly people centered
and rights based these arrangements are likely to be exploited by the dominant
and corportatized private sector. We envisage a community led and focussed
process. We further visualize the institutionalizing a process of community
based monitoring, planning and action for health. This process needs to evolve
from the learnings from the on going experiences in a number of states of the
country in which JSA partners are involved.
In addition to this we believe that there
needs to be greater internal democracy. The public health system is ridden with
hierarchies and power centralization. The private sector is driven by the need
of extracting profit from people in their weakest moment, and is characterized
by irrational and unnecessary interventions (both diagnostic and therapeutic).
These issues too need to be engaged with comprehensively.
IN CONCLUSION
We welcome the attention and policy level
commitment to health care, in this situation the JSA calls for the following:
·
A public debate on the contours
of the proposed universal health system. Such an important issue cannot be
rushed through and its various strands need to be discussed and understood
widely by the people.
·
A definition of a clear and
transparent and time bound road map for strengthening and expanding the public
sector, including the budget to be allocated.
·
There must be a process of
mapping and estimating need for health care services in each district and within
each district in areas with special needs. This must be transparent and widely
discussed by the people of the district.
·
There needs to be the enactment
of adequate laws guaranteeing the right for health, laying down the framework
for regulation of the health system and accountability and grievance
redressal.
·
The health system needs to
ensure adequate and disaggregated information (both qualitative and
quantitative) that is transparently collected and shared to guide its policies.
·
There should be no haste in
rolling out these concepts – even the looming
large of the General elections should not become an excuse for the
government to short circuit and co-opt the concept of Universal Health Care for
narrow political gains.
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