With the NDA’s Ayushman Bharat and the Congress’s promise of a Right to Healthcare Act “that will guarantee to every citizen the right to healthcare services, including free diagnostics, out-patient care, medicines and hospitalisation through a network of public hospitals and enlisted private hospitals”, these Lok Sabha elections are probably the first in India’s history in which health is part of the mainstream political discourse.
The Right to Health
The WHO defines the right to health as “a claim to a set of institutional arrangements and environmental conditions that are needed for the realisation of the highest attainable standard of health”. It “does not mean the right to be healthy”; it is “an inclusive right, which extends in addition to timely and appropriate health care also to the underlying determinants of health, such as housing, food and nutrition, water, healthy occupational and environmental conditions and access to health-related information and education”.
In other words, governments are required to create conditions in which everyone can be as healthy as possible. This was the reason the National Health Policy, 2017, discarded a right-based approach. “We realised it would take years to reach the manpower and infrastructure levels required for it. We simply did not have the resources. We needed huge investments in tertiary care,” an official said.
The draft NHP in 2015 had proposed a National Health Rights Act to make health a justiciable fundamental right similar to education. By 2017, however, the government had moved to an “assurance-based approach”. Health Minister J P Nadda told Parliament that the NHP “envisages providing larger package of assured comprehensive primary health care through the ‘Health and Wellness Centres’ and denotes important change from very selective to comprehensive primary health care package which includes care for major NCDs, mental health, geriatric health care, palliative care, rehabilitative care services”.
The policy, he said, advocates allocating at least two-thirds of resources to primary care, aims to ensure two beds per 1,000 population, and proposes “free drugs, free diagnostics and free emergency and essential healthcare services in all public hospitals”.
NITI Aayog figures show India’s doctor-to-population ratio at 1:1,655, against the WHO norm of 1:1,000. In the government sector, there is one allopathic doctor per 11,000 people on average, according to the National Health Profile, 2018. In Bihar, this number is 28,391; in Delhi, it is 2,203. The WHO puts the optimum ratio of hospital beds to population at 3.5 per 1,000; in India, it is 0.5 per 1,000 on average, World Bank data show. Rural areas are grossly underserviced and entirely dependent on government hospitals.
A 2015 working paper by the Delhi-based Institute for Studies in Industrial Development noted that the share of private hospitals in India went from 18.5% in 1974 to 74.9% in 2000, and the private sector’s share of hospital beds increased from 21.4% in 1974 to 50.7% in 2013. “The share of private medical institutions at the time of Independence was only 3.6%, whereas it… reached 54.3% in 2014”.
Universal Health Cover
Ayushman Bharat is in effect a blueprint for Universal Health Coverage (UHC) — for which the erstwhile Planning Commission had set up an expert group when UPA-2 was in power. According to the WHO, UHC “means that all people… can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while… ensuring that the use of these services does not expose the user to financial hardship”.
To achieve UHC, the government tries to reach every person with a health strategy and resources, including preventive services, through the health and wellness centres mandated under Ayushman Bharat. Of the targeted 1,53,000 centres, 17,000 have been set up. The other arm of the programme is the Pradhan Mantri Jan Arogya Yojana under which 10.74 crore families are being provided an annual health cover of Rs 5 lakh for secondary and tertiary care.
A right to health, on the other hand, assumes the availability of sufficient indoor and outdoor services, to demand which a citizen could theoretically move court. The government hopes that with the involvement of the private sector in Ayushman Bharat, there will be enough investment in healthcare, especially in Tier II and III cities, for infrastructure to eventually reach levels at which a Right to Health law could be considered.