The good news is that health has arrived on the country’s political agenda. The bad news is that health systems are in critical condition and there is significant public discontent over the lack of quality and affordable healthcare.
We can confirm that health is making an impact on the political scene, when on the one hand, Prime Minister Narendra Modi launches the Ayushman Bharat scheme a year before the elections — a programme that claims to benefit 50 crore Indians — and on the other hand, the Congress’s manifesto carries the party’s pledge to enact a Right to Healthcare Act. However, in the past five years, the Union health budget has stagnated in real terms, allocations to the National Health Mission do not cover inflation and there have been avoidable deaths of scores of children in public hospitals in Gorakhpur and other places that can be ascribed to the lack of material and human resources.
Governments have failed to regulate private hospitals effectively, leading to numerous instances of mismanagement and massive over-charging of patients, such as the tragic case of Adya Singh in Fortis hospital, Gurgaon. There are convincing facts which show that the “solution” being offered in the form of the Pradhan Mantri Jan Aarogya Yojna is not only seriously underfunded (current funds being less than one-fourth of required) but it will only scratch the tip of the iceberg of healthcare requirements in India.
Given this context, India needs a major health policy reboot. The general elections are an appropriate occasion to propose such comprehensive changes. The Jan Swasthya Abhiyan — a national coalition of health sector organisations and activists — has attempted do this through its People’s Health Manifesto 2019. The manifesto includes the following proposals:
One, adopting a Right to Healthcare legislation at the Centre and state levels. This would ensure that all residents of the country are entitled to healthcare facilities. Development of asystem for Universal Healthcare (UHC) would be a key constituent of this initiative, which would require expansion and strengthening of public health services at all levels. Private providers would also be involved, as per need, to supplement the public health system.
Two, increasing the public health expenditure exponentially through taxation. This expenditure should be increased from the current grossly inadequate 1.2 per cent of the GDP to reach 3.5 per cent of the GDP in the next five years, and eventually touch 5 per cent of the GDP in the medium term.
Three, ensuring major reform and strengthening of public health services with increased staff and infrastructure. A key component of this reform would be guaranteed provision of free essential medicines and diagnostics to all patients in public health facilities, by adopting systems for procurement and distribution which are similar to the current models in Tamil Nadu, Kerala and Rajasthan.
Four, there should be a comprehensive health sector human resource policy, which provides upgraded skill training, fair wages, social security and decent working conditions for all public health services staff. The services of all contractual health workers, including ASHAs and anganwadi workers, should be regularised.
Five, community-based monitoring and planning of health services that are being practised in a few states should be upscaled and user-friendly grievance redressal systems put in place to ensure social accountability and participation.
Six, the PMJAY component of Ayushman Bharat, which is based on a discredited insurance model, should be jettisoned. Such schemes need to be replaced by the universal healthcare system.
Seven, private hospitals must be brought under the ambit of regulations by modifying and adopting the Clinical Establishments Act in all states. This legislation must ensure that the Charter of Patient’s Rights is observed, it must provide a grievance redressal mechanism to patients, the rates for services must be regulated and standard treatment guidelines should be adopted in healthcare institutions.
Eight, essential medicines and medical devices must be subject to price regulation, based on their manufacturing cost. A Uniform Code for Pharmaceutical Marketing Practices should be put in place to curb unethical marketing practices. Manufacturers should be asked, in a stepwise manner, to sell medicines only under their generic name, and doctors should be directed to write generic names of medicines in prescriptions.
These initiatives must be accompanied by measures to ensure that people with special needs — women, children, differently-abled persons, people living with HIV — enjoy appropriate health services. Traditional social determinants of health such as nutrition, water supply, sanitation and healthy environment must be ensured. There should be plans in place to tackle new determinants like air and water pollution and addictions.
Such a paradigm shift towards a rights-based system for universal healthcare, based on massive increase in health budgets and strengthened health systems, is not an unrealistic dream. Several low- and middle-income countries such as Thailand, Brazil and Sri Lanka have such systems in place. The core ingredient required for UHC is political will. As we prepare to exercise our choice in the elections, we need to boost such political will by supporting parties which have pledged the right to health care to all.
This article first appeared in print under the headline: A manifesto for health
The writer is a National Convenor, Jan Swasthya Abhiyan