- Health is a state of complete physical, mental and social well-being: WHO
- Right to Health is not a fundamental right in Constitution
- Right to health is when the state is duty bound to provide health to all
New Delhi: According to the Constitution of India, health is a state subject. However, the central government also plays an important role in establishing public healthcare infrastructure. Together, the governments at the centre and state should provide adequate healthcare and preventive health facilities to the citizens but as of now, they are not constitutionally obligated to do so. This is because the ‘Right to Health’ has not been enshrined as a fundamental right in the Constitution. To understand what Right to Health is and why even after seven decades of independence the subject of health remains a low priority in the country where expenditure on health as a percentage of GDP is just a little over 1 per cent, NDTV spoke with Amitabh Behar, Chief Executive Officer of Oxfam India and Dr Yogesh Jain who runs a community hospital in rural Bilaspur, Chhattisgarh and is a member of Jan Swasthya Abhiyan, national network of civil society organizations and people’s movements working for health rights.
What Is Right To Health?
According to Dr Jain, Right to Health means a person’s right to remain healthy and to be able to access healthcare which also includes preventive healthcare such as adequate food, water and sanitation, environment and all the other requirements for preventing illnesses and promoting health. He stressed that health must be looked at in a holistic way as the World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Dr Jain further said that the right to health is something that is justiciable, and which holds the system to account that it provides care. Dr Jain said,
Right to health will make denial of health justiciable which empowers the citizens to sue the state if they are sick and unable to access care.
Even After Seven Decades Of Independence, Why Is Health Still Not A Fundamental Right In India?
There are multiple references to public health and the role of the government in the provision of healthcare to citizens in the Constitution of India such as:
- Article 21 of the Constitution guarantees protection of life and personal liberty to every citizen
- Article 39 (E) directs the State to secure the health of workers
- Article 42 directs the State to just and humane conditions of work and maternity relief
- Article 47 casts a duty on the State to raise the nutrition levels and standard of living of people and to improve public health
- Article 243G endows the Panchayats and Municipalities to strengthen public health
- The Directive Principles of State Policy in Part IV of the Indian Constitution provide a basis for the right to health
However, the Constitution gives no explicit recognition of the right to health or healthcare as a fundamental right. While talking about neglecting health as a fundamental right, Mr Behar said,
The question really is that why is health still not a political priority? If you look at successive governments, we have done lip service to the idea of the Right to Health. There are two major reasons behind this. First, the successive governments and the political system do not feel that health is a critical political issue and people would either reward or punish the government for their performance around health. Second, a large private sector lobby in healthcare has emerged in the last 2-3 decades which also ensures that the public health system remains weak. Broadly speaking, this is the whole problem of governance, that even after over 70 years of Independence we have not been able to provide basic services which are pretty much the fundamental rights of the citizens. Education is also in a similarly bad state, so is water and sanitation.
According to Dr Jain, people’s right to lead a good life does not find a way into the political discourse easily. He said,
The people who decide most of the things are not the ones who suffer the consequences of their decision and people who suffer the consequences don’t have the voice in the system. This is because our polity – whether it is the people in power or the people in opposition, are not taking side of the citizens. Sure, there are some schemes, but healthcare cannot run as schemes, it has to become a right.
Public Healthcare Infrastructure In India Marred By Acute Shortages
In its report earlier this year, the 15th Finance Commission for 2021-26 revealed the acute shortage of workforce and infrastructure faced by the public health sector in India. It said that every allopathic doctor in India caters to at least 1,511 people, much higher than the WHO’s norm of one doctor for every 1,000 people.
The shortage of trained nurses is even worse, with a nurse-to-population ratio of 1:670 against the WHO norm of 1:300, the 15th Finance Commission said.
The 15th Finance Commission report said,
Among the major states, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Maharashtra and Uttar Pradesh are way behind others in government doctors-to-population ratio. The shortfall of nurses is highest in Bihar, Jharkhand, Sikkim, Telangana, Uttar Pradesh and Uttarakhand.
The Finance Commission report described the hospital beds-to-population ratio as a “crude proxy” of the vulnerability of a health system.
India is estimated to have a total of 18,99,228 hospital beds (over 60 per cent of which are in the private sector), that is, roughly 1.4 beds per 1,000 population. This is lower than in many comparator countries: China’s bed density exceeds four per 1,000; Sri Lanka, the United Kingdom and the United States have around three per 1,000; and in Thailand and Brazil, hospital beds exceed two per 1,000 persons, it observed.
The WHO norm says that there should be at least 5 beds per 1,000 population. According to the Department-Related Parliamentary Standing Committee on Health and Family Welfare, 2020, in terms of the government hospital beds, in India, there are mere 0.5 beds for every 1,000 population.
The commission found that there was a significant shortfall in the number of centres required, ranging from 23 per cent for sub-centres to 28 per cent for Primary Healthcare Centres (PHCs) to 37 per cent for Community Healthcare Centres (CHCs). There is severe deficit of public health facilities in Bihar, Jharkhand, Uttar Pradesh and West Bengal, it said.
According to the Rural Health Statistics, 2019-20 released by the Ministry of Health and Family Welfare in May 2021, there is a shortfall of 78.9 per cent of Surgeons, 69.7 per cent of Obstetricians and Gynecologists, 78.2 per cent of Physicians and 78.2 per cent of Pediatricians in rural areas which, as per the Population Census 2011, has almost 69 per cent of the total population of the country.
High Out-Of-Pocket Medical Expenditure And Unequal Access To Healthcare
According to the Union Budget 2021-22, the public health expenditure in the country is just 1.2 per cent of the GDP (Gross Domestic Product) and is among the lowest in the world, lower even that of other South Asian countries like Sri Lanka (1.6 per cent) and Bhutan (3.5) per cent. The Economic Survey has strongly recommended increasing the public health spending to 2.5-3 per cent of GDP as recommended in the National Health Policy 2017 and said that increased public spending can decrease the out-of-pocket expenditure to 30 per cent.
According to the Economic Survey 2020-21, in India, 65 per cent of the overall health expenditure is out-of-pocket which is very high as compared to the world average of 18.2 per cent. It observed that bulk of the healthcare in India is provided by the private sector which is more expensive than the government facilities.
Private hospitals charge much higher than government hospitals for treatment of same ailment and higher charges do not assure better quality, it said.
The findings of the first phase of the National Family Health Survey, round 5 (NFHS-5) has also highlighted that average out of pocket expenditure for delivery in a public health facility has risen in 10 states and two Union Territories. Commenting on this, Dr Jain said that the available data of NFHS-5 reflects the situation before COVID-19 hit, and so the numbers are likely to be worse now as the country fights Covid. NITI Ayog has highlighted that because of high out-of-pocket expenditure, 6.3 crore people fall into poverty every year.
The government has also recognised the rising costs of healthcare and has been running a few schemes to deal with this –
• Ayushman Bharat- Pradhan Mantri Jan Arogya Yojna (PMJAY) that aims at providing a health cover of Rs. 5 lakhs per family per year for hospitalization to the poor
• Janani-Shishu Suraksha Karyakram (JSSK) under the National Health Mission (NHM) aims to make maternal services more accessible and affordable by providing free institutional deliveries, free medicines, free diagnosis at Government health facilities
• Surakshit Matritva Aashwasan is committed to provide assured, dignified, respectful and quality healthcare, at no cost to women and newborn at public healthcare facility.
• National Health Mission Free Drugs Service Initiative which provides essential drugs free of cost in public health facilities
However, out of pocket expenditure remains high and is still rising, say experts, adding that these schemes seem to be not working as efficiently as required. In September 2020, Oxfam’s ‘Commitment to Reducing Inequality’ Report ranked India fourth from the bottom in terms of expenditure on health. Mr Behar said,
Out-of-pocket expenditure is one of the biggest reasons for people falling into poverty, leading to a vicious cycle of poor health outcomes and poverty. Every government has said that investment will be made in the health of 2-3 per cent of the GDP but in reality, this does not happen. The budget for the Ministry of Health and Family Welfare for 2021-22, the allocation was lower than what was for health in 2020-21. This shows that no lesson was learnt from the experience till now. COVID-19 also has exposed a lot of faults in our public health system. Ayushman Bharat is something that has certainly not worked. Insurance schemes cannot substitute the right to health. Out-of-pocket expenditure is something that is not covered by Ayushman Bharat. Most of the cost that usually people incur are on diagnostic, medicines which is not getting covered here. Also, of the total admission, 65 per cent of claims were paid till last year. This means that 35 per cent of people who were admitted and wanted the claims were not paid.
Oxfam India’s ‘India Inequality Report 2021: India’s Unequal Health Story’ also highlgihts how the people from general category are better off in terms of access to health than people from the Scheduled Castes and Scheduled Tribes. It also revealed that Hindus perform better than Muslims, the rich perform better than the poor, men are better off than women, and the urban population is better off than the rural population on various health indicators such as life expectancy, infant mortality rate and nutrition.
Health in India is a luxury that can be afforded by the rich and those in the mainstream. The marginalised who face more vulnerabilities due to poor housing, lack of adequate sanitation, use of biomass as fuel, however, are still away from the health equity, said Dr Jain.
In A Country Where Healthcare Is A Luxury, Right To Health Is An Urgent Need Of The Hour: Experts
According to the experts, the COVID-19 pandemic should be a wake-up call, an alarm bell for universal access to health in the country where it is still a luxury and not a right. Mr Behar said,
It has been a devastating one and a half years. The second wave was absolutely heart wrenching to see people die, waiting for a bed but I still don’t see a serious rethink on what should be done on health. It is important to recognize that strong health laws will help build resilience to future pandemics. Three things that the country urgently need to do is- recognize right to health, fulfil the commitment of 2.5 per cent of GDP to be invested in health and focus on building public health infrastructure. Any public health insurance scheme can be an add on but not a replacement of the right to health.
In the past, various Members of Parliament (MPs) have introduced bills demanding right to health, state governments of states like Rajasthan, Chhattisgarh, Tamil Nadu have also talked considered the idea of right to health but nowhere in the country has it become a law yet.
NDTV – Dettol have been working towards a clean and healthy India since 2014 via Banega Swachh India initiative, which is helmed by Campaign Ambassador Amitabh Bachchan. The campaign aims to highlight the inter-dependency of humans and the environment, and of humans on one another with the focus on One Health, One Planet, One Future – Leaving No One Behind. It stresses on the need to take care of, and consider, everyone’s health in India – especially vulnerable communities – the LGBTQ population, indigenous people, India’s different tribes, ethnic and linguistic minorities, people with disabilities, migrants, geographically remote populations, gender and sexual minorities. In wake of the current COVID-19 pandemic, the need for WASH (Water, Sanitation and Hygiene) is reaffirmed as handwashing is one of the ways to prevent Coronavirus infection and other diseases. The campaign will continue to raise awareness on the same along with focussing on the importance of nutrition and healthcare for women and children, fight malnutrition, mental wellbeing, self care, science and health, adolescent health & gender awareness. Along with the health of people, the campaign has realised the need to also take care of the health of the eco-system. Our environment is fragile due to human activity, that is not only over-exploiting available resources, but also generating immense pollution as a result of using and extracting those resources. The imbalance has also led to immense biodiversity loss that has caused one of the biggest threats to human survival – climate change. It has now been described as a “code red for humanity.” The campaign will continue to cover issues like air pollution, waste management, plastic ban, manual scavenging and sanitation workers and menstrual hygiene. Banega Swasth India will also be taking forward the dream of Swasth Bharat, the campaign feels that only a Swachh or clean India where toilets are used and open defecation free (ODF) status achieved as part of the Swachh Bharat Abhiyan launched by Prime Minister Narendra Modi in 2014, can eradicate diseases like diahorrea and the country can become a Swasth or healthy India.