India's Healthcare in a Globalised World: Healthcare Workers’ and Patients’ Views of Delhi’s...

INDIA’S HEALTHCARE IN A

GLOBALISED WORLD:

Healthcare Workers’ and Patients’

Views of Delhi’s Public Health Services

A Collaboration Between

Hospital Employees UnionJobs with JusticeSociety for Labour and Development

July, 2007

Published by:Society for Labour and DevelopmentG-40, Jangpura Extn.New Delhi-110 014Tel. : 24322622

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Content of this report can be reproduced with due acknowledgement to thisPublication.

Acknowledgements i

Executive Summary iii

1. Motivation for Worker-Patient Study 1

2. Methodology of the Study 5

3. Health Policy in India 9

4. State of Health Care in Delhi 16

5. Health Sector and New Labour Jurisprudence 24

6. Right to Health in India: Arguments for Justice and Enforceability 30

7. Healthcare Reform Movement in the United States 36

8. Patients’ View of Delhi’s Public Health Services 44

9. Workers’ View of Delhi’s Public Health Services 52

10. Findings and Recommendations 71

References 77

Contents

Acknowledgements

Chapter One

This report is a collaboration between the Hospital Employees Union (HEU), Jobswith Justice (JwJ) and the Society for Labour and Development. This is the firsttime that a study is being done that includes both workers’ and patients’perspectives in healthcare in India. The collaborative effort builds on theHospital Employees Union’s experience with historic healthcare union strugglesin Delhi and Jobs with Justice’s experience with fighting for decent healthcarethrough coalition building among healthcare unions and patient communitiesin the United States.

Rajiv Agarwal, the General Secretary of HEU and also an eminent labour lawyer,must be commended for his openness to new perspectives and new ways ofworking at a time when the labour movement is on the retreat. Without hissupport, this research would not have taken place.

We are grateful to Fred Azcarate and Sarita Gupta of JwJ and to Tim Waters ofthe United Steel Workers who is also a Board Member of JwJ for being committedsupporters of this effort.

We are extremely fortunate to have had two excellent and experiencedresearchers conduct the research. They are Selvaraj Sakthivel and NawabWahabul Haque. Sakthi, the Senior Researcher and the primary architect of theproject, brought to it his deep understanding and experience as well as hiscommitment to social justice. Haque is an outstanding Field Researcher andconducted 500 surveys, under discouraging and difficult circumstances in theexhausting heat of Delhi’s summer, with a rigour that is hard to find.

Sakthi is the primary author of the report and it has benefited from his sharpanalysis and sympathy with ground realities. He has also demonstrated patienceand commitment in working with a union, which operates differently from aresearch organization.

Sanjoy Ghose, advocate in the Supreme Court, wrote the chapter on legaljurisprudence. His clear and intelligent analysis of how the judicial process hasrolled back legislated labour rights, gives us a concrete idea of the tasks beforeus.

Bobby Kunhu, a long-time activist on healthcare in India, a lawyer and aneducator, wrote the chapter on the arguments for the right to healthcare, fromthe perspective of justice and enforceability. His thoughts give us ideas on howto move forward for such a campaign.

Acknowledgements

i

Acknowledgements

Sarita Gupta, National Executive Director of Jobs with Justice in Washington,D.C. wrote the chapter on healthcare reform in the USA. She has played a keyrole in developing Jobs with Justice’s work in healthcare reform through coalitionbuilding between healthcare workers and patients’ communities; JwJ’s ownlessons from doing this work are useful to reflect on.

This report would not be in existence without the time given to us by the workersand patients of Delhi’s public health facilities. We are extremely grateful fortheir participation and are committed to building an inclusive and equitablehealthcare agenda.

I am honoured to have coordinated this project. As Secretary of HEU in Delhiand the International Organizer of JwJ, this project has enriched myunderstanding of how partnership with local organizations, based on equalityand mutual reciprocity, is the only way for global or international labour rightswork to ultimately find its feet on the ground.

Anannya BhattacharjeeSecretary, Central Committee of Hospital Employees UnionInternational Organizer, Jobs with Justice

ii

viiExecutive Summary

In India, indeed around the world, governments are increasingly abdicating theirresponsibilities towards their peoples and cutting back on basic services thatcitizens should be entitled to from their governments. Health, education,sanitation, water, and electricity are becoming profit making ventures ratherthan government services.

The healthcare industry is the world’s largest industry with global revenues ofan estimated 2.8 trillion USD. India is expected to become a major player dueto its high population, cheap labour, and skilled workforce. Yet, with India’sinsignificant coverage of social health insurance coupled with declining publicexpenditure and growing corporatization, household healthcare spending hasskyrocketed over the years. India is notorious as a developing economy wherehousehold out-of-pocket spending is extremely high. Two of the main reasonsfor untreated ailments are lack of facilities and the runaway cost of private healthcare.

Health workers and patients are two sides of the coin called the healthcareservice. The organizations partnering in this research project believe thatworkers and patients need to come together in addressing the issue ofhealthcare including working conditions and quality, accessibility, and adequacyof services. This study is the first attempt by a union taking leadership to bridgethis divide in India. It focuses on urban healthcare in Delhi, not forgettinghowever, that the vast majority of Indians live in rural areas.

People’s health is central to the nation’s prosperity and well-being. We face ahuge crisis today which can only be solved by bringing together communitiesthat access healthcare, workers who provide them, and governments andadministrations that control the delivery systems, along with human rightsgroups, legal experts, scholars, medical professionals, and policy makers. Theright to healthcare, labour rights and human rights are integrally linked. Wehope this study will help begin such conversations.

The study is based on a survey of public health care institutions in Delhi. Itwas conducted during June-August 2006 with the use of two questionnaires,one for the patients visiting the health care units and the other for the healthworkforce in these institutions. The total number of questionnaires wasrestricted to 500. Most of the hospitals under the Municipal Corporation of Delhi(MCD) and the Delhi Government were covered under the survey. In addition,we also visited smaller dispensaries/primary health centres/sub-centres.

Chapter One

Executive Summary

Background

Objective andMethodology

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viii Executive Summary

In order to understand the health care status of the country and the NationalCapital Territory of Delhi, we use secondary sources such as the SampleRegistration System (SRS) of the Registrar General of India; Directorate of HealthServices, Delhi; Health Information of India; Central Bureau of HealthIntelligence; and Government of India, and Delhi’s budget documents. Thisreport also makes use of the National Sample Survey Organisation (NSSO). Inorder to understand legal and international issues, other sources used are legalcases, international human rights documents and activist documents.

Chapter One explains the motivation for the study and the impact of neo-liberalpolicies on healthcare.

Chapter Two explains the methodology of the study including the healthcarefacilities covered and the breakdown of respondents.

Chapter Three traces the trajectory of India’s healthcare policies fromindependence till today, the gaps between responsible policies and vision andground realities, and the impact of global frameworks like TRIPS and GATS onhealthcare policies.

Chapter Four describes the status of healthcare in Delhi, including the variousinstitutions and authorities, and the current trends in healthcare financing andprovision under neo-liberal policies. It focuses on healthcare facilities as wellas associated issues like drug policies and diagnostics.

Chapter Five provides an analysis of the state of labour laws in India in thelight of recent judgements from the Supreme Court, and their implications forthe hospital industry.

Chapter Six provides a framework for developing a case for the Constitutionalright to health.

Chapter Seven gives us a look into the healthcare crisis in the United States. The US government and multinationals are at the forefront of privatization andcorporatization across the globe. Jobs with Justice shows us the other face ofAmerica – where people have some of the poorest health conditions in thedeveloped world and are fighting for just, accessible and affordable healthcare. The Jobs with Justice struggle for healthcare has revealed important lessons,which the chapter describes.

Delhi’s health care faces many of the same problems as the rest of the country,in spite of being the capital region. Delhi’s growth is enormous as are theattendant inequities.

Chapter Eight and Nine gives us an analysis of Delhi’s public healthcareinstitutions, based on our survey of workers and patients.

Structure of theReport

iv

ixExecutive Summary

We have found that:

� A significant portion of patients’ out-of-pocket spending goes into payingfor drugs and expensive diagnostic services. Services such as diagnosticswhich used to be free, have been outsourced to private companies thatcharge high fees. Opportunities for corruption have increased becausemedical practitioners often get commissions from the diagnostics servicesfor recommending patients to them.

� Departments such as security, kitchen, laundry and cleaning have beenpartially or fully contractualised. Contract workers are hired for performingtasks that were previously done by regular and permanent workers. Thestudy shows the dire situation of these workers, in terms of all aspects oflabour standards. 81% of contract workers are found among the lower paidworkers such as ward boys / ayahs, security guards, sweepers, etc. Labourcontracting has implications for both the quality and cost of the servicesas well as the working conditions of the service providers.

� Workers are poorly managed. Inadequate hiring of staff, preferentialtreatments, and unprofessional supervision result in arbitrary practices. Corruption takes hold as political influence and bribery keeps the poormanagement practices firmly in place. The end result is that patients aresubjected to overcrowding, long waits, absent workers, bribery, disrespectand rudeness. Workers face high workload, mismatch between job andskills, unfilled vacancies, corruption, lack of professional supervision, andlow morale.

� Social discrimination appears to be institutionalized within the public healthfacilities. Three fourth of the patients using public health facilities belongto lower castes or socially disenfranchised groups. Nearly sixty percent ofthe patients asserted that the healthcare staff is not polite and respectful,which is partly the result of social discrimination based on caste, classand economic status. Among the workers or service providers, the surveyshows that the same class and caste form the majority of the lower endworkers such as ward ayahs, ward boys, safai karamcharis (cleaners), andso on, while the upper castes dominate the higher end. This caste breakup is directly related to the level of exploitation as lower classes of workersare subjected to more discriminatory practices.

� The infrastructure of the public health institutions is shockingly poor. Over25 percent of patients find the drinking water unclean and over half ofthem find no water in the toilets. The presence of rats, inadequate suppliesand malfunctioning equipment add insult to injury for both workers andpatients. Both patients and service providers face poor sanitation,dangerous risk of further infection and illness from exposure to hospitals,and low morale.

� The patients’ communities and the public in general that use the publichealth services do not have avenues through which they can voice theiropinions and in fact have little awareness of rights and responsibilities ofgovernments.

v

x Executive Summary

� Labour organizations have not yet developed the practices required toaddress the severe crisis the workers face today, let alone the patientswith whom they have either no contact or an antagonistic relation. Workersappear to want to be part of organizations like unions in order to improvetheir professional lives. However, higher end workers are more organizedthan the lower end workers and this speaks to the need for building bettercohesion among hospital workers and better organizations. Contractworkers are a growing part of the workforce and any formation of workersat any level has to address their issues.

� The hospital and the larger governmental administration have failed todeliver to the public under the mandate given to them. As public healthservices for the vast majority suffer, they look to further gutting them,shifting public resources into private hands, and making conditions moreinsecure for workers and patients alike.

� Local politicians play a significant role in intervening negatively inadministration practices at various points. Often enough, their interventionmay supersede management priorities and public interest.

� Unwise and unjust macro policies have a major impact on healthcare: theseinclude judicial efforts to roll back labour protection and push hospitalsout of the realm of labour laws; drug policies that reduce the productionof essential drugs and make drugs a source of profit rather than cure;inadequate primary health care centres which put an additional burden onthe public hospitals; and a total lack of social health insurance which canhave catastrophic consequences for household budgets.

Chapter Ten gives the major findings and recommendations of the report. Itrecommends that representatives from communities that access healthcare,workers who provide them, and government and management (public or private)that control the delivery systems must develop a consultative, accountable, andtransparent process so that an effective and affordable healthcare system canbe built. Tripartite systems of grievance solving, transparent and enforceablestandards, and avenues for promoting public participation are essential.Coordinated and strategic multi-stakeholder platforms and initiatives musteventually lead to a movement for public accountability and build power forthe constitutional right to healthcare in India.

Findings andRecommendations

vi

Motivation for Worker-Patient Study 1

In India, indeed around the world, governments are increasingly abdicating theirresponsibilities towards their peoples and cutting back on basic services thatresidents of a nation should be entitled to from their governments. Health,education, sanitation, water, electricity, and so on are becoming profit makingventures rather than government services.

The healthcare industry is the world’s largest industry with global revenues ofan estimated 2.8 trillion USD. India is expected to become a major player dueto its high population, cheap labour, and skilled workforce. India is alreadythe sixth most privatized country in the world, in terms of healthcare. Yet, onlyten percent of the market potential of this industry has been tapped.

The Hospital Employees Union in Delhi, a public sector health workers union,is witnessing the disintegration of public health services and its effect onworkers. Across India, people’s health organizations have protested the grossinadequacies of the healthcare system. However, although unions and people’shealth organizations are dismayed by this growing crisis, the two rarely engagein a dialogue. Hospital unions limit their responsibilities to traditional workers’issues like wages and benefits and people’s health organizations focus on thecommunities that are served.

However, health workers and patients are two sides of the same coin. Theorganizations partnering in this research project believe that workers andpatients need to come together in addressing the issue of healthcare includingworking conditions, quality of services, accessibility of services, adequacy ofservices, and so on. This study is the first attempt by a union to bridge thisdivide. The study focuses on urban healthcare in Delhi, not forgetting however,that the vast majority of Indians live in rural areas.

Chapter One

Introduction

Neo-liberal IndiaNeo-liberal economic policies, since the 1980s, have uprooted welfare statesacross the globe, diminishing the role of the state in the delivery of basicservices and support to its people. The dominance of the market in all spheresof economic and social life is the core philosophy of the new economic policies.

Healthcare in India would have to be re-defined by an alliance between manysectors: unions and workers, patients, mass organizations, social justiceorganizations and human rights groups, scholars, medical professionals, and policymakers. The right to healthcare, labour rights, and human rights are integrallylinked. We hope this study will help begin such conversations.

Motivation for Worker-Patient Study2

The role of the state is restricted to minimal intervention such as–regulation andadjudication in times of disputes between different market players. Otherwise,state intervention in the economic sphere is considered to be a distortion.

The guiding principles behind the invisible hand of the market are price andprofit. Economic liberalization aims at removing all obstacles in the cross-bordermovement of trade and investment but places hurdles in the movement ofpeople between countries, particularly on unskilled workers. However, evenskilled professionals such as, say, physicians and nurses originating from Asia,are discriminated against in the United Kingdom where there is an obviouspreference for European health professionals. Division of and discriminationagainst labour is one of the cornerstones of the neo-liberal regime across theworld. The result is growing inequality between the developed and developingworld, between skilled and unskilled workers, and between the rich and poorwithin countries

India jumped on the bandwagon of liberalization in the early 1990s. Since then,numerous market-oriented economic policies have been put in place. One ofthe contentious issues in the ongoing reform process has been labour marketflexibility. The reformers argue that the current labour laws and stateinterventions in India are responsible for the slow growth of the economy andare the reasons for low investment and employment in the country.

The employers essentially seek ‘hire and fire’ polices and a free hand incontrolling trade union activities. Under these conditions, the employers arenot bound by either employment regulations or social security provisions likeprovident fund and pension rules. The main target of reform-seekers isabrogation of key provisions of the Industrial Disputes Act, 1947 (IDA, 1947).

In spite of the hype about restrictive labour laws, the Indian economy has beengrowing at a scorching pace of over seven percent in the last three years.Investment and employment have accelerated quite dramatically irrespective oflabour market reforms. Covert liberalization of the labour market is alreadyunderway. Firms are increasingly dispensing with permanent workers andreplacing them with temporary or contractual workers. This is taking place inboth the private sector as well as the public sector “either through outsourcingto other firms or directly recruiting more and more such ‘flexible’ workers.”1

Retrenchment and closure of units is happening without much successfulresistance from trade unions. In fact, recent evidence points to the decline inthe closure of units due to labour-led strikes and an increase in employer-ledlock-outs because of reasons such as non-payment of power tariff, non-paymentof loans, etc.

It is observed that ninety two percent of Indian workers are engaged as informalworkers. There is hardly any job security, social security is a misnomer andminimum wage provisions are invariably breached. Effectively, the provisionsof IDA, 1947 are in force in less than eight percent of units in India, out ofwhich a significant share is accounted for by public sector jobs. Impromptu1 Sharma (2005).

Motivation for Worker-Patient Study 3

labour market flexibility is already taking place in a significant way. In fact,“the fear of losing jobs has impelled unions to accept relocation, downsizing,productivity linked wages, freezes in allowances and benefits, voluntarysuspension of trade union rights for a specific period and commitment tomodernization” (Sharma 2004; Papola and Sharma 2005).

One often hears about the phrase ‘reforms with a human face.’ This impliesthat while economic reforms are carried out on market principles, the socialsectors get special attention from policy-makers. This would mean higherspending on health, education, water supply, sanitation and a protective netfor those who lose jobs in the process of structural adjustment.

However, health sector reforms typically involve privatization of provisioningas well as financing. This essentially means that health care delivery, bothinpatient and outpatient treatment, is left to the market forces. As far asfinancing is concerned, tax-funded government financing of the health sectoris replaced by out-of-pocket payments, borne by households and firms. Thepreventive and promotive aspects of health care are supposedly handled bythe public sector and curative care is left to the private sector.

While policy-makers rhetorically promise to enhance the share of publicspending in social sectors like health, evidence in the last one decade or sopoints to declining government expenditure. Public health expenditure (bothcentral and state government) as a percentage of GDP was well over one percent(the highest ever) in the mid-1980s but declined to less than one percent inthe mid-1990s and since then has remained stagnant at that level.

Given the insignificant coverage of social health insurance in the country,coupled with declining public expenditure, household out-of-pocket spendinghas skyrocketed over the years. Out-of-pocket (OOP) spending is an inefficientand unjust finance mechanism. Only those who can afford to pay can utilizethe health care system in a timely manner. Therefore, access to health care islimited by ability-to-pay. When this happens in the backdrop of a crumblingand dilapidated health infrastructure, households are in danger of falling intoa deep debt trap.

Neo-liberal policiesand Healthcare

Catastrophic health expenditure can devastate not only the poor but even themiddle class population, plunging them below poverty line. Many developing countriesare caught up in the triple-burden of disease: old and new infectious diseasesrefuse to die down while life-style diseases are increasing. New infectious diseaseslike HIV/AIDS, non-infectious diseases such as cancer, heart disease, diabetes, etc.can plunge households without insurance into a deep financial hole.

As a result of the gradual withdrawal of the state from the health sector, healthcare delivery is rapidly and significantly falling into the hands of profit-seekingprivate players. Households are increasingly being forced to seek care from

Motivation for Worker-Patient Study4

private health facilities. Nearly eighty percent of outpatient care and aroundsixty percent of inpatient (hospitalization) services were in the private domainin the year 2004, according to National Sample Survey (NSS, 2006) data.

Moreover, over the years, certain services in public health facilities have beeneither privatized or contracted out to private parties due to which patients whoseek treatment from public hospitals/centres are forced to pay out-of-pocketfor the services. These services mainly include drugs and diagnostics. Thisresults in significant cost to the patient because drugs account for seventy toeighty percent of outpatient expenditure and forty five to fifty percent ofinpatient treatment.

Two vital policy decisions in recent years have grave implication for the costsof medical care. For one, the private health insurance industry is now allowedto operate in the Indian health care market in the post-liberalization era. Yet,evidence all across the world points to the fact that medical costs invariablyescalate when private insurance is introduced. Secondly, the product patentregime has come into force in India, and is expected to push up drug pricesquite considerably. Therefore, access to drugs, which has not been a significantissue so far, is emerging as a big threat to health security in the country.

Parts of healthcare services that are gradually being privatized/contractualisedinclude diagnostics, nursing, cleaning (ward boys/ayahs, sweepers), kitchen,laundry, ambulance services, security, electrical works, etc. Apart fromincreasing the financial burden of households, privatization andcontractualisation of services have severely affected working conditions of healthworkers.

Another vital issue that is adding to the deterioration of India’s public healthservices is the significant erosion of skilled labour, such as, physicians, nurses,dentists and pharmacists who are gradually heading towards the private healthcare system. Given the heavy workload in public sector health care institutionsand the higher pay and incentive package offered by the private sector,dissatisfied and demoralised skilled talent is moving from the former to thelatter. An associated cost of this process is that the government is losing thereturns on its investment in educating these professionals.

Methodology of the Study 5

The twin objectives of the study are to understand

� working conditions of the health workforce in Delhi’s public health careinstitutions (health care institutions under the Municipal Corporation ofDelhi and the Delhi Government) and

� access to and quality of health care services in Delhi from the patientspoint of view.

The study is based on a survey of health care institutions in Delhi (a list ofhealth care institutions covered by the survey is provided in the followingpages). The survey was conducted during June-August, 2006 with the use oftwo questionnaires, one for the patients visiting the health care units and theother for the health workforce in these institutions. The total number ofquestionnaires was restricted to 500. Almost all hospitals under MCD and DelhiGovernment were covered under the survey. In addition, we visited smallerdispensaries/primary health centres/sub-centres.

The conditions and problems associated with the health workforce vary fromdoctors to ward boys. Therefore, due care has been taken to cover all types ofworkers in the health care institutions, such as doctors, nurses, pharmacists,ISM (Indian Systems of Medicine) practitioners, diagnostic personnel, wardboys/ayahs, sweepers, clerks, cooks, laundry workers, drivers, securitypersonnel, lift operators, etc.. The sample distribution of workforce covered andtheir respective number of samples are depicted in the following Chart 1. Thetotal number surveyed among the health workforce of Delhi was 400.

Chart 2 brings together the sample distribution and number of samplesadministered among the patients visiting these health care institutions. Thenumber of samples administered among both inpatients and outpatients were50 each, covering all institutions mentioned below (in all 100 patients weresurveyed). The survey covered all types of wards in hospitals/dispensaries,such as general ward, special ward, maternity ward, emergency care, etc. Sincethe conditions of treatment vary from allopathy to ISM (homeopathy, ayurveda,unani, siddha, etc.) the sample design was structured to include both allopathyand ISM systems, and the number of samples differs according to the weightof each.

Among the health workforce, the survey collected data relating to socio-economic characteristics, employment particulars, working conditions of theworkers, wage/salary structure, case-load handled by the employees/workers,

Chapter Two

Survey Design ofData Collection

Methodology of the Study6

particulars of union activity among different sections of workers, workers’knowledge of privatization/contractualisation, etc.

On the other hand, the questionnaire administered among the patients includessocio-economic data of the patients, particulars of medical treatment receivedas inpatient of a hospital in the last one year (365 days), particulars of treatmentreceived as outpatient of a hospital/dispensary in the last one year (365 days),number of facilities available/availed, the quality of service available/availedby the patients and other conditions of hospitals/dispensaries.

Chart 1

TTTTType ofype ofype ofype ofype of WWWWWorkorkorkorkorkererererersssss(Samp(Samp(Samp(Samp(Sampllllleeeees)s)s)s)s)

1) Allopathy Doctors (7)

2) Nurses (15)

3) ISM Doctors/Nurses (7)

4) Diagnostic Personnel (10)

5) Pharmacists (7)

6) Ward Boys/Ayahs (35)

7) Sweepers (30)

8) Clerks (15)

9) Cooks (7)

10) Washerman (7)

11) Security Personnel (15)



2) Nurses (15)


4) Diagnostic Personnel (10)

5) Pharmacists (8)


7) Sweepers (30)

8) Clerks (15)

9) Cooks (10)

10) Washerman (5)

11) Drivers (8)

12) Administrative Assistants (8)

13) Security Personnel (15)



2) Nurses (10)


4) Pharmacists (5)


6) Sweepers (20)

Methodology of the Study 7

In order to understand the health care status of the country and the NationalCapital Territory, we draw data from the Sample Registration System (SRS) ofthe Registrar General of India. Specific data relating to the number of healthcare institutions are obtained from the Directorate of Health Services, Delhi. Inaddition, various issues of Health Information of India, Central Bureau of HealthIntelligence, Government of India, and Delhi’s budget documents (Demand forGrants) for respective years were used in this report. The report also drawssubstantially from unit level household data of quinquennial consumerexpenditure surveys (50th round of NSS- 1993-94 and 1999-00). This data helpsus in understanding the level and growth of out-of-pocket health expenditurein the country as well as in the National Capital Territory of Delhi.

This report also makes use of the decennial survey by the National SampleSurvey Organisation (NSSO) on the issue of morbidity and health care in India,conducted in the 60th round of NSS, during 2004. The 60th round survey coversaspects that are part of the earlier health care surveys, such as, 42nd round(1986-87) and 52nd round (1995-96). The survey covers broad areas such asmorbidity and utilization of the curative health care services including maternitycare and immunization, outpatient and inpatient treatment of ailing persons,expenditure incurred on treatment of ailments and the problems of the elderly.

The 60th round survey of NSS was carried out by interview method using arecall period for short-term duration ailments at fifteen days preceding the dateof survey; the reference period for hospitalized treatment was 365 dayspreceding the date of enquiry. The 60th survey spans the period January-June,2004, and is spread over two sub-rounds of three months each.

Secondary DataSource

Chart 2

Methodology of the Study8

The NSSO adopted a two-stage stratified sampling design, in which First-Stage-Units (FSUs) were villages and blocks in rural and urban areas respectively,while the Second-Stage-Units (SSUs) were households from chosen rural villagesand urban blocks. The number of FSUs covered by the central sample were4,755 and 2,668 (7,663 and 4,991 during 1995-96) for respective village andurban blocks. As far as SSUs are concerned, the number of householdssurveyed were 47,302 and 26,566 (71,284 and 49,658 during 1995-96)respectively for rural and urban areas.

Delhi Government Hospitals

1. Ram Manohar Lohia Hospital

2. Deen Dayal Upadhyaya Hospital

3. G.B.Pant Hospital

4. Guru Tegh Bahadur Hospital

5. Lal Bahadur Shastri Hospital

MCD Hospitals

1. Hindu Rao Hospital

2. Kasturba Hospital

3. Ratan Babu TB Hospital

4. Maharishi Dayanand Hospital

5. Swami Dayanand Hospital

Dispensaries

1. East Patel Nagar Dispensary

2. Kalidas Hospital Gulabi Bagh. (Homoepathic)

3. Laxmi Nagar Dispensary (Homoepathic)

4. Sadipur Dispensary

5. Zakhira Dispensary (MCD)

6. Seemapuri Dispensary (Homoeopathic)

7. Jahangirpuri Dispensary (Homoepathic)

8. Kalkaji Dispensary

9. Hindu Rao Dispensary (MCD)

10. Patpar Ganj Dispensary

11. Krishna Nagar Dispensary (Homoepathic)

12. Wazirpur Dispensary (MCD)

13. Karampura Dispensary

14. Malaviya Nagar Dispensary

15. Seelampur Dispensary

16. Hauz Khas Dispensary (MCD)

List of Hospitals/DispensariesSurveyed for thepresent study

Health Policy in India 9

Chapter Three

The post-colonial economies of the 1950s viewed the state as the dominantmode of development. The state was supposed to play a leading role in shapingthe national health system by ushering in proactive policies and strategies. The Bhore Committee of 1946 had set the stage in recognizing the role of state. The state was to take the lead in health provisioning and financing. The BhoreCommittee derived its essence from the model of Britain’s National HealthService (NHS) which is predominantly state-run. Unfortunately, India’s publichealth care system is deviating from this lead role as the state has begun towithdraw from health care services since the 1980s and more specifically fromthe early 1990s, with the initiation of privatization-liberalisation-globalisationpolicies. Today, India’s health care services are driven substantially by privateprovision and financing.

Tracing theTrajectory ofHealth Policy inIndia

Post-colonial vision

The first two FiveYear Plans (1951-56 and 1956-61), based on the BhoreCommittee report, emphasized the development of basic health infrastructureand skilled personnel. But the notable development that took place during theFirst Five Year Plan was the launching of vertical programmes under whichdisease-wise programmes and targets were fixed. These included: controlprogramme on malaria, tuberculosis, filariasis, leprosy and venereal diseases. By creating such a vertical programme, the integration of the health systemsuffered.

However, the third plan (1961-66) witnessed a major shift of focus frompreventive health services towards family planning. Intensification of the familyplanning programme (essentially population control programme) reached itspeak during the National Emergency (1976-77). During this period, in the nameof family planning, forcible population control methods were adopted.

Another shift in focus towards universal health services and against verticalprogrammes was articulated in 1978 at Alma Ata where the World Health

The Bhore Committee recommended a health care system catering to the economically andsocially deprived and vulnerable sections of society. The structure of health services envisagedwas strong primary level care with referral linkages to secondary and tertiary care. Sinceaccess to drugs is a crucial component of any health system, the Bhore Committee stronglyurged the then government to invest heavily in developing an indigenous pharmaceuticalindustry. It strongly advocated the principle of universality and equality in access tohealth services as large sections of the people were living in abject poverty.

Health Policy in India10

Organisation (WHO) initiated the World Health Assembly. The Alma AtaDeclaration brought back the primacy of Primary Health Care. The goal of “Healthfor All by 2000” by the Alma Ata Declaration and the ICMR/ICSSR report (1980)were a watershed in the development policies. The National Health Policy of1983 incorporated some of the suggestions made at Alma Ata and madecomprehensive and universal provision of health services the main focus. Unfortunately, the policy remains on paper till date. In actual practice, thecountry witnessed re-introduction of programme-driven policies and verticality. The emphasis then shifted towards technical health interventions that gaveprimacy to immunization, oral rehydration, breastfeeding and anti-malarial drugs.

Although the entry of the private sector in health services was happeninggradually, it sped up greatly from the early 1990s. The withdrawal of the statefrom health services is almost complete now. The sharp and substantial declinein state funding of the health sector (both at central and state level) which wasinitiated in the early 1990s as part of ‘fiscal disciplining’ under structuraladjustment policies of the government is still underway.

In spite of this development, the intention of the National Health Policy (NHP),2002 cannot be faulted. It underscores the imperative of moving away fromvertical programmes towards programme integration. The NHP, 2002 calls forstrengthening health infrastructure, provision of universal health services,decentralization through panchayati raj institutions and private health careregulation.

The present government has launched a National Rural Health Mission (NRHM). The main resolve of this Mission is to set right the basic health care deliverysystem in the country.

Today’s Promises

The NRHM adopts a synergistic approach involving an inter-sectoral model with nutrition,sanitation, hygiene and safe drinking water along with good health as integralcomponents. This is to be achieved with District Health Plans, outlined by the DistrictHealth Missions. The NRHM is expected to initially cover only 18 states that havedismal public health indicators and/or weak infrastructure.

The NRHM proposes to integrate all National Disease Control Programmes forimproved programme delivery, launch new initiatives to control increasing life-style diseases, strengthen the disease surveillance system and bring the IndianSystem of Medicine (ISM) into the mainstream. It intends to stem the declineof public expenditure and increase it from one percent of GDP to two to threepercent of GDP in a few years, reduce regional imbalances in healthinfrastructure, strengthen existing Primary Health Centres (PHCs) and CommunityHealth Centres (CHCs) and provide CHCs with thirty to fifty beds for every1,00,000 population for curative care.

The NRHM also aims to professionalise the governance of healthcare, by


inducting management and financial personnel into the health system at thedistrict level, upgrade capacity-building of panchayati raj institutions so thatpublic health services could be managed efficiently in a more de-centralisedmanner, and introduce ASHAs (Accredited Social Health Activists), who wouldinterface between the public health system and community.

In terms of private sector delivery and insurance, the NRHM would encouragepublic-private partnerships (PPPs) keeping in view public health goals, seekregulation of the rapidly growing private sector health care, and ensure properaccess, affordability and accountability of health care, by putting in place asocial health insurance system for effective and viable risk pooling.

Lack of motivation plays a negative role in the mismanagement of the healthworkforce. Mismatch of skills is widely prevalent. It is commonplace to notepostgraduate medical students recruited and placed at PHCs where their skillsare of little relevance. Transfers of health workers are often arbitrary andmisused by politicians and the ruling class, justifying the image of the overallhealth system as inefficient and corrupt.

Absenteeism from the workplace is another major impediment to public healthcare. Although absenteeism is a major issue among all levels of healthpersonnel, it is worst among doctors. Health personnel, particularly the doctors,are often known to moonlight and engage in private practice. Apart from themoral and ethical issues involved, moonlighting breeds inefficiency andcorruption in the system.

Globally, the drug industry is one of the most manipulated sectors leading tomega profits. Recognizing the importance of the drug industry and thecomplications arising out of manipulations, the industry is subject to controlsand regulations. A host of policy instruments are exercised to rein in drug pricesfrom rising to unreasonable levels. Such controls take the following forms: capon mark-up, fixed margins to wholesalers/pharmacists, price freezes,reimbursements, contributions to insurance premium, etc.

India’s tryst with statutory control on drugs dates back to 1962. However, owingto criticism from the industry (then controlled largely by MNCs with the domesticindustry having hardly any market share), the then government made changesin the statutory control. Subsequently, the government identified a list of 18essential drugs and referred them to the Tariff Commission. The Drug PriceControl Order, the first of its kind, was introduced in 1970. It was meant tokeep the prices of drugs at affordable levels while ensuring that the manufactu-rers received reasonable returns. The then Order applied to 347 bulk drugs.

In 1975, a broad-based drug policy was formulated on the recommendations ofthe Hathi Committee Report. The government announced the Drug (Price Control)Policy, 1979 whose key objectives were to:

i) ensure adequate drug availability;

Policies toRegulate HumanResources/Drugs/MedicalTechnology

Lack of policies forhuman resourcedevelopment

Drug ControlPolicies


ii) provide drugs at affordable prices;

iii) achieve self-sufficiency in production and self-reliance in drug technology.

However, over the years the controls are being gradually dismantled and thenumber of bulk drugs that were under price control has been brought down toa minimum level.

Medical DeviceTechnology

Global HealthPolicy Changes

Trade RelatedIntellectualProperty Rights(TRIPS under WTO)

In 1979, 347 bulk drugs were under the Price Control Order; the number camedown to 142 in 1987. Drastically pruning the list further, the Drug Price ControlOrder of 1995 sought to limit the control list to just 76 drugs which account forjust one-fourth of the total market.

Along with gradual reduction in the number of drugs under price control, certainprocedures were greatly simplified and coverage of price-controlled drugsunderwent enormous changes over the years.

With the spread of information technology, medical device technology is gainingmomentum across the globe. However, medical device technology has hugecosts associated with it. The misuse of such technology often raises not onlyethical and moral questions, but has significant social ramifications. The classiccase is the misuse of sonography for sex determination tests of the fetus. Several Indian states such as the north Indian states of Punjab, Haryana andDelhi has been witnessing rapid and substantial decline in sex ratios. Recentevidence from the capital’s poshest south Delhi colonies reported one of theworst sex ratios of less then eight hundred females per one thousand males. Therefore, it is pertinent on the part of regulatory authorities to stamp out suchpractices. Although there is a policy of regulation of diagnostics for sexdetermination of the fetus, at the ground level there have been no tangibleresults so far.

With the spread of private health insurance in India, medical bills are escalating.The problem of over-use and unnecessary medical tests, even for apparentlysimple health problems, is resulting in bloated medical costs. This problem isexacerbated by the outsourcing of such tests in public health facilities. Thecollusion between medical practitioners, diagnostic service providers and theinsurance companies is clearly leading to high medical costs. It is well-knownthat many medical practitioners in both the public and private sectors haveinformal contracts with private providers of diagnostic services that yield thema commission on each referral made to the concerned diagnostic serviceprovider.

The Patents Act, 1970 which has been instrumental in encouraging anddeveloping the indigenous drug industry and containing medicine prices, isunder threat since the establishment of WTO in 1995. Under the TRIPS, WTOmember countries including India are supposed to change over to a morestringent patent regime. The TRIPS requires member countries to change their


legislation in such a way that they grant product patent to the pharmaceutical,chemical, food and agricultural sectors as well. The period of product patentrights is to be changed in the Indian case from seven to twenty years.

General Agreementon Trade inServices (GATSunder WTO)

The General Agreement on Trade in Services (GATS) is the first of its kind in thearena of multilateral trade agreements which would cover trade in services suchas health services of nurses, doctors, etc.

Health services under WTO broadly cover the following:

a) Professional Services – to include medical and dental services; servicesprovided by midwives, nurses, physiotherapists and para-medicalpersonnel; and

b) Health Services – to include hospital services; human health services andsocial services.

Trade in services under the GATS is covered under four items called Modes.

I) Cross-border Supply or Outsourcing (Mode 1): This is outsourced healthwork from developed countries to developing countries such astelemedicine, medical transcription, teleradiology, telepathology, etc. GivenIndia’s strength in high technical skills including information technologyand in the backdrop of successful BPO operations, there appears to beenough potential to tap the global market for such services. Alongside,the pharmaceutical business is also exploring research and developmentcapacities in India.

II) Consumption Abroad or Medical Tourism (Mode 2): In the Indian context,this is medical/health tourism. With the phenomenal expansion in worldclass private corporate hospitals in India in recent years, along with theemergence of the Indian System of Medicine, medical tourism has attractedsubstantial business and is likely to grow rapidly in the coming years. Inview of India’s strength in relatively low cost but high quality healthservices for people from developed economies, medical tourism is expectedto garner big business and attract significant foreign exchange earnings.Apart from foreign business that high end health services attract, placeslike Kerala attract domestic tourists as well to cater to Indian systems ofmedicine, such as, naturopathy, siddha, ayurveda, etc..

Since the 1970s, India had been following a process patent regime. While a processpatent is provided to the inventor of drugs using an innovative process, the productpatent, on the other hand, hands out monopoly power to the innovator for theproduct itself. This allows for the innovator company to indulge in monopoly pricesand profit for a 20-year long period. The provision of compulsory licensing (under thenew dispensation) can be harnessed only when there is a clear case of nationaldisaster or emergency.


III) Commercial Presence or FDI in Health (Mode 3): India already allows foreigncommercial presence because it allows hundred percent foreign directinvestment in health – a liberal policy compared to the restricted practicesof other countries.

IV) Presence or Movement of Natural Persons or Labour Migration (Mode 4):This facilitates Indian health professionals (doctors, nurses, pharmacists)to move to most of the developed economies, where there exist severeshortages of skilled personnel. The shortages that exists now and are likelyto rise are due to the ageing workforce in the developed economies. However, there are several and significant impediments to the freemovement of labour. For instance, recent policy pronouncements inBritain’s NHS suggest that the recruitment policy for nurses in Britain islikely to be biased against non-Europeans. Britain’s NHS is likely to providefirst preference to British nurses, followed by Europeans, thereby signalinga non-tariff barrier in health care services.

The pace of urbanization in India has been phenomenal, particularly in the lastone decade, in terms of urban population and area. According to Census 2001,over one-fourth of the Indian population (28 percent or285 million) lives in urbanareas, growing rapidly at a pace of 3.12 percent per annum as against ruralpopulation growth of 1.79 percent per annum. It is estimated that a mega citylike Delhi has witnessed a massive 4 percent growth and with it the slumpopulation has grown by 5-6 percent.

Urban HealthHazards

The phenomenal expansion in urban population is due to various reasons: i) everenlarging boundaries of cities; ii) significant inward migration into cities in searchof jobs; iii) natural rise in urban population. The slum population which is a reflectionof urban poverty has been rising rapidly. Estimates suggest that as a proportion oftotal poverty, the urban component of poverty has risen to almost 25 percent in themid-1990s as against 15 percent in the early 1970s.

India’s urban areas are increasingly becoming vulnerable to the ‘triple burdenof disease.’

� While infectious disease like cholera, malaria, diarrhea, dengue, etc.continue, new infectious diseases are emerging due to complete neglectof sanitation and clean drinking water. This applies to not only slums, butalso to many middle-class areas. Along with it, under-nutrition continuesto be a major problem which increases the vulnerability of the poor andworking class population.

� Rapid urbanization and industrialization is causing an unprecedented risein life-style diseases, such as, diabetes, heart diseases, cancers, mentaldisorders, etc. Treatments for life-style diseases are not only extremelycostly, but also leads to reduction in productivity, loss of income and


disability. Catastrophic health expenditure is directly linked to life-stylediseases. With little or virtually no universal health insurance, the urbanpopulation including the middle class are left to fend for themselves.

� Another problem that urbanization faces is the rise in accidents andinjuries. Delhi, which contains three-fourths of the total cars in the country,has high mortality and disability rates arising from accidents. India’s urbanhealth system is unable to cope with the number of cases. The need fortrauma care has only recently been recognized in policy circles; so far ithas been the preserve of the private health care system.

The National Health Policy, 2002 prescribed an organized primary health carestructure in urban areas. Given the diversity and heterogeneity of populationin the urban areas, the need to have different population norms was felt.

National HealthPolicy, 2002

The two tiered structure proposed in the NHP-2002 envisaged:

a) a first-tier, in which the primary structure ensure that 100,000 people benefitfrom all the national health programmes. The primary health center is supposedto provide OPD (out patient department) facility and essential drugs; while

b) the second tier is the government general hospital which acts as a referral fromthe first-tier.

The funding for the scheme was to come from all three executive machineries:centre, states and local governments. Recognizing the importance of reducingmortality arising out of accidents, NHP-2002 envisaged the establishment oftrauma care networks across large urban agglomerations.

State of Health Care in Delhi16

Delhi’s health care faces many of the same problems as the rest of the country,in spite of being the capital region. Delhi’s growth is enormous as are theattendant inequities. It too faces a declining share of public health institutionsin both outpatient and inpatient care, an explosion of private facilities andoutsourcing. The absence of a universal social health insurance system andthe alarmingly rising household out-of-pocket (OOP) spending can plunge asizeable section of even the well-off into poverty. New and expensive medicaldevice technology and the rising cost of drugs due to deregulation of pricecontrol are adding to the spiraling cost of healthcare.

Public health facilities suffer from unfilled vacancies and absenteeism of healthworkforce, shortage of medicines and supplies, etc. Private insurance ischaracterized by adverse selection, moral hazards, cost escalation, skimming,skimping, etc. Apart from bloating administrative expenses of the insurancecompanies, private insurance is an intermediary between households and healthcare providers, firms and health care providers, etc. Financially, theestablishment of Third Party Administrators (TPA) has become one moreadditional cost burden that insurance holders have to bear.

Delhi boasts of higher mean life expectancy of around 70 years compared tothe national average of roughly 63 years. Delhi’s death rate of 5 per 1000population is among the lowest in India. The Infant Mortality Rate (IMR) is notonly low in Delhi but falling steadily over the years. In 2002, IMR in Delhi was30 as against 63 per 1000 live births in India. Another striking feature of Delhi’shealth status is its Total Fertility Rate which is 1.6, in fact, lower than Kerala’s1.8 and well below the national replacement rate. (SRS, 2002)

Further, from the 1998-99 National Family Health Survey, we observe that 84percent of mothers received at least one ante-natal check-up, and 73.1 percentreceived three ante-natal check-ups in Delhi, while 78 percent of mothersreceived iron and folic acid supplementation. It is interesting to note that 59percent of births in Delhi were delivered in medical facilities and 35 percentwere delivered in the respondent’s own home. Among births delivered at therespondent’s home, 19 percent were assisted by a health professional and 76percent by a traditional birth attendant.

Delhi’s health system is characterized by multiple public and private providersof health care. It is estimated that Delhi, with a total population of over oneand a half crores (15,000,000), has 2183 hospitals, 932 dispensaries and roughly550 registered nursing homes and 1560 unregistered nursing homes.

Chapter Four

Introduction

Health Status ofDelhi

Health CareInstitutions inDelhi

State of Health Care in Delhi 17

The Department of Health and Family Welfare in the state is the major playerwith its network of over 30 hospitals (including 3 ISM&H hospitals), 174allopathic dispensaries, 70 mobile van dispensaries, 433 school health clinics,20 Ayurvedic dispensaries, 62 homoepathic dispensaries and 8 Unanidispensaries.

In the private sector, as of 2004, there were 550 registered private hospitalsand nursing homes with 12,000 hospital beds. Delhi also has a strong networkof charitable non-profit institutions. (Delhi Human Development Report (DHDR),Draft Report).

The public health system in Delhi falls under multiple organs since the state is unique inthe sense that the administration falls under the control of both the state and centralgovernment. The most important are:� Delhi Government’s Department of Health and Family Welfare� Municipal Corporation of Delhi (MCD)� New Delhi Municipal Council (NDMC)� Central Government

Table 4.1Number of Health Care Institutions in Delhi

Sl. Organization Hospi- No. of Dispen- Allopa- Homoeo Ayur Unani SHS MHS MCWC TotalNo. tals Beds saries thic

1 Delhi Govt 31 6388 378 180 51 12 0 63 72 0 378

2 MCD 15 3625 274 37 14 99 15 0 0 109 274

3 NDMC 2 200 45 11 12 10 12 45

4 ESIC 4 1000 34 34 34

5 Central Govt. 10 3840 99 84 11 3 1 99

6 Autonomous 6 2994 0 0

7 Defence 3 1850 1 1 1

8 DVB 0 24 24 24

9 DJB 0 15 14 1 15

10 DTC 0 27 27 27

11 SBI 0 9 9 9

12 RBI 0 8 8 8

13 Railways 2 466 12 12 12

14 BHEL 0 3 3 3

15 Indian Airlines 0 3 3 3

16 Regd. NH 550 12274 0

17 Unregd. NH 1560 5000 0

Total 2183 37637 932 447 88 125 16 63 72 121 932

Source: Municipal Corporation of Delhi, Government of Delhi.


Table 4.3Percentage of Spells of Ailments Treated by Source

State Percentage of Source of TreatmentAilments Treated Government Private

Delhi 95 23 77

India 89 19 81

Source : Government of India (2004), Morbidity, Health Care and the Condition ofthe Aged, January-June.Note : Ailments treated (non-institutional) during 15 days preceding the survey in urbanareas.

The recent national survey on health care by NSSO (2004) indicates that nearly15 percent of all illnesses go untreated in India. Two of the main reasons foruntreated ailments are lack of facilities and the runaway cost of private healthcare. Although inaccessibility to medical facilities was responsible for little over11 percent of untreated ailments in rural areas of the country, financial reasonsaccounted for well over 25 percent. In urban areas too, the cost of over-heatedprivate health care was responsible for 20 percent of untreated ailments.

Utilisation ofHealth CareInstitutions inDelhi

Untreated Illnesses

Table 4.2Percentage Distribution of Untreated Spells of Ailments

by Reason for No Treatment

Reason for No Treatment Rural Urban

2004 1995-96 1986-87 2004 1995-96 1986-87

No Medical Facility 12 9 3 1 1 0

Lack of Faith 3 4 2 2 5 2

Long Waiting 1 1 0 2 1 1

Financial Problem 28 24 15 20 21 10

Ailment Not Serious 32 52 75 50 60 81

Others 24 10 5 25 12 6

All 100 100 100 100 100 100

Source : Government of India (2004), Morbidity, Health Care and the Condition ofthe Aged, January-June

Privatisation ofOutpatient Care

The health care survey of NSSO (2004) further reveals that government healthcare facilities cater to only one-fifth or 20 percent of the total outpatientpopulation (non-hospitalised cases) in India. However, state-wise analysisdemonstrates growing insecurities as more and more people are pushed towardsthe expensive and unregulated private health care market, as shown in Table4.3. The picture in Delhi is gloomiest where the government’s share inoutpatient care has fallen quite sharply and is at less than one-fourth of thetotal outpatient care. The neglect of urban public health care nationwide isclearly palpable as the share of government institutions has declined drastically,most notably in the southern states.


Out of every 1000 persons, 11 were hospitalized in the state of Delhi during2004, which is far less than the all-India average of 31 for urban and 23 forrural (NSSO, 2006).

Privatisation ofInpatient Care

Table 4.4Number (Per 1000) of Hospitalised Cases Treated in

Public and Private Hospitals

State Government Hospital Private Hospital

Delhi 373 627

India 382 618

Source : Government of India (2004), Morbidity, Health Care and the Condition ofthe Aged, January-June.

Note : Number of hospitalized during 365 days preceding the survey in urban areas.

Evidence from the National Sample Survey, 2004 indicates that the majority ofpeople are now utilizing the private sector for inpatient care as well. As can beseen in Table 4.4, the share of public hospitals in hospitalization is little overone third of the total hospitalization cases.

Financing is the most critical element of a health system. While public financingis most equitable, a system that relies heavily on household OOP is mostinequitable. India is notorious for having the highest out-of-pocket expenditureamong the developing economies.

Estimates suggest that 71 percent of the health spendingin India is contributed by the private sector, of whichhouseholds spend 69 percent (National Health Accounts,2001-02). During 2001, India spent an estimated 4.8percent of its GDP on health care; households spent anestimated 3.3 percent of GDP. Of the total healthexpenditure in the country, the central, state and localgovernments spent 7.2 percent, 14.4 percent and 2.2 percentrespectively. Altogether public expenditure accounted forless than 25 per cent of total health expenditure.

Health CareFinance

While social insurance, largely by the Employees’ State Insurance Scheme (ESIS)and the Central Government Health Services (CGHS) accounts for around 2.36percent of health expenditure in India, the share of private insurance isestimated at less than one percent of the total health budget.


It is clear that the Indian health care system is dominated by the private sector,both in terms of provisioning and financing. NSS data on household consumerexpenditure suggests that households spend about 11 percent of their non-food consumption expenditure on health. On account of such an iniquitousfinancing system, catastrophic health expenditure plays havoc on householdsin both poor and middle-income groups, as the vast majority of the Indianpopulation is not covered by any social insurance schemes. Ninety three percentof India’s workforce is informal in nature, with meagre earnings and little accessto a network of institutional mechanisms.

Financing of health care is also rapidly falling under the private sector in India. In fact, the extent of this problem has reached serious proportions. It isestimated that three percent of GSDP is spent as health expenditure by a statein India. Ninety percent of this expenditure is borne by households whereasthe share of public spending to total health care expenditure is a paltry 8percent. High reliance on out-of-pocket expenditure of households reflects anextremely iniquitous system of health finance. Given high poverty levels, thepoor face a greater risk of falling ill because of poor nutrition, unhealthy livingand working conditions etc. and are forced to spend disproportionately onhealth care than the well-to-do. Access to health care becomes heavilydependent on ability to pay. With virtually no social insurance and a dilapidatedand decaying public health system, the predatory private health system wreakshavoc on the most vulnerable.

Chart 4.1National Health Accounts, 2001-02


Further, the above table demonstrates that Delhi’s per capita householdexpenditure is little over Rs. 1000, which is just above the average per capitaexpenditure for India as a whole. It is evident from the data that the differencebetween India’s average per capita public expenditure on health and that ofprivate expenditure is quite wide. However this is less true of Delhi. Per capitapublic expenditure on health in Delhi is double the national average. This isdue to the fact that most of the outpatient as well as inpatient services in publichospitals in Delhi are being gradually contracted out — services like diagnostics, drugs, etc. which drive overall expenditure. In other words,although these costs may appear as public expenditure since they occur throughthe public hospitals, in reality, the cost is actually borne by private individualsor patients. The other reason why private per capita expenditure on health inDelhi is lower than the all-India average is due to the fact that access to publicfacilities in terms of transportation is not an issue in the national capital region.

Table 4.5National Health Accounts

Public and Private Health Expenditure, 2001-02

State Public Expenditure Private Expenditure Total Expenditure

Health Expenditure in (Rs. ‘000)

Delhi 5,942,856 8,672,248 14,615,104

India 214,391,018 818,104,032 1,032,495,050

Per Capita Expenditure in Rs.

Delhi 426 622 1,048

India 207 790 997

Source : National Health Accounts, India, 2001-02

Table 4.6Average Medical and Other Expenditure Per Treated Person

During 15 Days by Source of Treatment

State Expenditure By Source of Treatment Other Total

Government Private All Expenditure Expenditure(in Rs)

Delhi 11 381 392 11 403

India 7 299 306 20 326

Source : Government of India (2004), Morbidity, Health Care and the Condition ofthe Aged, January-June.Note : Ailments treated (non-institutional) during 15 days preceding the survey in urbanareas.


Similarly, mean expenditure per episode of hospitalization in Delhi iscomparatively higher than the average all-India spending. The Table 4.8demonstrates the seriousness of the extremely high household spending thata person has to incur during an episode of hospitalization. Moreover, the meanexpenditure per hospitalization is not only high at Rs. 10,000 but the lossincurred due to per episode of hospitalization is also high. The financial burdenthat illness imposes on households in terms of productivity and income loss islikely to be greater among the lower income groups, as they possess little orvirtually no property to fall back upon in times of crisis. This causesindebtedness and further impoverishment.

Drugs and medicines form a substantial part of household OOP expenditure onhealth. Estimates from the 55th Consumer Expenditure Survey reveal that three-fourths of the OOP health expenditure is spent on drugs in rural and urbanIndia. The break-up of drug expenditure in outpatient and inpatient care showsthe following: the share of drugs to total outpatient treatment in rural India isas high as 83 percent while in urban India it is 77 percent. The respectiveshare of drugs in inpatient care in rural and urban India was roughly 56 and 47percent. In contrast, both central and state expenditure on procuring drugsamounts to as little as about 10 percent of the health budget.

At the same time, production priorities of the drug industry do not serve theinterests of the majority. Irrational, non-essential and hazardous drugs haveflooded the market.

Table 4.7Average Medical Expenditure Per Hospitalisation Case (in Rs)

Type of Hospital Rural Urban

2004 1995-96 1986-87 2004 1995-96 1986-87

Government 3238 2080 3877 2195

Private 7408 4300 11553 5344

All 5695 3202 8851 3921

Source : Government of India (2004), Morbidity, Health Care and the Condition ofthe Aged, January-June

Table 4.8Average Medical and Other Expenditure Per Hospitalisation

During 365 Days by Source of Treatment (In Rs.)

State Expenditure By Source of Treatment Other Total

Government Private All Expenditure Expenditure

Delhi 3,847 14,065 10,568 338 10,906

India 3,877 11,553 8,851 516 9,367

Source : Government of India (2004), Morbidity, Health Care and the Condition ofthe Aged, January-June.

Note : Per Hospitalisation Case during 365 days preceding the survey in urban areas.

Access toEssential Drugsand Medicines


Worldwide, drug prices are subject to controls and regulations. In India, DrugPrice Control Order (DPCO) is essentially based on sales turnover, marketturnover of companies, etc. rather than the criteria of ‘essentiality’. Over theyears, the number of bulk drugs under control has been slashed from 347 in1979 to 76 drugs in 1995. The new draft policy (Cabinet Note) on drugs offerssome hope, as all 345 essential drugs (under the National Essential Drugs List)are to be brought under price control. The drug industry, both domestic andforeign, is opposed to such a policy. Interestingly, the domestic industry tendsto side with civil societies when it comes to the TRIPS agenda, as it affectstheir bottom line.

Both the volume and cost of diagnostic services have shot up in recent times.Medical practitioners in both the public and private sector have informalcontracts with diagnostic service providers. Through these ‘informal contracts’,each of the referrals made by medical practitioners yields them a commission. Overuse of medical equipment, particularly in the corporate hospitals, hasbecome the norm, with the pressure to recoup large investments in the newmedical devices. A recent study (Varshney, 2004) notes the lop-sideddistribution of medical technology: 63 percent of the sample MRIs were locatedin five major cities (Bangalore, Chennai, Delhi, Hyderabad and Mumbai) whosepopulation accounts for 4.5 percent of India’s population.

The exclusive growth strategy followed since the early 1990s has only widenedthe socio-economic divide. On the other hand, an inclusive policy initiative callsfor affordable, accessible and decentralized public health services, be it primary,secondary or tertiary care.

The main national trends of healthcare are also reflected locally in Delhi. Bothoutpatient and inpatient care is dominated by the private sector. Theconsequence is that the escalating medical costs are borne by householdsdirectly. Contracting out services that are in the realm of public sector healthcareto private companies escalates the cost of healthcare for households.

The lack of regulation of private healthcare facilities leads to questionablequality, corruption and unnecessary inflation of costs. Along the same lines, apharmaceutical industry and policy that is based on corporate profit rather thanhealth needs leads to production of non-essential drugs and escalating costs.

DiagnosticServices

Conclusion

In 1999, out of the top ten drugs sold in the country, two belong to the category ofirrational vitamin combination and cough syrup, while the other drug is a useless liverdrug. Ten of the top 25 medicines sold in the market belonged to either one of thesecategories: blood tonic, cough expectorant, non-drug analgesics, nutrients, liver drugs, etc.which fall under the category of hazardous, irrational and non-essential drugs (NationalCommission on Macroeconomics and Health, 2005).

Health Sector and New Labour Jurisprudence24

Globalisation has led to an increased interest in the health care sector as asource of revenue and profit. There has been a rise in foreign investment inthe health sector and health insurance, a rise in health tourism (with pricedifferential in operative procedures attracting foreign patients to Indianhospitals), increasing “contractualisation”/hiving off of non-core services andincreasing hostility to the use of collective bargaining mechanisms such asstrikes in hospitals.

The hospital industry has faced certain challenging fundamental tests. The issueof whether a “hospital” is an “industry” at all (and therefore ruled by labourlaws in India) has been a vexed question with contrary judgements pronouncedby various courts. The Supreme Court in the Safdarjung Hospital Case2 heldthat a “hospital” did not fall within the definition of “industry”.

Then, the Supreme Court finally settled the issue in the Bangalore WaterSupply’s Case3 holding that a “hospital” was an “industry.”

The Parliament responded by amending the definition of “industry”4 andclarifying that the definition of “industry” would not include “hospitals ordispensaries”. At the same time, a bill had been introduced in the Lok Sabha5

to provide for a separate enactment to deal with hospitals. However, the LokSabha bill lapsed. The Parliamentary amendment also was not notified by theGovernment. Till date, the Court’s position from the Bangalore Water Supply’scase holds the field6 and hospitals remain an industry ruled by the IndustrialDisputes Act.

Chapter Five

Regulation ofLabour Laws inthe HospitalIndustry

1 This chapter is written by Sanjoy Ghose, advocate in Delhi. The substratum of this paper is influenced from anotherpublication of the author titled “The Supreme Court and New Industrial Jurisprudence” (2007) Lab IC 1 (Jour).

2 (1970)1SCC735

3 (1978)2SCC213.

4 Industrial Disputes (Amendment) Act, 1982 (Act 46 of 1982)

5 The Lower House of Parliament. A bill introduced in the lower house of parliament lapses with the dissolution of thehouse.

6 The Court in Union of India v Shree Gajanan Maharaj Sansthan (2002)5SCC44

Health Sector and New Labour Jurisprudence 25

The impact of liberalization of economic policy on the new or more recent labourjurisprudence of the Supreme Court is perhaps best evident from the orbiter(passing and legally superfluous remark) of the Court in State of U.P.vs. Jai BirSingh8 where the issue of definition of “industry” as per Section 2(j) of the I.D.Act has been referred for reconsideration to a larger bench, as the Court wasof the opinion that the decision in the Bangalore Water Supply case9 requiresa re-look given the present economic situation of the country.

The above case indicates how the Supreme Court has attempted to interpretthe legislative provisions in the context of economic policy and on the basis of“trends”. The Court states that the experience of the judges in the apex Courtis not derived from the case in question but from cases regularly coming to theSupreme Court through the Labour Courts. The Court states that there has beenan over-emphasis on the rights of the workers and an undue curtailment of therights of the employers to organize their business.

Trend of theSupreme Court

With globalization, there has been an increasing demand to re-look at the expansivedefinition of “industry” as per the Bangalore Water Supply case. The advocates ofglobalization argue that labour laws should be made more flexible, otherwise India wouldnot be viewed as a favourable investment destination. It is contended that labour lawssomehow encourage industrial indiscipline and impede efficient management. This viewhas been echoed in recent judgements of the Supreme Court7.

The new mantra is “exploitation of workers and employers have to be equally checked andparticularly industrial law needs to be so interpreted so as to ensure that neither the employeenor the employer are in a position to dominate the other”. This is a significant departure fromthe “old” jurisprudence which was premised on the assumption that the working class was theweaker party and, therefore equal treatment of both parties, while formally complying with theequality mandate, would be offensive to the guarantee of substantive equality enshrined inArticle 14 of the Constitution of India.

The challenge for the health care sector, in such circumstances, is to reinventan effective dispute resolution mechanism which would provide for healthworkers a measure of job security and access to legal remedies in mattersrelating to incidents of service (such as wages, denial of pay parity, duty hours,etc) as well as occupational hazards (such as sexual harassment in theworkplace).

7 See Hombe Gowda Educational Trust v State of Karntaka (1970)1SCC735

8 (2005)5SCC1 per Dharmadhikari J.

9 (1978)2SCC213.


The Industrial Disputes Act, 1947 has provided a veritable canvas serving as anoutlet for fertile judicial creativity. The most salient principles of industrialadjudication have evolved more through judicial decisions than by legislation.Therefore, the importance of the Court in the evolution and development ofindustrial jurisprudence cannot be overemphasized.

Take for example the concept of reinstatement of service with back wages inindustrial adjudication10. In the absence of a legal remedy for illegal terminationof a worker, the industrial adjudicator, through judicial exposition, was vestedwith the power to direct reinstatement of a worker whose termination was foundto be illegal. The unique power of an Industrial Adjudicator to create, alter,modify or change a contract of employment was noticed by the Federal Courtin Western India Automobile Association’s Case11 and this principle has beenrepeatedly reiterated in decisions of the successor Court in its early years12.

The other unique features of industrial adjudication, such as the inapplicabilityof strict laws of procedure and evidence13 as well as the bar on appearance oflegal practitioners,14 were all designed to meet the primary challenge inindustrial adjudication, namely to provide an even playing field for twofundamentally unequal disputants – workman and management. These featuresallowed workers to be able to represent their issues in a process whichotherwise could be prohibitively costly. It is for this reason that the unionsworking in health care have been seeking access to the remedies under the IDAct than having to resort to cumbersome civil suits or writs (in case of publichospitals).

The attraction of the ID Act remedy lay also in the fact that the IndustrialAdjudicator could grant the remedy of reinstatement and back-wages. The Court,however in recent cases, has now held that award of back wages is not the“normal” rule and that the workman would have to establish hisunemployment15. It is indeed a great challenge for labour law practitioners toestablish a proposition in the negative. For example, if workman “X” has toestablish that he is not employed, in theory, he would have to lead the evidenceof every employer and even potential employer in the world to depose that ‘X’

Positive Powersof IndustrialAdjudication

Supreme CourtOver-ridesPositive Powersof IndustrialAdjudication

10 Bharat Bank Ltd v Its Employees AIR1950SC188:1950SCR459.

11 1949FCR321.

12 JK Iron and Steel Co v Mazdoor Union AIR1956SC231, See also:

Bidi, Bidi Leaves’ and Tobacco Merchants Association vs. The State of Bombay [1961] 1 S.C.R. 381, N.M.C. Spg. & Wvg. Co.vs.Textile Labour Association AIR 1961 SC 867.

13 Grindlays Bank Ltd v Central Government Industrial Tribunal 1980SuppSCC420:AIR1981SC606. See also SindhuResettlement Corporation Ltd v Industrial Tribunal of Gujarat AIR1968SC529, (1968)1SCR515, Western India Match Companyv Industrial Tribunal Madras (1962)1LLJ629:(1962)4FLR180.

14 Section 36 ID Act, considered in Paradip Port Trust v Workmen (1977)2SCC339:AIR1977SC36.

15 Departure from the Three Judge decision in Hindustan Tin Works (P) Ltd v Employees (1979)2SCC80 is evidenced inHindustan Motors Ltd v Tapan Kumar Bhattacharya (2002)6SCC41, Indian Rly. Construction Co td v Ajay Kumar(2003)4SCC579, MPSEB v Jarina Bee (2003)6SCC141, Rattan Singh v Union of India (1997)11SCC396.


is not his servant. Certainly, the workman can, on the pain of perjury, deposeon affidavit that he is unemployed. It may well be asked that given the factthat his affidavit is “self serving”, why should he be believed as regards hisunemployment?

The novelty of industrial adjudication, as stated above, was the fact that aworker could obtain the relief of reinstatement as well as damages for wrongfultermination quantified in terms of back wages in a case where he was able todemonstrate that termination was not in accordance with law.

The “new” jurisprudence seems to favour compensationin lieu of back wages and also confines reinstatement tothe rarest of the rare, thereby reducing what was oncethe “norm” into just an exception16. The Court is nowalso considering further dilution to make the remedy notbe reinstatement or back wages or compensation, but bea payment of the notice pay and compensationcontemplated in the provision17.

The ID Act also provides for the facility of collective bargaining and strikes.This feature should be held precious by health care unions and the managementalike. While the health care unions would have access to facilities such ascollective negotiations and conciliation of disputes, the management could usethe ID Act to deal with the issue of strikes. If the hospitals were removed fromthe purview of the ID Act, the mechanism to regulate strikes and bargainingwould also be absent.

The growing problem of health workers arising out of “contractualisation” hasalso met with a blow in the SAIL case18 where the Court held that the WritCourt could not direct absorption of contract workers into the regular workforce.The case of Uma Devi proved to be even more fatal.

The new jurisprudence on regularisation has been set out in the ConstitutionBench decision in Uma Devi’s case19. The Court has held that no person hasthe right to be regularized. Uma Devi arose in the context of writ petitions beingallowed by the High Court directing the regularization of the services oftemporary/daily wage employees. The Supreme Court has not shownappreciation for the powers of an Industrial Tribunal to intervene in a contract

16 Rolston John v Central Government Industrial Tribunal cum Labour Court 1995Supp(4)SCC549:AIR1994SC131, Central P& D Institute Ltd v Union of India (2005)9SCC171: AIR2005SC633, Haryana Tourism Corporation Ltd v Fakir Chand(2003)8SCC248:AIR2003SC4465, MP State Agro Industries Development Corporation Ltd v SC Pandey (2006)2SCC716.

17 State of Punjab v Des Bandhu (2005)6SCC677.

18 (2001)7SCC1

19 (2006)4SCC1.


of employment as noticed by the Federal Court in Western India AutomobileAssociation20. The Constitution Bench also did not examine the impact of Item10 of Schedule V of the I.D. Act, which describes as being “unfair labourpractice” the employment of workman as Badli/casual or temporary andcontinuing them for years with the object of depriving them of the status andprivileges of permanent workman.

Interestingly, the way the Court dealt with the Uma Devi case does not haveanything to do with the propriety of engaging temporary workers for years onend and extracting work without making payment at par with regular counter-parts. The contrast between the “old” jurisprudence and the “new”jurisprudence is most startling in the obiter (passing remark) of P.K.Balasubramanyan J. which says that the argument based on Articles 14 and 23on exploitation and legitimate expectation cannot be accepted as the personaccepts the employment “with open eyes”— although he may not be in aposition to “bargain at arm’s length since he might have been searching forsome employment so as to eke out his livelihood and accepts whatever hegets.” This may be contrasted with the doctrine propounded by the Courtspeaking though P.N. Bhagwati J. (as his Lord Chief Justice then was) in theASIAD Workers case21 to the effect that Article 23 would operate even if theforced labour had its origin in a “voluntary” contract to perform service forless than minimum wages. This principle of “economic coercion” was appliedin the context of even famine relief work a year later22. What was applicable inthe context of minimum wages in the 1980s, given the passage of time and thegreat economic strides made by the nation, would surely apply to living wagesof today.

Therefore, health care workers who have been continued as ad hoc, temporaryor as leave substitutes for years on end are left with little succour.

Yet another aspect is the growing problem of sexual harassment at theworkplace faced by health workers. Presently, the ID Act mechanism offers littlesolace to such victims. Under the ID Act mechanism, only complaints oftermination from service can be directly filed by workers, for every thing else,espousal by a trade union is required. A trade union is sometimes patriarchalin its attitude and may not be willing to espouse a victim’s cause.

The last aspect is the growing tendency of the Court to favour a “pigeon hole”approach to the definition of “workman”. The Court has held that unless theworkman is able to bring himself within the categories specified in Section 2(s) of the ID Act, namely “manual”, “unskilled”, “skilled”, “technical”,

SexualHarrassment

Definition ofWorkman/Worker

20 Cited supra.

21 Peoples’ Union for Democratic Rights v Union of India (1982)3SCC235.

22 Sanjit Roy v State of Rajasthan (1983)1SCC525:AIR1983SC328


“operational”, “clerical” or “supervisory” he would stand excluded23. In thehealth sector, there may be a number of persons (such as trainee doctors) whomay need protection in service but who may fail to qualify under the presenttest of “workman”. Also while Bangalore Water Supply’s case is clear that aresearch institution is also an industry, there seem to be some recent decisionswhich suggest that research activities should be exempted from the purview ofthe ID Act.

23 See HR Adyanthya v Sandoz (India) Ltd(1994)5SCC737, See also MK Tripathi v SeniorDivisional Manager LIC (2004)8SCC387:AIR2004SC4179

Given the judicial trends, unless the current reverses in industrial jurisprudence areset aside through legislative amendments to the ID Act, the ID Act will cease to bean effective dispute resolution machinery for the health care sector, and for thelarger world.

Right to Health in India: Arguments for Justice and Enforceability30

Chapter Six

Health is a basic service that the government must provide for its people andfor which it must accept ultimate responsibility. In India, the Constitution,judgements of the Supreme Court and international treaty obligations togetherprovide a framework for articulating the “Right to Health” as a fundamentalright of a citizen.

The Constitution The Constitution of India also specifies rights in the form of policy goals (withoutprovisions for enforceability) in Part IV of the Constitution – these are theDirective Principles of State Policy. However, Directive Principles only serve as

guiding principles and do not have theconstitutional enforceability of rightsarticulated in Part III. Further thelanguage used under Article 47 of theDirective Principles indicates that it is aduty of the state to improve public healthas one of its primary duties and not aright guaranteed to the citizen.

It is noteworthy that originally issues ofhealth care and rights based access to it were relegated to the DirectivePrinciples of State Policy. However, even as Directive Principles, there is noarticulation of a Right to Health as framed within Article 12 of the InternationalCovenant on Social, Economic and Cultural Rights – “recognize the right ofeveryone to the enjoyment of the highest attainable standard of physical andmental health.” Articulation of health in the Directive Principles of theConstitution (Articles 42 and 47) is limited to exhorting the state to providehumane conditions of work, maternity relief, increase the level of nutrition,standard of living and improve public health.1 It gives a guiding principle onwhich the drug policy of the government of India prior to its TRIPS commitmentswas based – and drug policies deeply affect the Right to Health.

The Constitution of India provides a framework forfundamental rights in India. Part III of the Constitutionarticulates various rights and Article 32 of theConstitution provides for direct access to the SupremeCourt of India in the case of violations of these rights.One can argue for a just and enforceable Right to Healthin India on the basis of these provisions.

1 Article 42, “Provision for just and humane conditions of work and maternity relief- The State shallmake provision for securing just and humane conditions of work and for maternity relief”.

Article 47, “Duty of the State to raise the level of nutrition and the standard of living and to improvepublic health- - - - - The State shall regard the raising of he level of nutrition and the standard of living of itspeople and the improvement of public health as among its primary duties and, in particular, the Stateshall endeavour to bring about prohibition of the consumption, except for medicinal purposes, ofintoxicating drinks and of drugs which are injurious to health”

Right to Health in India: Arguments for Justice and Enforceability 31

Article 21 guarantees an individual’s life or personal liberty against all threatsexcept through a procedure established by law. The Right to Health wasexplicitly read into Right to Life in State of Punjab and others vs. MohinderSingh2 and asserts the constitutional and enforceable obligation on the part ofthe state to provide health facilities. It is further made clearer in Paschim BangaKhet Mazoor Samiti v. State of West Bengal3, where non-availability of servicesin government health centreswas seen as a violation ofArticle 21 and it was held that“Article 21 imposes anobligation on the State tosafeguard the right to life ofevery person. Preservation ofhuman life is thus ofparamount importance. Thegovernment hospitals run bythe State and the medicalofficers employed therein areduty-bound to extend medicalassistance for preservinghuman life. Failure on the partof a government hospital toprovide timely medical treatment to a person in need of such treatment resultsin violation of his right to life guaranteed under Article 21”. It was orderedthat primary health centres have to be equipped to deal with medicalemergencies, adding that the state cannot use lack of financial recourses toshirk from its responsibility under Article 21. This has been re-affirmed by theSupreme Court with respect to provision of primary health centres.4

The argument that Right to Health falls squarely within Article 21 also can beread from other judgments of the Supreme Court around health issues. Rightto Life has continuously been interpreted to mean a right to a dignified life.Extending this argument in Bandhua Mukti Morcha5, it was also held to includeadequate nutrition as part of life with dignity. Further, humane workingconditions, health services and medical care were read as an essential part ofthe Right to Life guaranteed under Article 21.6 This has been extended toemergency medical care and an obligation on every doctor, in government orprivate practice, to extend his/her services in Paramanand Katara v. Union ofIndia.7

The SupremeCourt and theJudiciary

The rights discourse within the Indian judicial paradigm underwenta huge shift after the state of Emergency in 1977, wherein, thejudiciary, particularly the Supreme Court, started expanding thenotion of rights and creatively using the Right to Life guaranteedunder Article 21 of the Constitution to include various social andeconomic rights that have not been expressly mentioned in PartIII of the Constitution of India, making them enforceable as amatter of justice. The Right to Health featured prominently throughthis process and was continuously read into Article 21 throughboth the tool of public interest litigation and individual petitionsreading Right to Health into transgressions into Right to Life.

2 AIR1997SC12253 AIR1996SC24264 Common Cause v. Union of India AIR2005SC44425 Bandhua Mukhti Morcha v. Union of India 1997 (10) SCC 5496 Common Education and Resource Centre v. Union of India 1995 (3) SCC 427 1989 (4) SCC 286


Article 738 of the Constitution lays an obligation on the Government of India tohonour and implement its international treaty obligations. The Supreme Courthas clearly enunciated that this obligation has to be fulfilled through executiveand legislative processes.9

India is a signatory to the International Covenant on Social, Economic andCultural Rights and Article 12 of the Covenant which calls for the right to thehighest attainable standards of health.10 According to the General Commentsof the Committee for Economic, Social and Cultural Rights (ECOSOC) the Rightto Health requires availability, accessibility, acceptability and quality with regardto both health care and underlying preconditions of health. The Committeeinterprets the Right to Health, as defined in Article 12.1, as an inclusive rightextending not only to timely and appropriate health care but also to theunderlying determinants of health, such as access to safe and potable waterand adequate sanitation, an adequate supply of safe food, nutrition and

InternationalTreaties

8 Extent of executive power of the Union.— — — — — (1) Subject to the provisions of this Constitution,the executive power of the Union shall extend— (a) to the matters with respect to whichParliament has power to make laws; and (b) to the exercise of such rights, authority andjurisdiction as are exercisable by the Government of India by virtue of any treaty oragreement: Provided that the executive power referred to in sub-clause(a) shall not, saveas expressly provided in this Constitution or in any law made by Parliament, extend in anyState to matters with respect to which the Legislature of the State has also power to makelaws.

(2) Until otherwise provided by Parliament, a State and any officer or authority of aState may, notwithstanding anything in this article, continue to exercise in matters withrespect to which Parliament has power to make laws for that State such executive power orfunctions as the State or officer or authority thereof could exercise immediately before thecommencement of this Constitution.

9 Visakha v. State of Rajasthan AIR1977SC3011

10 1. The States Parties to the present Covenant recognize the right of everyone to theenjoyment of the highest attainable standard of physical and mental health.2. The steps to be taken by the States Parties to the present Covenant to achieve the fullrealization of this right shall include those necessary for: (a) The provision for the reductionof the stillbirth-rate and of infant mortality and for the healthy development of the child;(b) The improvement of all aspects of environmental and industrial hygiene; (c) Theprevention, treatment and control of epidemic, endemic, occupational and other diseases;(d) The creation of conditions which would assure to all medical service and medical attentionin the event of sickness.


housing, healthy occupational and environmental conditions, and access tohealth-related education and information, including on sexual and reproductivehealth.11

11 The right to health in all its forms and at all levels contains the following interrelatedand essential elements, the precise application of which will depend on the conditionsprevailing in a particular State party:

(a) Availability. Functioning public health and health-care facilities, goods and services, aswell as programmes, have to be available in sufficient quantity within the State party. Theprecise nature of the facilities, goods and services will vary depending on numerous factors,including the State party’s developmental level. They will include, however, the underlyingdeterminants of health, such as safe and potable drinking water and adequate sanitationfacilities, hospitals, clinics and other health-related buildings, trained medical andprofessional personnel receiving domestically competitive salaries, and essential drugs, asdefined by the WHO Action Programme on Essential Drugs.

(b) Accessibility. Health facilities, goods and services have to be accessible to everyonewithout discrimination, within the jurisdiction of the State party. Accessibility has fouroverlapping dimensions:

Non-discrimination: health facilities, goods and services must be accessible to all, especiallythe most vulnerable or marginalized sections of the population, in law and in fact, withoutdiscrimination on any of the prohibited grounds.

Physical accessibility: health facilities, goods and services must be within safe physical reachfor all sections of the population, especially vulnerable or marginalized groups, such asethnic minorities and indigenous populations, women, children, adolescents, older persons,persons with disabilities and persons with HIV/AIDS. Accessibility also implies that medicalservices and underlying determinants of health, such as safe and potable water andadequate sanitation facilities, are within safe physical reach, including in rural areas.Accessibility further includes adequate access to buildings for persons with disabilities.

Economic accessibility (affordability): health facilities, goods and services must be affordablefor all. Payment for health-care services, as well as services related to the underlyingdeterminants of health, has to be based on the principle of equity, ensuring that theseservices, whether privately or publicly provided, are affordable for all, including sociallydisadvantaged groups. Equity demands that poorer households should not bedisproportionately burdened with health expenses as compared to richer households.

Information accessibility: accessibility includes the right to seek, receive and impartinformation and ideas concerning health issues. However, accessibility of information shouldnot impair the right to have personal health data treated with confidentiality.

(c) Acceptability. All health facilities, goods and services must be respectful of medical ethicsand culturally appropriate, i.e. respectful of the culture of individuals, minorities, peoplesand communities, sensitive to gender and life-cycle requirements, as well as being designedto respect confidentiality and improve the health status of those concerned.

(d) Quality. As well as being culturally acceptable, health facilities, goods and services mustalso be scientifically and medically appropriate and of good quality. This requires, interalia, skilled medical personnel, scientifically approved and unexpired drugs and hospitalequipment, safe and potable water, and adequate sanitation.

(Committee on Economic, Social and Cultural Rights Twenty-second session 25 April-12May 2000)


Further, to make this possible the State parties are obligated to respect, protectand fulfill the above in a progressive manner:

“The right to health, like all human rights, imposes three types orlevels of obligations on State parties: the obligations to respect,protect and fulfill. In turn, the obligation to fulfill contains obligationsto facilitate, provide and promote. The obligation to respect requiresStates to refrain from interfering directly or indirectly with theenjoyment of the right to health. The obligation to protect requiresStates to take measures that prevent third parties from interferingwith Article 12 guarantees. Finally, the obligation to fulfill requiresStates to adopt appropriate legislative, administrative, budgetary,judicial, promotional and other measures towards the full realizationof the right to health.” (Ibid)

The Alma-Ata Declaration, attempting to address the existing gross inequalityin the health status of the people, particularly between developed anddeveloping countries, as well as within countries, states that this disparity ispolitically, socially and economically unacceptable and is, therefore, of commonconcern to all countries. State parties have a core obligation to ensure thesatisfaction of, at the very least, minimum essential levels of each of the rightsenunciated in the Covenant, including essential primary health care.

In the ECOSOC’s view, these core obligations include at least the followingobligations:12

(a) To ensure the right of access to health facilities, goods and services on anon-discriminatory basis, especially for vulnerable or marginalized groups;

(b) To ensure access to the minimum essential food which is nutritionallyadequate and safe, to ensure freedom from hunger to everyone;

(c) To ensure access to basic shelter, housing and sanitation, and an adequatesupply of safe and potable water;

(d) To provide essential drugs, as from time to time defined under the WHOAction Programme on Essential Drugs;

(e) To ensure equitable distribution of all health facilities, goods and services;

(f) To adopt and implement a national public health strategy and plan ofaction, on the basis of epidemiological evidence, addressing the healthconcerns of the whole population; the strategy and plan of action shall bedevised, and periodically reviewed, on the basis of a participatory andtransparent process; they shall include methods, such as right to healthindicators and benchmarks, by which progress can be closely monitored;the process by which the strategy and plan of action are devised, as wellas their content, shall give particular attention to all vulnerable ormarginalized groups.

12 http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En?OpenDocument as on 29th June 2007


The Committee also confirms that the following are obligations of comparablepriority:

(a) To ensure reproductive, maternal (pre-natal as well as post-natal) and childhealth care;

(b) To provide immunization against the major infectious diseases occurringin the community;

(c) To take measures to prevent, treat and control epidemic and endemicdiseases;

(d) To provide education and access to information concerning the main healthproblems in the community, including methods of preventing andcontrolling them;

(e) To provide appropriate training for health personnel, including educationon health and human rights.

What we have witnessed is the trend of the Indian SupremeCourt to read the Right to Health into Right to Life. Thisprovides a framework for building a case for enforceabilityof Right to Health as a matter of justice and as afundamental right under Article 32 of the Constitution ofIndia, when read in the light of judicial pronouncementsand international treaty obligations.

Healthcare Reform Movement in the United States36

Chapter Seven

The United States government and multinational corporations have been at theforefront of pressuring other countries, especially in the Global South, toimplement neo-liberal policies. These policies seriously undermine basic humanneeds and dignity not only for people living outside the United States but alsofor those living within.

The United States is the only industrialized country in the world that does notguarantee health insurance for its population. The U.S. spends far more perperson on health care than any other country in the world – in fact more thantwice as much as the average for other rich countries. Yet people in the UnitedStates do not have good health.

The Health CareCrisis in theUnited States

The United States ranks near the bottom of the industrialized worldin life expectancy, infant mortality and other standard measures ofhealth. Most developed countries provide some form of universal healthinsurance coverage. But in the U.S. more than 45 million Americanshave no health insurance and many more are underinsured.

Even the well-insured have found their health compromised when theirinsurance company or Health Maintenance Organization (HMO) denies paymentfor certain procedures or medication. HMOs aim to lower the cost of medicalcare by requiring approval from the primary care physician for specialized care.HMOs act as gatekeepers, using a strict set of guidelines to authorize treatment.If the treatment does not fall within the HMO guidelines, the individual will notreceive access to the requested services.

The US has a reached a new level of crisis in its health care system. Accordingto Americans for Health Care, a grassroots health care reform organizationsponsored by the Service Employees International Union (SEIU):

� Every minute, nearly 5 people lose their health insurance in the U.S.

� More than 74 million people went without coverage for part of the last twoyears. This equates to every man, woman and child in California, Texasand New York.

� 74 percent of those without insurance come from working class families.

� 9 million children in America have no health care.

Healthcare Reform Movement in the United States 37

� The number of people earning more than $75,000 a year who lost theirinsurance increased by 28 percent in the last year, making healthcare anissue for the middle and upper middle class.

� The number of people with college degrees who lost their insuranceincreased by 29 percent last year.

� Close to 1 million of those who lost their health insurance this year have afull-time job.

� 13 percent of people aged 55-64, or 5.2 million people, were uninsured in2000.

� One in ten married women aged 50 to 64 become uninsured when theirhusbands turn 65 and retire.

Cost, access and quality are all essential to understanding the health care crisisin the United States.

Yearly average insurance premium increases of 12 to 16 percent are forcingmany businesses to drop employee coverage or demand that workers pay more.The average share that workers pay for health insurance premiums hasincreased by nearly 50 percent since 2000. In 2005, wages increased 4 percent,while insurance premiums increased 15 percent. By2006, the cost of a family premium reached$14,500 a year. These rising costs make it difficultfor small businesses to provide basic coverage. Asa result, employers seek cost savings by limitingbenefit packages. Moreover, to offset an economicdownturn, businesses demand a decrease inemployee wages or benefits, commonly known asa “giveback.” For unionized workers, employerdemands for healthcare givebacks make it increasingly difficult to make anybargaining gains in wages or other benefits.

Safety nets provided by the government in conjunction with employers, suchas unemployment insurance and Medicaid, are retreating. The Balanced BudgetAct and Welfare Reform Act, passed in 2005, have increased budgetarypressures on Medicaid and Medicare, programmes designed to provide healthcare to the poor and elderly. The number of uninsured therefore continues togrow. There are over 45 million Americans without health insurance. This isexacerbated by the decrease in government funding for public healthcaresystems, hospitals and community clinics, leaving people with few alternativesfor seeking care.

The consolidation of privatized healthcare facilities is also causing under-staffingamong healthcare providers and threatening the quality of patient care. Front-line healthcare workers are overworked and forced to work overtime withoutadequate pay. Understaffing has worsened the nurse to patient ratio, makingnurses responsible for more patients thereby decreasing the quality of care.

Health Care Costsare Skyrocketing

Limited Access toHealth Care

There is a continuing trend for employers toshift the social costs of their business to theworkers themselves, forcing workers to beresponsible for the costs of their own healthinsurance, pension and vacation time. Healthcare cost increases are outpacing wages.

Worsening WorkingConditions AffectQuality of HealthCare


While everyone agrees that the Medicare programme has been enormouslysuccessful, many people believe that covering everyone would be too expensive– that the country simply cannot afford to insure its entire population.

“The collapse of health care reform in the first two years of the Clintonadministration will go down as one of the great lost political opportunities inAmerican history. It is a story of compromises that never happened, of dealsthat were never closed, of Republicans, moderate Democrats, and key interestgroups that backpedaled from proposals they themselves had earlier co-sponsored or endorsed.” Paul Starr, Advisor to President Bill Clinton

According to Paul Starr, nearly every major health care interest group hadendorsed substantial reforms. The American Medical Association (AMA) andHealth Insurance Association of America (HIAA), the two great, historicopponents to compulsory health insurance, both went on record in support ofan employer mandate and universal coverage. The U.S. Chamber of Commerceendorsed an employer mandate, as did many large corporations. Other groupscame out variously for reform options that ran along a spectrum, from Canadian-style single-payer programs – – – – – in which the government essentially replaces theinsurance company––––– on the left to managed competition and medical savingsaccounts and radical changes in tax policy on the right. Given this, “it waseasy to believe the country was ready for substantial reform and that a market-oriented, consumer-choice approach to universal coverage, positioned in thecenter, could become a platform for consensus.”

“It was easy to believe, but it turned out to be wrong.”

Overconfident about the desire for reform, the health care politics of 1993 wasmisjudged as a change in the climate when it was only a change in the weather,according to Starr. “We wrongly assumed that the leading Republicans and keyinterest groups that had endorsed substantial reforms would at least maintaintheir positions and might be pulled closer to ours in a final bargain. But byspring 1994, they had no reason to accept a deal. Republicans were alreadyanticipating big midterm election gains; killing reform in the 103rd Congresswas rational.” Starr adds that, “with unemployment down, Americans wereworrying less about their jobs and health coverage and more about crime. Ashealth care inflation eased primarily because inflation was generally undercontrol, businesses worried less about health care cost containment and moreabout the political implications of an expansion of government authority.” Giventhis, opponents were successful in taking the focus off of health care reform.

As public healthcare facilities shut down and private facilities aim to lower costs, jobsecurity for healthcare workers is becoming an important concern. Access to qualityhealthcare for working families is intrinsically connected to the workplace conditionsfor healthcare workers.

Finding a Solution

The Attempt atHealth CareReform in the1990s


“Instead of health care, the focus of debate became government, which was adebate we were sure to lose.”

During this time, Jobs with Justice occupied the political space as theprogressive/left wing of the health care justice movement. Both mobilization/field activities and national policy advocacy were discussed within the Jobs withJustice tent, which included labour unions and key health care advocates. In1990, millions of union members and community supporters at 50,000 worksitestook part in Jobs with Justice Healthcare Action Day. Rallies, teach-ins, andworkplace actions demanded Healthcare for All: requiring employers tocontribute to healthcare; guaranteeing a comprehensive benefits package;controlling costs; and protecting front-line healthcare workers. This was thefirst in a series of mobilizations for National Healthcare coordinated by Jobswith Justice. These actions provided opportunities for outreach and educationthat built a constituency for this issue inside and outside of workplaces. Ourrole shifted somewhat with the creation of the Campaign for Health Security, ashort lived coalition of primarily the members of Jobs with Justice, which waspart of the final single-payer push before our historic collective collapse in theface of the Clinton Administrations Health Care Reform proposal.

Powerful special interests successfully fought the Clinton Administration’sHealth Care Reform proposal. These special interests continue to shapereform solutions that will be to their benefit. The special interests includethe American Medical Association (doctors), the American HospitalAssociation, Drug/Pharmaceutical companies, and Insurance companies.Because these interests are in conflict with one another, reform ispolitically paralyzed.

Although there was strong support for the ingredients of reform in the 1990s,the proposed plans were complex to understand and the intense criticism leftthe public uncertain. The opposition was successful in focusing attention onwhat those with good health care might lose with reform. They spent millionsof dollars on the infamous “Harry and Louise” commercials and otheradvertising, lobbying, and campaign contributions. These groups helped tocreate public anxiety and political paralysis.

There was agreement among supporters that health care reform is necessary,but there was much disagreement about how universal coverage could beachieved. As a result, the supporters of reform could not mobilize our bases ina united manner to keep the confidence of the greater public and to counterthe efforts of our opponents.


Through this work we have learned many important lessons that inform how toadvance new models. Three are worth mentioning here:

1) We must engage front-line healthcare workers in the movement forcomprehensive reform so as to build a broad enough coalition to have thepower to achieve meaningful victory.

2) We must build a diverse and powerful grassroots base that understandsthe links between their struggles to access health care, protecting thesafety net, and their struggles as health care workers (cost, access, andquality) that can be mobilized and united to take on our opponents andhold elected officials accountable.

3) Ultimately, a more comprehensive solution to the ongoing healthcare crisismust include proactive proposals that move us beyond defending thecurrent system.

Fighting Back –Building aConstituency forHealth CareReform

The Solution isHealthcare For All

We, at Jobs with Justice, believe that the solution to the healthcarecrisis is comprehensive and meaningful healthcare reform that ensuresaccess to quality care to all people residing in the United States. Amore comprehensive solution to the ongoing healthcare crisis mustinclude proactive proposals that move us beyond defending the currentsystem. We think that a national healthcare system is ultimately cheaperand more effective than continuing to rely on employers and a dwindlingpublic safety net.

We identified a key barrier to achieving meaningful healthcare reform: the lackof a strong constituency that demands it. The time has come to build thatconstituency and move forward with proposals at the state and federal level.

In 2001, Jobs with Justice organized a delegation of healthcare workers andconsumers to Canada to learn about their healthcare system. Everyone on thedelegation was very impressed with the Canadian system. Despite the cutsthat have forced similar conditions for healthcare workers as in the US (overtime,understaffing, etc.), the limitations on the breadth of services covered(homecare, prescription drugs, and other things not covered), and limited accessto some populations (particularly immigrants), the system is still much betterthan our system in the US. One insight was that the problems in Canada werecaused by inadequate spending, not by corporations making profit withoutproviding care, as in the US. At its worst, the Canadian system provides muchmore quality healthcare for its residents than the US system at its best. Ourexperience underscored the value of a universal healthcare system, but alsohighlighted the need for constant vigilance by stakeholders to protect againstthe collapse of the social programme. We are using this knowledge to buildour healthcare campaign in the US.


Jobs with Justice has been involved in a number of initiatives that suggest newopportunities for coalition-building and potentially for meaningful reform. LocallyJobs with Justice supports campaigns to oppose hospital mergers and closings;municipal and statewide efforts to make prescription drugs affordable and toreform HMOs; organizing community-based support for large scale healthcareworker organizing; and, supporting equitable resolutions when labour-management contract negotiations centre around costs and quality of healthcarebenefits. We are optimistic about the potential to build a unique alliancebetween consumers and healthcare workers.

National JwJ supports local coalitions in developing healthcare justice plansthat link on-going work with broader healthcare demands. The goal is toincrease the level of healthcare organizing in cities to build a constituency forhealthcare and in that way begin to rebuild a national movement for healthcarereform. The issues of cost, access and quality can be used as a road map tobuilding a powerful movement for reform. Therefore, Jobs with Justice coalitionsare developing and supporting campaigns that:

1) Improve working conditions for healthcare workers — engaging caregivers,people who have had bad experience with the system

2) Improve working families’ access to healthcare through employer-providedinsurance — engaging workers, especially union members (and possiblysome employers)

3) Expand healthcare access to the uninsured by strengthening the safetynet – engaging the uninsured and the underinsured, people concernedabout specific groups with disease or who are at risk, communities thathave lost access to services/ health care facilities

One inspiring example of JwJ’s local healthcare campaigns is the successfuleffort to beat a proposed increase in co-pays for prescription drugs and visitsat Grady Hospital in Atlanta, Georgia in the late 1990s. This meant that patientswould have to pay more for prescription drugs and visits to this public hospital,making health care services unaffordable for many. Grady Hospital is one ofthe few remaining public hospitals that provide services to the poor anduninsured – who are largely African Americans. Atlanta has a long history ofracism and therefore this policy was considered a racist one – denyingthousands of African Americans access to quality and affordable health care.Initiated by the community and religious organizations with tremendous laboursupport (including healthcare workers), the campaign engaged more than 50community, religious, labour and elected officials in direct action on at leasttwo separate occasions. The significance of religious involvement was that manyof the community members, especially in the African American community,attend a church and so engaging the religious community allowed us to reacha broader group of people. We were also able to incorporate a moral frame tothe campaign. One factor that contributed to the campaign’s success was itsmessage, which extended beyond the specific Grady Hospital struggle topromote the need for comprehensive solutions to the healthcare crisis.

Jobs with JusticeHealthcareCampaign


An example of a successful local campaign that involved health care workerstook place in St. Louis, Missouri. The St. Louis JwJ’s Worker’s Rights Board(WRB) worked to support caregivers with the Missouri Department of MentalHealth in their battle against under-compensation, lack of family healthinsurance, dangerous amounts of mandatory overtime and understaffing. Workers’ Rights Boards (WRBs) engage the power of religious and communityleaders who, along with academics and elected officials, exert moral, publicand political pressure aimed at turning around an unfair employer or exposingabuses of workers and communities. After an unfair dismissal of two caregiversresulting from “whistle blowing” on a matter of patient abuse, JwJ took theopportunity to engage the caregivers, state legislators and pastors from thecommunities surrounding the facilities. As a result, the WRB organized a publichearing that included key staff from two state senators and put together asummary of findings approved by three state senators. Ultimately, this resultedin the two caregivers getting their jobs back.

Another great example of our local work is from Boston, MA. In January 2003,IUE – CWA (International Union of Electrical Workers-Communications Workersof America) Local 201, which represents General Electric workers in Lynn, MAparticipated in a two- day national strike for health care which was the firstnational action since 1969. Local 201 organized a forum to defend health careduring the strike. Simultaneously, IBEW-CWA Verizon workers were negotiatingtheir contract, with health care cost shifting and cuts to retirees (coverage ofretired workers) a major issue. Boston JwJ proposed and organized a state-wide Health Care Action Day in support of these two struggles. More than60,000 workers and citizens across the state of Massachusetts came togetherand wore stickers on Health Care Action Day to demand a political solution tothe health care crisis. Various rallies and work place actions took place, andmore media attention was brought to support workers suffering health carecost shifting and communities facing health care cuts. Verizon and GE workerssoon after won health care in their contract negotiations, and other locals lookedto the JwJ for support in their health care struggles. Jobs with Justice was alsoable to bring health care reform groups to the coalition that were not able tounite prior to Health Care Action Day but found themselves able to unite underthe concept of ‘health care for all’.

Over the last few years, we have coordinated the documentation of this work,strategically prioritized these struggles and made progress in knitting our worktogether into something bigger than the sum of its local parts. We won manylocal healthcare victories, as mentioned in the examples provided. Wecoordinated information exchanges and strategizing across more than 20 localcoalitions through monthly healthcare conference calls and a healthcaregathering. Most importantly, we succeeded in raising the visibility of healthcareas a major problem for working families. We were able to assert through ourorganizing that the problem is not simply an employer who is shifting healthcarecosts to the workers, it is the system that is the problem. This is the first steptowards building a broad constituency engaged and active in a campaign formeaningful healthcare reform.


As we continue to raise the profile of the healthcare crisis, we will now beginthe next step of lifting up national healthcare as the solution. We will be workingwith allies to develop a national strategy that is committed to building a broadconstituency demanding health care reform. We believe that another politicalopening is approaching with the increasing crisis sweeping over the country.We have another opportunity to change our broken health care system.

Jobs with Justice is uniting workers, theuninsured, and caregivers to take action onthe job and in their community to putpressure on employers to become part ofthe solution and to force politicians to standup against the special interests for healthcare for all!

Patients’ View of Delhi’s Public Health Services44

The health sector is a classic case of market failure. Government interventionis not only necessary in terms of regulation but also for provisioning andfinancing universal health care services. These are essential ingredients of

any welfare state. Unfortunately, overthe years, and particularly since theearly 1990s, service delivery andfinancing in India is rapidly fallinginto the hands of unscrupulousprivate players.

Household out-of-pocket paymentshave witnessed a significant andrapid rise. A declining health budgetand insignificant coverage by social

insurance will bloat consumer expenditure enormously. In such circumstances,catastrophic health spending in the absence of free and universal socialinsurance could plunge households into the misery of vicious poverty.

Large-scale industrialization and urbanization have produced disastrous resultsin recent years as crowded cities are becoming a breeding ground for new andold diseases to emerge in a virulent form. Indeed, mass and rapid transportfacilities have quickened the pace of the spread of infectious diseases – SARS,Avian flu, etc. The urban public health service delivery mechanism is unable tocope with the demand for services, as it is being drained of much neededresources – both personnel and finance. Patients suffer due to escalating costsof medical treatment as they are directed to buy drugs and diagnostic servicesfrom private players.

In order to understand the content and quality of public health services in Delhi,we had canvassed a separate schedule among patients. The broad issues thatwe discuss here are: a brief description of demographic characteristics of therespondents; particulars of medical treatment received as inpatient of a hospitalduring the year preceding the survey and as outpatient during the last 15 daysbefore the survey; and the magnitude and quality of medical facilities availablein the surveyed hospitals.

The survey was carried out among 100 patients in Delhi’s hospitals, of whichover two thirds of the respondents (69%) were male and one third were female(31%). 82 percent of them were Hindus and 18 percent Muslims. ScheduledTribes and Scheduled Castes were 20 percent and 18 percent respectively, while

Chapter Eight

A Classic Case ofMarket Failure

While the state and central governments provide fiscal andnon-fiscal incentives to the private sector to set up healthcare facilities, the same governments attribute the significantdecline in public spending on health care to fiscal crisis. Subsidized land at throw-away prices in prime locations,five to ten year tax free environments, reduced import-duty on medical goods, etc. are provided, with stategovernments competing in doling out corporate incentives.

DemographicCharacteristics ofRespondents

Patients’ View of Delhi’s Public Health Services 45

the share of OBC (Other Backward Castes) and others was 35 percent and 27percent respectively.

The per capita monthly average expenditure of the respondents was estimatedat Rs. 682, which appears to be less than urban mean expenditure per capitaderived from the National Sample Survey (NSS). The difference could essentiallybe due to the nature of respondents chosen, since substantial share of therespondents belonged to the socially and economically backward communities. The other notable statistics relates to household size. The average householdsize stood at little over six (6.13). The estimate is higher than the nationalurban average of 4.4 (NSSO, 2006).

A substantial percentage of the surveyed population (73 percent) appears to be dependenton the public hospitals as it truly reflects their economic background. The economicallyweaker sections of the population tend to belong to socially disadvantaged groups. Therefore, it is no wonder that close to three fourths of the respondents belonged tothe socially deprived sections of society that are dependent on public health facilities.

Table 8.2Average Per Capita Expenditure and Household Size of the Respondents

Variables Mean Standard Minimum MaximumDeviation

Per Capita 682 300.98 0 1200Expenditure (Rs.)

Household Size 6.13 2.32 1 10(Numbers)

Table 8.1Sample Distribution of Respondents by Social Categories and Gender

Social Groups Male Female All

Caste Groups

Scheduled Tribes 12 8 20

Scheduled Castes 15 3 18

Other Backward Castes 26 9 35

Others 16 11 27

Total 69 31 100

Religious Groups

Hindus 61 21 82

Muslims 8 10 18

Total 69 31 100


Nearly 60 percent of the respondents who visited hospitals/public healthfacilities had used the public mode of transport. A little over 20 percent usedtaxis and over 10 percent used bikes to come to the health facility. Nearly 40percent of the patients are from Delhi, while neighbouring Uttar Pradeshaccounted for 31 percent and the other neighbouring state Haryana accountedfor 12 percent of the patients. A sizeable share of patients also originated fromMadhya Pradesh. Although the place of origin of patients varied, predominantly95 percent of the patients are presently staying in Delhi.

Table 8.3Mode of Transport and Place of Origin of the Sample Respondents

Mode of Transport Percentage Place of Origin PercentageDistribution Distribution

Bus 59 Delhi 39

Car 7 Uttar Pradesh 31

Bike 11 Haryana 12

Taxi 21 Madhya Pradesh 13

Rickshaw 2 Others 5

All 100 All 100

An examination of the workforce status of the respondents suggests that while14 percent were not employed, 15 percent of the patients were students and asizeable 28 percent of them were self-employed. The survey further shows that27 percent of the respondents were employed in nearby companies, close toone-tenth were engaged in clerical jobs and six percent of the respondentswere housewives.

Nearly two-thirds of the patients surveyed had been hospitalized and so, hadused inpatient services. 61 of the total of 63 persons were hospitalized duringthe preceding year (three of them reported multiple hospitalization). Interestingly, all of the respondents surveyed were in free wards and none ofthem opted to pay for a cabin/private ward. The mean duration of hospitalstay per patient was roughly six days per episode of hospitalization.

Inpatient andOutpatient HealthServices

Out of PocketExpenditure

Table 8.4Percentage Hospitalised by Type of Hospital

Gender General Hospital ISM Centres All

Male 40 (100) 0 (0) 40 (100)

Female 19 (83) 4 (17) 23 (100)

Total 59 (94) 4 (6) 63 (100)

Note: Figures in parenthesis indicate percentage distribution


With the trend of privatization intensifying, patients pay for an increasing arrayof services even in a public hospital that is supposed to provide services free. We attempted to capture this aspect by asking the respondent to classify theexpenditure, if incurred, during the stay of their hospitalization:

a) Not received a particular service/not applicable

b) Received free

c) Partly free

d) On payment. Patients were reported to be spending out-of-pocket, on an average,Rs. 2,000 per episode of hospitalization of which a significantcomponent goes into buying drugs and expensive diagnostic services.

A sizeable 30 patients had to pay for physicians’ fees. The survey results revealthat only one person paid for hospital admission charges and room rent whileone person had to partially pay for surgery. Medicine and diagnostic serviceswere generally paid for by the patients from outside the hospital. Half of thepatients hospitalized had to spend money out of pocket for medicines, whilethe rest obtained them from the hospital. Apart from drugs, the other servicesthat hospitals are increasingly throwing open to the market are the diagnosticservices. Except for two patient-respondents, almost all of them availed of X-ray/ECG/Scan services from outside the hospital. As far as other diagnostictests are concerned (pathological tests), 45 of the 63 patients paid for them. High cost, high technology diagnostic services like CT Scan/MRI/X-ray etc. aredriving up costs globally. Reflecting the global trend, the Indian health sectoris also experiencing high cost services.

Table 8.5Number of Patients Receiving Treatment as

Inpatient Care by Mode of Payment

Outpatient Not Received Partly On Non- TotalTreatment Received Free Free Payment Hospita-

lisation

Hospital Admission - 62 - 1 37 100Charges

Hospital Room Rent - 62 - 1 37 100

Surgery 36 26 1 0 37 100

Doctors’ Fee - 31 2 30 37 100

Medicine - 30 2 31 37 100

X-Ray/ECG/Scan - 2 - 61 37 100

Other Diagnostics 10 16 1 36 37 100

Transport Costs 60 1 - - 37 100

Food Charges 34 26 3 - 37 100

Attendant Charges 56 7 - - 37 100


We also surveyed 37 outpatients who received medical treatment in thepreceding 15 days of the survey. They were canvassed among the outpatientdepartments of the public hospitals (MCD and Delhi Governments hospitals). While 16 of them sought treatment from a doctor once in the last 15 days,seven patients visited an outpatient doctor in the hospital four times. In fact,three of the outpatients visited doctors five times during the last 15 days oftheir ailment.

The average expenditure per episode of ailment (outpatient treatment) in publichospitals turned out to be Rs. 475. Outpatients, like inpatients, did not incurany out-of-pocket expenses towards hospital admission charges. Except fourpatients, the rest did not pay doctors’ fee.

On the other hand, almost half of the outpatients who visited the publichospitals in question had ended up paying for medicine. Similarly, a majorityof 28 out of 37 outpatients were required to pay for diagnostic services.

Waiting Time,Overcrowding,Attitude

Table 8.6Number of Patients Receiving Treatment as

Outpatient Care by Mode of Payment

Outpatient Not Received Partly On Non- TotalTreatment Received Free Free Payment Hospita-

lisation

Hospital Admission - 37 - - 63 100Charges

Doctors’ Fee - 33 - 4 63 100

Medicine - 19 4 14 63 100

X-Ray/ECG/Scan 4 4 1 28 63 100

Other Diagnostics - 3 2 32 63 100

Transport Costs - 37 - - 63 100

Food Charges 4 33 - - 63 100

Attendant Charges 4 33 - - 63 100

Other indicators of the quality of services provided by health facilities are thelength of queues, waiting time to meet a doctor/nurse or to receive diagnosticservices, and the time taken to perform various tasks. There is a tendency tounderrate public health facilities on grounds of long waiting time, overcrowding,etc.. We examined this issue in Delhi’s public health facilities.

The number of hours involved in admitting a patient into the hospital/wards ofa public hospital was over one and a half hours. The average number of patientsper bed in a public hospital was around 1.5, reflecting the terrible overcrowdingin Delhi’s public hospitals. It took close to four hours to consult an allopathic


doctor, while it took less than one hour less than one hour to consult an ISMdoctor. It is also interesting to note that to access staff nurses, the mean timereported was around two hours. For ward boy/ayah, it took little over an hourto get them to perform a task. The average time for a diagnostic test turnedout to be 45 minutes.

Table 8.7

Variable Mean StandardDeviation

Time taken for Admission into 1.64 1.83Hospital/Wards (In Hours/Day)

Number of Patients per bed (In Numbers) 1.49 0.86

Waiting time to Access a 3.75 6.84Allopathic Doctor (In Hours/Day)

Waiting time to Access a ISM Doctor (In Hours/Day) 0.59 1.05

Time taken by Nurses to Perform a Task (In Hours/Day) 2.05 4.76

Time taken for a Diagnostic Tests 0.45 0.16

Time taken for a Ward Boy/Ayah to Perform a Task 1.05 4.40

Further, nearly 60 percent of the respondents asserted that the staff were notpolite and respectful whereas 40 percent thought otherwise.

All survey respondents agreed that it is important to have a functioningcomplaint cell in the hospital. However, where there were complaint cells,patients found that in the absence of connections to hospital staff or seniorofficials their complaints went unnoticed. In general, patients did not find suchcomplaint cells useful.

Public health facilities are often derided on the charges of poor physicalconditions, such as dry taps, dirty toilets, dingy rooms, high noise pollutionand so on. To get a sense of these conditions, our study attempted to examinethe issue from the patients’ viewpoint. To the query of ‘how often is the bed-linen changed?’ 62 percent of the respondents replied that it is done alternatedays, 22 percent said it is done ‘once in a week’ and the rest did not respond.

Used syringes are a cause for spreading infectious diseases, including thedeadly HIV virus. Mismanagement and lack of funds are often blamed for reuseof syringes in public health care institutions. However, if survey response isany indication, this is not the case; 88 percent of the respondents revealedthat hospitals used new disposable syringes.

As far as noise and heat level is concerned, 83 and 88 percent of the patientsrespectively believed that to be at medium level, whereas 14 and 6 percentbelieved that noise and heat levels were tolerable.

Complaint Cell forPatients

Physical Quality


However, roughly 70 percent of the patients surveyed appear to rate dust levelin the hospital to be clean.

With declining health budgets and a growing number of health services beingoutsourced from public health facilities, we attempted to understand the contentand quality of services provided in Delhi’s public health care institutions. Ourresults clearly suggest that public health facilities are overwhelmingly beingused by the lower caste population, reflecting the poor economic conditionsthat drive them to the public facilities.

Table 8.8Level of Heat and Noise in the Public Hospital

Level Noise Heat

No 1 1

High 1 4

Medium 83 88

Low 1 1

Tolerable 14 6

Safe potable water is a prerequisite in health facilities as infection is bound to spread toother patients and to health workers as well. Roughly over 25 percent of the samplepatients asserted that the drinking water is not ‘clean’, while nearly 20 percent of therespondents said that it is tolerable. Over half of the respondents replied that the water isclean.

When asked ‘do you get adequate water in toilets’, nearly half of the respondents repliedin the negative, whereas 43 percent of the responses were in the affirmative and 7 percentsaid that it was tolerable.

Table 8.9Availability of Adequate and Clean Drinking Water

Responses Drinking Water Water in Toilets

No 27 50

Clean/Yes 55 43

Tolerable 18 7

All 100 100

Shockingly, roughly one-third of respondents reported having spottedthe presence of rats, cockroaches, etc. in Delhi’s public hospitals.

Conclusion


The composition of urban India’s health facilities has changed dramatically inthe last two decades, as an increasing share of the population seeks care fromthe private health providers. The neglect of public health facilities has thrownopen doors to the private players in a large way.

Those who can afford to pay for better services have shifted to private players,while the economically and socially poor are being left with public healthfacilities. Public facilities are also increasingly being priced out of reach of thevulnerable sections of society, as they are paying out-of-pocket for evenessential medicines and diagnostic services. Since these services are beingcontracted out to private players, the burden on weaker sections of society ispalpable.

Many of the problems of the present public health facilities stem from theoverload of work that the lower end of the health workforce is burdened with. This is due to unfilled vacancies, poor worker management, inadequate primaryhealth facilities and overloaded hospitals. Since the services of health workerssuch as ward boys, ayahs, sweepers, security personnel etc. are beingcontractualised and privatized, their workload has increased but wages havefallen and working conditions have deteriorated. On the other hand,absenteeism and moonlighting of more skilled service providers such asphysicians has thrown health services out of gear, resulting in tremendous lackof confidence among both the public that uses these facilities and the lowerlevel cadres who are supposed to be guided by them.

Patients also face shockingly appalling infrastructure. The absence of adequatedrinking water and toilet water, presence of rats and so on can lead to furtherinfection and diseases of patients from exposure in health facilities!

It is ironic that the Indian Government and the private sector are trying to make Indiaa world-class provider of health facilities for medical tourists. The global public wouldbe shocked at India’s record of taking care of its own people!

Workers’ View of Delhi’s Public Health Services52

Chapter Nine

Economic reforms initiated in India since the early 1990s have plunged most ofthe social sectors – education, health, water, sanitation, etc. – into a crisis inthe name of ‘fiscal discipline’. The social sectors are being denied their dueshare in the developmental process. The process of globalization whose mantrais the ‘survival of the fittest’ has unleashed unequal bargaining betweencountries and between people, as is evident from the worldwide shift towardsa product patent regime mandated by intellectual property rights (TRIPS, WTO)and the General Agreement on Trade in Services.

Ageing in the industrialized world, along with global demographic imbalances,has triggered a ‘brain drain’ of health professionals. Skilled personnel are notonly drained towards developed countries from the developing countries, butalso to the private health sector within the developed countries. Demoralizationand dissatisfaction among health professionals is causing disruption in thepublic health services.

The multiple assaults of economic reforms are clearly visible in the labourmarket. A major agenda of the present reform process is labour market‘flexibility’ which seeks to undo hard won protective labour legislations anddeny labour their basic rights. ‘Flexibility’ entails the unfettered freedom ofthe employers to hire and fire at will, deny social security to the workers andthrottle the legitimate basic right of forming a union. Of course, in a countrywhere informal workers constitute roughly 92 percent of the total workforce,protective labour legislations protected only a small number of workers andeven this protection was often illusory. In practice, employers always enjoyedthe right to hire and fire and hardly contributed to legitimate social securitybenefits. Now, organized or formal workers are also losing their rights andare being pushed into the unorganized or informal labour force.

Over the last decade and a half, privatization and contractualisation of healthservices in the public sector has become clearly visible as regular or permanentjobs are being replaced by contract jobs. The growing list of those servicesthat are privatized or on contract include services of nurses, security personnel,cooks, lift operators, diagnostic services, and drug dispensing. Contract workersare not only denied basic pay but also stripped of benefits and job security.

The survey collected data among the health workforce in terms of their socio-economic characteristics, employment particulars, working conditions, wage/salary structure, case-load handled by the employees/workers, particulars ofunion activity among different sections of workers, workers’ knowledge of

Introduction

Workers’ View of Delhi’s Public Health Services 53

privatization/contractualisation, etc. The survey was carried out among thehealth workforce in Delhi’s public health institutions (under MunicipalCorporation of Delhi and Delhi Administration).

To understand the aforementioned issues, we conducted a survey of 400 healthworkers in Delhi’s public health sector. Of the total 400 workers surveyed,four-fifths were male and one-fifth female. 97 percent were Hindus and therest Muslims. Interestingly, a caste-wise break-up of respondents showed that82 percent of them belonged to the socially vulnerable sections of society. The share of Scheduled Castes in the survey stood at over one-third (35 percent),while that of Scheduled Tribes and Other Backward Castes (OBCs) was 24percent and 23 percent respectively.

The average age of the surveyed respondents was 34 years and 94 percent ofthe persons sampled were married. Over two-thirds of the sample healthworkers preferred buses to reach the hospital, a little over one-fifth came bycar and another 6 percent on bikes.

Socio-economicCharacteristics ofthe Respondents

Table 9.1Sample Distribution of Respondents by Social Categories and Gender

Social Groups Male Female All

Caste Groups

Scheduled Tribes 79 16 95

Scheduled Castes 118 22 140

Other Backward Castes 72 22 94

Others 53 18 71

Total 322 78 400

Religious Groups

Hindus 313 76 389

Muslims 9 2 11

Total 322 78 400

Over one-third of the sampled workers had completed secondary leveleducation, with another one-fifth each having had higher secondary educationand graduate degrees. Only 10 percent of the respondents were illiterate andanother six percent had primary education. 60 percent did not possess anytechnical qualifications. 12 percent had M.D., M.S. degrees, another 4 percenthad MBBS degrees. While nurses accounted for 12 percent of the respondents,the share of B.Pharm/M.Pharm, diploma holders, ISM degree holders, etc. was2-3 percent each.


The table above clearly brings out the dominance of caste categories by typeof occupations. While the dominance of ‘OBC’ and ‘Other’ castes which areresidual consisting mostly of ‘upper castes’ was clearly visible among thephysicians, the ‘lower castes’ were found to be concentrated among occupationssuch as ward boys, sweepers, security personnel, chowkidars, etc.. The lattertype of jobs is considered to be ‘low’ in the ladder of occupations by castehierarchy. In spite of over half a century of positive discrimination, the groundlevel evidence appears to be grim; the adverse economic conditions of the ‘lowercastes’ in the health sector are a pointer to the maintenance of the status quothat the upper castes favour.

Table 9.2Occupational Categories by Caste

Occupation ST SC OBC Others Total

Doctors 12(16.22) 17(22.97) 25(33.78) 20(27.03) 74(100)

Nurses 17(33.33) 14(27.45) 9(17.65) 11(21.57) 51(100)

Pharmacists 3(15.79) 6(31.58) 2(10.53) 8(42.11) 19(100)

Ward Boys 10(31.25) 13(40.63) 3(9.38) 6(18.75) 32(100)

Ayahs 0(0.00) 1(20.00) 2(40.00) 2(40.00) 5(100)

Sweepers 14(26.42) 27(50.94) 7(13.21) 5(9.43) 53(100)

Drivers 10(32.26) 8(25.81) 9(29.03) 4(12.90) 31(100)

Security 14(22.95) 25(40.98) 16(26.23) 6(9.84) 61(100)Personnel/Chowkidars

Attendants 8(22.86) 12(12.00) 10(28.57) 5(14.29) 31(100)

Others 7(17.95) 17(43.59) 28.21(94.00) 10.26(71.00) 100(100)

Total 95 140 94 71 400

Note: Figures in parentheses denote percentage distribution


In order to understand the working conditions, the facilities offered, theworkload, etc. of the workforce, we captured the entire mix of workers: closeto one fifth (18.5 percent) of the respondents wee doctors, followed by sweepersand nurses constituting around 13 percent each. The other major samplesincluded store keepers (roughly 9 percent), ward boys (8 percent), drivers (8percent), attendants (5 percent), etc. The gender break-up of the sample revealsthat the major concentration of females is among nurses and doctors at thetop end, while at the bottom we found them among ayahs and sweepers. Onan average, the mean years of experience of the workforce was close to sixyears.

Table 9.4Composition of the Sample Workforce by Gender

Occupational Category Male Female Total

Doctors 58 (78.0) 16 (22.0) 74 (100)

Nurses 4 (8.0) 47 (92.0) 51 (100)

Pharmacists 15 (79.0) 4 (21.0) 19 (100)

Ward Boys/Ayahs 32 (86.0) 5 (14.0) 37 (100)

Sweepers 50 (94.0) 3 (6.0) 53 (100)

Others 163 (98.0) 3 (2.0) 166 (100)

All 322 (80.0) 78 (20.0) 400 (100)

Note: Figures in parentheses indicate percentage distribution

Table 9.3Educational Status of Workforce

Educational Number Technical Education NumberQualification (Percentage) (Percentage)

Illiterate 38 (9.5) No Technical 243 (60.75)

Primary Education 24 (6.0) M.D, M.S. 48 (12.00)

Middle 15 (3.7) M.B.B.S. 17 (4.25)

Secondary 153 (38.25) Nursing 48 (12.00)

Higher Secondary 81 (20.25) M.Pharm/B.Pharm 20 (5.00)

Graduation 89 (22.25) ISM Degree & Others 24 (6.0)

Total 400 (100) Total 400 (100)



With few exceptions, almost the entire health workforce appears to be employedas full time workers. Nearly 67% of workers surveyed were contract workers orregular workers (that is, not daily wage workers). Nearly 44 percent of the 67%were regular government workers, predominantly in the categories of doctors,nurses and pharmacists, laundry workers and electricians. 23 percent of the67% were on contract but may have the perception that they are “permanent”because their contracts have been getting renewed for a long time.

Employment Status

Two types of contract work exist: one that is contracted through a labour contractorand one that is directly on contract with the government. The latter is found mainlyamong doctors, nurses, etc. Table 6.5 shows that 81% of contract workers in thesample were lower paid workers such as ward boys/ayahs, security, sweepers, etc. whoare generally hired through labour contractors.

The other 33% of the workforce surveyed were daily wage workers, mostlyayahs, ward boys, security personnel, attendants, etc. Almost the entire lowerlevel health personnel, particularly drivers and store keepers were on dailywages as were half of the ward boys and sweepers. The trend of employingmore daily wage workers is clearly visible even among the nurses, wherein 10

Table 9.5Status of Work by Occupational Categories

Occupation Contract Regular Daily Wage AllWorkers* Workers** Workers

Doctors 2 (2.70) 72 (97.30) 0 (0.00) 74 (100)Nurses 9 (17.65) 37 (72.50) 5 (9.80) 51 (100)Pharmacists 0 (0.00) 19 (100) 0 (0.00) 19 (100)Ward Boys 11 (34.38) 0 (0.00) 21 (65.63) 32 (100)Ayahs 4 (80.00) 0 (0.00) 1 (20.00) 5 (100)Sweepers 15 (28.30) 5 (9.43) 33 (62.26) 53 (100)Cooks 2 (66.67) 1 (33.33) 0 (0.0) 3 (100)Washermen 2 (12.50) 12 (75.00) 2 (12.50) 16 (100)Drivers 3 (9.68) 5 (16.13) 23 (74.19) 31 (100)Admn. Assts. 0 (0.00) 3 (100) 0 (0.00) 3 (100)Security 45 (93.75) 0 (0.00) 3 (6.25) 48 (100)PersonnelAttendants 0 (0.00) 11 (52.38) 10 (47.62) 21 (100)Store Officers 0 (0.00) 1 (2.86) 34 (97.14) 35 (100)Electricians 1 (11.11) 8 (88.89) 0 (0.00) 9 (100)Total 93 (23.25) 174 (43.50) 133 (33.25) 400 (100)

Note: Figures in parentheses denote percentage distribution*Workers who are on contract usually have been getting their contracts renewed, givingthe perception that they are permanent and regular when in fact, they are not.**Regular permanent workers


percent of the sampled nurses were working on daily wages. It is generallyargued that the employment status of workers be upgraded from daily wageinto the regular/permanent category – however, many daily wage workersremain in that status for many years. An analysis of years of experience amongthese workers clearly suggests that the mean years of experience were in therange of 3-5 years as against 6-8 years for doctors, nurses and pharmacists.

The overall trend of privatizing and contracting out public services hasintensified since the mid-1990s in India. Privatization and contractualisationof services entail loss of job security and social security for workers. Longworking hours, uncompensated over time work, denial of basic minimum needs,indecent working environment, etc. have become synonymous with privatizationand contractualisation of the workforce.

Privatisation andContractualisationof Services

The sample workforce in Delhi’s public hospitals was queried about the privatization andcontractualisation of health services. Three fourth of the respondents replied that healthservices are partially privatized/contractualised in their respective health facilities. About70 percent of them asserted that security is the worst affected department in terms ofprivatization. The other services which are feeling the effects of privatization are lift operators,sweepers, ward boys/ayahs and nurses.

Contract workers are hired for performing tasks that have previously been doneby regular, permanent workers. Nearly 23 percent of the hospital employees ofDelhi’s public hospitals are engaged on contract. Among these 15 percentreported that they paid the contractor commission in the range of Rs. 200-600,which means that they had come in through labour contractors. Over fivepercent of the contractual workers, who had government contracts, were on aone-year contract and two percent had a three-month contract with a breakafter three months after which they got an extension of the assignment. Themode of recruitment takes place as per vacancy according to close to one-fifthof the survey respondents. Only three percent were recruited under tender call.

Table 9.6Terms and Conditions of the Contract

Terms and Conditions Number Percent

Payment to Contractor on Commission Basis 60 15.00

Short-term Direct Contract (3 Months) 8 2.00

One Year Contract 21 5.25

Others 311 77.75

All 400 100


The survey further collected information on the terms and conditions attachedto appointment of employees. Employees at Delhi’s public health facilities arefrequently not given proper appointment letters, the terms and conditions arescripted in favour of the employer, discriminatory terms and conditions arespecified for different sets of employees, etc., as the sample results showed.

Only 50 percent of the surveyed employees received proper appointment letterswith clearly laid down terms and conditions of appointment. Around 30 percentof the respondent workers appear to have been given a letter about daily wagecontract. Nearly 20 percent of the respondents were asked to fill-up adeclaration form (used by labour contractors mainly) about their employment. These figures roughly tally with the figures for employment status where wefound 43.5 percent to be regular workers, 33.35 percent to be daily wagers and23.35 percent to be on contract.

Appointment andTermination

Predictably, the sample showed that hospital managements had issued lettersof appointment to almost all the physicians and pharmacists and to 90 percentof the nurses. The discrimination and contractualisation of the lower levelworkforce is clearly visible from the table below which reveals that instead ofproviding proper appointment letters, such categories of workers were eithergiven letters for daily wage appointments or some sort of declaration was filledup.

Table 9.7

Letter of Appointment Number Percent

Yes 198 49.50

No 3 0.75

Yes – Declaration Form Filled-up 74 18.50

Yes – Letter for Daily Wage Basis 125 31.25

All 400 100


A declaration form is a general form usually provided by labour contractors toworkers who are engaged as Class IV workers or security guards in the hospitals.It consists of brief details about the worker and is signed by the workerdeclaring that the information is true. But this is not a compulsory process andmost of the contractors try to stay away from paper work.

Over half of the employees reported termination of the work contract as mutualand the rest reported work termination as not being mutual. To the query ofwhether prior notice is required for termination of work, half of the surveyedpersons responded that no such provision exists while 45 percent of themreported that no prior notice was required when termination takes place. Onlysix percent of the respondents said that one week’s notice is required fortermination of contract.

It is interesting to learn that two thirds of the respondents considered thepresent number of staff as adequate. On the other hand, over one fourth ofthe other respondents believed that hospitals are extremely understaffed. While

Table 9.8Terms and Conditions of Appointment by Occupation

Occupation Letter of Letter of Declaration Letter forAppointment – Appointment – Form Filled Daily Wage

Received Not Given

Doctors 74 (100) 0 (0.00) 0 (0.00) 0 (0.00)

Nurses 46 (90.2) 0 (0.00) 1 (1.96) 4 (7.84)

Pharmacists 19 (100) 0 (0.00) 0 (0.00) 0 (0.00)

Ward Boys 1 (3.13) 0 (0.00) 12 (37.50) 19 (59.38)

Ayahs 1 (20.00) 1 (20.00) 2 (40.00) 1 (20.00)

Sweepers 6 (11.32) 1 (1.89) 14 (26.42) 32 (60.38)

Cooks 1 (33.33) 0 (0.00) 2 (66.67) 0 (0.00)

Washermen 14 (87.50) 0 (0.00) 0 (0.00) 2 (12.50)

Drivers 4 (12.90) 0 (0.00) 5 (16.13) 22 (70.97)

Admin. Assts. 3 (100) 0 (0.00) 0 (0.00) 0 (0.00)

Security 19 (31.15) 0 (0.00) 32 (52.46) 10 (16.39)Personnel/Chowkidars

Attendants 0 (0.00) 0 (0.00) 0 (0.00) 35 (100)

Others 10 (58.82) 1 (5.88) 6 (35.29) 17 (100)

Total 198 (49.5) 3 (0.75) 74 (18.50) 400 (100)

Note: Figures in brackets indicate percentages.

Workload /Overtime


doctors did not complain about understaffing, those who complained of anexcessive burden due to understaffing were nurses, ward boys, sweepers,security personnel and drivers.

When we compare this with the patients’ survey, it is surprising that doctorsdo not find themselves understaffed although the waiting time for a patienttrying to consult an allopathy doctor is an incredible four hours. Theunderstaffing of nurses and ward boys/ayahs could be the reason for a patienthaving to wait two hours and one hour respectively to get a request respondedto. The workers least satisfied with their present condition of staffing wereward boys/ayahs, sweepers and security guards — these are also the areaswhere contractual work and daily wage appointments are most prevalent.

Table 9.9Perceptions about Adequacy of Staff

Occupation Understaffed Overstaffed More Staff Satisfied TotalRequired with Present

Conditions

Physicians 0 (0.00) 0 (0.00) 2 (2.70) 72 (97.30) 74 (100)

Nurses 15 (29.41) 1 (1.96) 5 (9.80) 30 (58.82) 51 (100)

Pharmacists 2 (10.53) 0 (0.00) 2 (10.53) 15 (78.95) 19 (100)

Ward Boys/ 25 (67.57) 4 (10.81) 6 (16.22) 2 (5.41) 37 (100)Ayahs

Sweepers 19 (35.85) 5 (9.43) 2 (3.77) 25 (47.17) 53 (100)

Drivers 11 (35.48) 1 (3.23) 0 (0.00) 17 (54.84) 31 (100)

Security 26 (54.17) 4 (8.33) 6 (12.50) 10 (20.83) 48 (100)Personnel

Others 8 (9.20) 0 (0.00) 0 (0.00) 75 (86.21) 87 (100)

All 107 (26.75) 17 (4.25) 26 (6.50) 250 (62.50) 400 (100)


Alongside over one-fourth of the other respondents finding themselvesunderstaffed, one-fifth of the respondents worked overtime but a majority didnot get compensated. The section of the workers that were most exploited wereof course those on contract or on daily wage, such as, ward boys/ayahs, securitypersonnel, sweepers and even to some extent nurses who may be hired on acontract basis. None of them got the double wage which they are supposed towhen they put in overtime.


Public health services generally attract large numbers of patients and hencethe workload of employees, whether they are doctors or ward boys, tends tobe extremely challenging. Given the nature of the tasks – emergency and routineservices – the job demands constant and immediate attention. The challengeis usually met by working over-time, having different shifts, etc. Rotational shiftsand attractive overtime compensation are normally the features of healthservices. However, with increasing privatization and contractualisation of jobs,all the rights and entitlements of workers are being brutally throttled. In thiscontext, we attempted to canvass the opinion of workers on the issue ofovertime, shifts, compensation to workers, etc.

With the exception of three percent of the respondents, all the others workedone shift a day. On the question of multiple shifts, 80 percent replied in thenegative. The mean hours of a shift was roughly eight hours. Cooks, ward boysand security personnel reported a little more than the average, ranging from 9-10 hours per shift.

15 percent of the workforce surveyed appears to change shift twice a week. Itis common practice to work in night shifts in health facilities. Given thestrenuous nature of night shifts, allocation of assignments among the healthworkforce is usually done on a rotational basis. Among those on night shifts,the survey results show that 45 percent worked on a fixed shift whereas 55percent worked on rotation. Nearly half of the respondents believed that the

Chart 9.1Response on Overtime and Compensation

Shifts


night shift involves overwork and strain. Over one-fourth of them asserted thatnight shift is associated with paucity of staff and seven percent of therespondents did not feel safe working at night. In fact, in response to a pointedquery on whether the department they worked in was adequately staffed atnight, over 90 percent replied in the negative.

In this section, we shall look at the mode of payment, social security benefitsand wage differential among Delhi’s public health workforce. Recent years havewitnessed enormous erosion in the rights of workers. Among others, withdrawalof social security benefits and widening wage differentials between differentsets of employees are the striking feature of labour market conditions in thecontemporary world.

Over half of those surveyed in the public health institutions in Delhi do not getsalary/wage on a pay scale. A pay scale defines salary components in terms ofbasic pay, house rent allowance, dearness allowance, deduction andcontribution of provident fund, etc. Evidence from the table below suggeststhat a majority of physicians and nurses receive pay scales while those in thelower category of jobs are not on a pay scale but get lump sum wages. Theconsequence of lump sum payment is withdrawal of benefits, de-linking priceincrease from wage rise.

Table 9.10Response on Shifts

Shift Number (Percent) Multiple Shifts Number (Percent)

One 388 (97.00) Yes 81 (20.00)

Two 12 (3.00) No 319 (80.00)

All 400 (100) All 400 (100)0)

Note: Figures in parentheses indicate percentage distribution.This table needs to be read two columns at a time.

Salary/Wage andSocial SecurityBenefits


Although wage differentials among different sets of employees in theprivate sector are the cause of a growing wage gap, the differentials areless wide in the public sector. This is clearly brought out in the surveywhich shows monthly mean wage (net salary/wage) for the entire publichealth sector to be roughly Rs. 5,900. A doctor’s average net salary isclose to Rs. 9,000 per month, which is followed by pharmacists andnurses, receiving on an average Rs. 8,100 and Rs. 7,100 respectively permonth. As expected, ward boys/ayahs and sweepers receive a lowermonthly average wage of roughly Rs. 3,500 each. The wage differentialmay not look striking, since we have left out in our analysis qualificationssuch as experience and education which may account for larger paypackages of employees at the higher end of the spectrum.

Table 9.11Pay Scale by Occupation

Occupation Receive Pay Scale No Pay Scale

Physicians 73 (78.49) 20 (21.51)

Nurses 37 (72.55) 14 (27.45)

Pharmacists 19 (10.00) 0 (0.00)

Ward Boys 4 (12.50) 28 (87.50)

Sweepers 6 (11.32) 47 (88.68)

Drivers 9 (42.86) 12 (57.14)

Security Personnel/ 19 (32.20) 40 (67.80)Chowkidars

Attendants 4 (11.43) 31 (88.57)

Others 19 (51.35) 18 (48.65)

Total 190 (47.50) 210 (52.50)

Note: Figures in parentheses denote percentages.


Public health facilities are gradually being denied basic resources. There isan all round shortage or complete absence of equipment and consumables. Public health services are unable to cope with the increasing demand forservices as they are unable to replenish supplies or undertake repairs andmaintain operations in a timely manner. For instance, it is common forhospitals to run out of oxygen cylinders, syringes, drugs, inhalers,thermometers, etc. The sweepers’ common complaint is that they run outof mopping tools, buckets, brooms, etc. while drivers cannot operateambulances because there is not enough money to fill petrol/diesel.

Table 9.12Reported Net Salary/Wage by Occupation

Occupation Mean Standard Deviation Frequency

Doctors 8932 7313 74

Nurses 7137 2514 51

Pharmacists 8157 3516 19

Ward Boys 3544 1419 32

Ayahs 3500 0 5

Sweepers 4384 1811 53

Cooks 4383 2396 3

Washermen 5768 2705 16

Drivers 3929 2114 31

Admin. Assts. 7833 288 3

Security Personnel 4900 699 40

Chowkidars 2475 1552 8

Attendants 5643 1878 21

Stores Officers 4361 1762 35

Electricians 7358 2452 9

Total 5868 4113 400

Less than half (45 percent) of the employees surveyed receive payments through thebank and the rest (55 percent) are paid in cash.

Equipment / JobSatisfaction


We attempted to understand this issue from the hospital employees themselves.The survey shows that 30 percent of the employees believed that there wasinadequate supply of equipment/items in their respective departments while70 percent asserted that there was no such problem. Half the store keeperscomplained of short supply of equipment and consumables. Half of the sweepersreported that they often run out of buckets, mopping tools, brooms, bowls,disposables, dustbins, etc. Half of the ward boys/ayahs also believe thatconsumables were in short supply and did not reach in time. Interestingly, one-third of the nurses firmly asserted that short supply of consumables is a regularfeature in public hospitals, denying them the ability to provide decent serviceto the public.

Table 9.13Adequate Supply of Equipments and Consumables

Reponses Supply of Responses Supply ofConsumables Equipments

Yes 278 (69.67) Yes 277 (69.42)

No 122 (30.33) No 123 (30.58)

All 400 (100) All 400 (100)


To a specific query of ‘whether the equipments are functioning normally?’ 30percent of the respondents replied in the negative. The mean duration to repairequipment, according to the hospital employees, is close to 10 hours. 70 percentof the workforce surveyed agreed that the task of equipment maintenance isoutsourced to private agencies.

It is ironic that public health facilities which are supposed to keep away toxicmaterials, as infection from such materials tend to affect the patients muchmore severely, have become dumping grounds for such materials. Due careand timely removal of toxic materials is not only essential but critical to keephealth services functioning normally. One-fifth of the surveyed employees ofpublic hospitals in Delhi complained of exposure to toxic materials. Almostthree-fourth of the surveyed respondents replied that removal of toxic materialsis carried out by MCD vehicles.

Two-thirds of the workforce surveyed was satisfied with the present workingconditions in Delhi’s public hospitals. However, one-third did not consider thepresent job to be a remunerative one. In Table 6.8, we see that with regard tothe complaint about “unpleasant environment”, the daily wagers were mostreticent. Contract workers found it most unpleasant and given that most of the


contract workers are hired through labour contractors, this data shows theirdissatisfaction with the employment situation. With regard to remuneration,we see that the daily wagers are most vocal about their lack of remunerationwhile regular workers are the most satisfied.

Table 9.14Perceptions on Present Working Conditions

Issues Contract Regular Daily Wage TotalWorkers* Workers** Workers

Not 22 (26.00) 20 (24.00) 42 (50.00) 84 (100)Remunerative

Unpleasant 13 (45.00) 10 (34.00) 6 (21.00) 29 (100)Environment

Health Hazard 1 (33.00) 2 (67.00) 0 (0.00) 3 (100)

Problem with 13 (100) 0 (0.00) 0 (0.00) 13 (100)Contractors

Other Problems 7 (64.00) 3 (27.00) 1 (9.00) 11 (100)

Satisfied 37 (14.00) 139 (53.00) 84 (32.00) 260 (100)

All 93 (23.00) 174 (44.00) 133 (33.00) 400 (100)

Note: Figures in parentheses denote percentage distribution*Workers who are on contract usually have been getting their contracts renewed, givingthe perception that they are permanent and regular when in fact, they are not.**Regular permanent workers

The majority of the respondents asserted that they do not receive uniformsregularly although uniform book entries may or may not be made. Maintaininga uniform book is part of labour legislation but it appears that uniforms aregiven to a few at the top but denied to the large majority.

The survey reveals that 43 percent of the employees receive free uniforms onceor twice a year. However, 12 percent of the respondents replied that they werenot provided with uniforms; 19 percent replied that although uniforms areprovided the cost is deducted from the salary; and another 19 percent assertedthat they had to buy uniforms themselves.

Those who get uniforms have several problems with them and these workersare mainly Class IV employees (ward boys and ayahs, sweepers, etc.) and thereare differences between regular workers and contract workers. Sweepers whowork under the labour contractors are offered uniforms only in some hospitals.

Uniforms


For instance sweepers who work under the contractors in Guru Tegh BahadurHospital are provided a big coat each, which is of no use to them. However liftoperators working under contractors are provided uniforms while security guardsreceive uniforms once or twice a year. Fourth grade regular staff of thegovernment hospitals are supposedly provided with uniforms but it dependsupon the availability. Generally the uniforms supplied do not fit with the bodysize. In many cases the low grade workers had no uniforms.

Usually regular staff is entitled to promotion after three years. But interviewswith some of the doctors, nurses, dressers and sweepers who are regular staffof the hospitals showed that there is no specific time period for promotions.Some have been working for ten years without any promotion. Employeesperceive promotion as linked to possessing political connections or developinggood relations with senior officials. However, in most cases regular employeesgot an increase in their pay scales even if they were not promoted.

In case of contractual workers there is no specific rule for promotions. Forexample, if a nurse joins under contractual agreement with the government, s/he would get an appointment letter for ninety days, then a break, and thenagain an appointment letter with the same procedure – this process cancontinue indefinitely without any promotion or increase in pay scale. Workerswho work under private labour contractors do not have any provision forpromotion but there may be a slow and arbitrary increase of salary.

One of the indicators for assessing working conditions is entitlements in termsof leave/holidays, such as earned leave, casual leave, medical leave andnational holidays. Increasingly, entitlements are viewed as give-aways ratherthan as a right. The number of holidays and leave are decreasing over theyears, and this is particularly so for the contract workers/daily wage workers.

The survey tends to validate this phenomenon quite tellingly. The mean daysof earned leave among all workers was around 7 days, the average number ofcasual leave per annum was 4.4 days, medical leave 1.76 days and the numberof national holidays 4 days in a year.

Promotion

Leave/Holidays

Table 9.15Type of Leave/Holidays

Type of Leave/Holidays Mean Std. Deviation Minimum Maximum

Earned Leave 6.60 12.44 0 30

Casual Leave 4.40 8.29 0 20

Medical Leave 1.76 3.32 0 8

National Holidays 4.00 0 4 4


Legitimate labour rights do not figure in the discourse of the contemporaryworker. The labour movement that won us many of the present rights andentitlements is under severe threat. The bargaining power of the workers vis-à-vis the employer is at its weakest. While the employers are being given allsorts of incentives and freedom in the name of economic growth, labour rightsare being weakened and portrayed as a threat to development. The situationis no different in public sector undertakings. Efforts are on to weaken theworkers’ rights, if recent pronouncements of the judiciary, executive andlegislature are any indication.

Survey results show 80 percent of employees are aware of the presence of atrade union in the hospital. Over one third of the hospital employees surveyedsaid that they are part of the association/union but the rest do not belong toany association. It is interesting to note the break-up of those who areunionized: half are doctors, followed by nurses and a sizeable section ofpharmacists. It is ironic to observe that union membership is the least amongthose who have poor bargaining power, such as, ward boys/ayahs, cooks,security personnel, sweepers, etc.

Trade UnionActivity andMembership

Chart 9.2Awareness of Union Activity and Membership in the Union


The reason given for joining the union is work-related rather than political. Among those who are union members, the majority believe that the union/association is recognized by the hospital administration. Unfortunately, in spiteof being a member of the trade union, a majority of them did not think thattheir bargaining position vis-à-vis the employer has improved considerably. Ofthose who replied that their bargaining power has increased, the most notableimprovement is in the working conditions.

One of the vital objectives of this study was to examine the working conditionsof the health workforce in Delhi’s public health services. In addition, our interestwas to ascertain from the health personnel their opinion of present unionactivities, the issue of privatization and the challenges that the unions face.

Chart 9.3Composition of Membership in the Union

Conclusion

Social discrimination appears to be institutionalized within the health facilities. Lower orbackward caste dominates the low end of the work – namely, ayahs, ward boys, sweepers,kitchen, laundry, security, etc. while the upper castes dominate the higher end. This castebreak up is directly related to the level of exploitation as lower class workers are subjectedto discriminatory practices.

We found that lower class workers are more likely to be hired as daily wagers,not get paid according to pay scale, not be compensated for over time and notget appointment letters. The discrimination also plays out in the contract worker


arrangements. Higher end workers tend to have written contracts of employmentwith the government. However, the lower end workers are contracted not withthe government but with private labour contractors who extract commission,give no contract letter and are not held accountable.

Workload and understaffing are more severe problems for lower end of workers.Rotation of shifts which gives workers relief is also an area of conflict, muchmore so for contract workers, because this is not professionally managed butdone in a whimsical fashion by supervisors.

Workers clearly suffer, like patients, from shockingly poor infrastructure. Asidefrom the general unsanitary state of the facilities as mentioned in the patientsurveys, workers have to deal with toxics unprotected, equipments that are indisrepair and dangerous and supplies that make a cleaning job a riskyoccupation.

Workers appear to want to be part of organizations like unions in order to improvetheir professional lives. However, higher end workers are more organized than thelower end workers, which speaks to the need for building better cohesion amonghospital workers as well as better organizations.

Contract workers are a growing part of the workforce and any formation ofworkers at any level has to address their issues. Management uses contractworkers to cut down on costs and to extract more productivity through punitivemeasures (such as job insecurity). This is a short-sighted solution to a problemwhich needs a more thoughtful approach.

It is imperative on the part of the management to understand the critical rolesplayed by all its employees. Discriminating against and exploiting one set ofworkers not only affects the rights and entitlements of all workers but also hasa direct bearing on the services that they offer. Therefore, to usher in qualityand improve efficiency in the public health services, the primary concern andtarget of reform should be to provide sufficient security of employment andsocial security benefits to employees. The governments at both central and statelevel need to scale up enough resources to refurbish the dilapidated publichealth system so that it can deliver health services in an efficient and equitablemanner. Labour organizations also have to learn new ways of functioning todeal with the crisis of both decent work and high quality services.

Findings and Recommendations for Advancing India’s Health and Prosperity 71

Chapter Ten

People’s health is central to the nation’s prosperity and well-being. We face ahuge crisis today which can only be solved by bringing together communitiesthat access healthcare, workers who provide them and governments andadministrations that control the delivery systems.

This study has revealed to us the multiple issues that both healthcare serviceworkers/providers as well as the communities of patients face. Some issues,at a superficial level, may appear as conflicting between the two human sidesof healthcare delivery but if we examine the deep-seated causes, we find muchin common. The report confirms the importance of building a healthcare agendaby bringing service providers and workers together with the patients they serve,along with the government and administrations.

FINDING 1:Outsourcing ofServices

Findings and Recommendations for India’s Health and Prosperity

Services such as X-ray, ECG, and other diagnostics in public hospitals, whichused to be free, have been almost fully contracted out to private companiesthat charge substantial fees. This has resulted in rise in healthcare costs forpatients who may then decide to not seek treatment. 20% of urban patientssurveyed pointed to financial reasons for not treating illnesses.

Patients spend on an average, out-of-pocket, Rs. 2,000 per episode ofhospitalization of which a significant component goes into buying drugs andexpensive diagnostic services. Half of the patients hospitalized had to spendmoney for medicines and almost all of them got X-ray/ECG/Scan services fromoutside the hospital.

Outsourcing of diagnostic services and medicines has also given rise tocorruption because medical practitioners often get commissions from thediagnostics services for recommending patients to them. Private facilities arenot accountable in the same way that the public hospital administration wouldbe, resulting in unreliable quality of services.

Departments such as security, kitchen, laundry and cleaning have been partiallyor fully contractualised. The hospital administration contracts with a labourcontractor or agency to hire contract workers and relinquishes responsibilitytowards them. The study shows the dire situation of these workers in terms ofall aspects of labour standards – workload and work hours, compensation,timely payment, sense of security, discrimination and so on.

FINDING 2:Contractualisationof Departments

Findings and Recommendations for Advancing India’s Health and Prosperity72

Labour contracting has implications for both the quality and cost of the servicesas well as the working conditions of the service providers. Contractualisationhas become a punitive practice for controlling the workers, based on insecurityrather than constructive professionalism, and for managing costs in anunplanned, chaotic manner.

Several demoralizing management practices have surfaced through this study.These have severe impacts on the quality of services delivered to patients andon the working conditions and job satisfaction of healthcare workers.

Inadequate hiring of staff with regard to numbers and skills, arbitrary transfers,preferential treatment in assigning shifts, and preferential treatment in excusingabsences or poor performance take place often for reasons that have little todo with intelligent administration and more to do with political influence andcorruption.

Shockingly unprofessional management and supervision result in arbitrarypractices. From basic services such as trolley facilities to surgery, workers andpatients face arbitrary practices, favouritism, arbitrary and informal fees,misappropriation of essential materials, over-charging etc.

The end result is that patients are subjected to services of questionable quality. They face overcrowding, long waits, absent workers, bribery, disrespect andrudeness. Workers face high workload, mismatch between job and skills, unfilledvacancies, corruption, lack of professional supervision and poor morale. Corruption takes hold as political influence and bribery keeps poor managementpractices firmly in place.

Public health services are used by patients who come mainly from lower castesor socially disenfranchised groups. Among the workers or service providers,the survey shows that the same class forms the majority of the largest sectionof the health services workforce – the Class IV employees such as ward ayahs,ward boys, safai karamcharis, and so on.

Significant discrimination exists between higher end employees (Class 1 and2) and lower end (Class 3 and 4). For example, higher classes are more likelyto get paid according to pay scale, receive appointment letters and timely andproper uniforms; the lower classes are unlikely to get these although they havebeen fighting for them for a long time.

Friction arises between patients and workers who may be from the same socio-economic background as well as between workers from higher social statusand patients from lower social status. This is partly due to the larger societaldiscrimination that is institutionally practiced in the facilities.

Workers face lack of morale, disrespect and rudeness, internal divisions due todifferential treatment; and patients face poor quality services, disrespect andrudeness. Ultimately social respect for public health services suffers.

FINDING 3:DemoralisingManagement andSupervision

FINDING 4:InstitutionalizedSocialDiscrimination


Completely inadequate supply of drinking water and water in toilets aredebilitating circumstances for both workers and patients. The presence of rats,in the hospitals of the capital city reflects shocking negligence and shows utterdisrespect for public facilities which serve poor to middle class patients andworkers alike.

Inadequate supplies and malfunctioning equipment add insult to injury for bothworkers and patients. The exposure to toxics that workers have complainedabout also affects the patients who are in the same facility.

Both patients and service providers face shockingly poor sanitation, dangerousrisk of further infection and illness from exposure to hospitals, and low morale.

Expensive private clinics and hospitals are replacing the public hospitals whichhave been the only recourse for poor and low-income families. These facilitiesare largely unregulated in terms of quality, cost, and access. At the same time,they receive government subsidies for their infrastructure. So, whereas, theprivate companies get welfare subsidies that come from the public’s taxes, thepublic is losing its own welfare services and paying for services on top ofpaying taxes.

Patients pay more and receive services from unregulated health facilities. Low-income patients are unable to access these services even though these facilitiesare required to serve a certain number. Government subsidies are shifting fromserving the public to subsidizing the private companies.

The study shows that workers who identify with unions do so primarily forimproving their working conditions and not for political reasons. That is, thereason is professional. We also find that higher end workers identify morewith their associations and unions than lower end workers, although labourorganizations or unions for all the classes of workers.

Labour organizations have not yet developed the practices required to addressthe severe crisis the workers face today, let alone the patients with whom theyhave either no contact or an antagonistic relation. Unity, vision and strategicthinking are in short supply.

The hospital and larger governmental administration has failed to deliver tothe public under the mandate given to them. As public health services for thevast majority suffer, they look to further gutting them, shifting public resourcesinto private hands and making conditions more insecure for workers andpatients alike.

Different levels of government and administration are responsible for the crisisin varying ways but as a system, they do function together and must be heldresponsible for the present situation.

FINDING 5:ShockingInfrastructure

FINDING 6:UnregulatedPubliclySubsidisedPrivate Services

FINDING 7:Role of LabourOrganisations /Unions

FINDING 8:Role ofAdministration


Local politicians play a significant role in intervening negatively in administrationpractices at various points. Often enough, their intervention may supersedemanagement priorities and public interests.

Macro health policies are deeply problematic and need a re-orientation so thatIndia’s prosperity and well-being is genuine.

(i) Industrial Disputes Act: The healthcare system is in danger of being pushedout of the realm of just and enforceable laws, as described in the chapteron jurisprudence. The judicial system is echoing the larger rhetoric of thepresent government and private sector, pronouncing judgements based onequating economic development and progress with erosion ofinternationally recognized and constitutionally protected rights.

(ii) Drug Policy and Pharmaceutical Industry: Unregulated drug prices, changein patent laws from process to product patents, the reduction of essentialdrugs and the rising production of expensive non-essential drugs havemade drugs a source of profit rather than cure.

(iii) Lack of Adequate Primary Health Care: Other than cost, the reason foruntreated patients is the lack of adequate facilities. Not only are existingfacilities being hollowed out, the inadequacies of primary health carecentres put an additional burden on the public hospitals as they have todo the work of PHCs and also that of hospitals, with their weakenedinfrastructure.

(iv) Health Insurance: There is hardly any social health insurance, resulting infamilies having to pay the bulk of healthcare expenses, which can havecatastrophic consequences for household budgets. This further increasespoverty.

The overall outcome for both patients and workers is diminishing of legitimatehuman rights protection. They lack essential medicines and incur high coststo buy them, face overcrowding, deplorable infrastructure, heavy workload,frustration, and lack of protection. The end result is lack of health securitycontributing largely to poverty.

FINDING 9:Role of Politicians

FINDING 10:Macro PoliciesJeopardizingIndia’s Healthand Prosperity


Health is a basic human need as without proper healthcare a person cannotlive a full life and work to his or her capacity. This is not a special need but infact, basic to human survival. Affordable, accessible and adequate healthcareis not an ideological demand. Regardless of political leanings, it is a basicdemand that a nation must meet in order to be civil and functionable and thento prosper.

A national healthcare agenda or a local healthcare issue cannot be solved inisolation by any one group of people, be it patients, workers or administration. Labour-patient collaboration is essential to build a circle of trust and mutualconcern. Only in such an environment can we build a thoughtful healthcareagenda. Workers’ organizations (whether associations or unions or mutual aidgroups) and people’s health organizations need to confront the new realitiesand develop new ways of functioning.

It is time to shine the light on Delhi’s public sector hospital system and examinethe issues from different angles: workers, patients and administration. Delhi,as the capital city and India, as a site for global health delivery, makes this anessential task. A Tripartite Public Hearing is recommended – with a full reportof findings and recommendations that should be delivered to those managingthe hospitals and politicians that can be held accountable for making changesthat address issues raised at the hearing.

Representatives from communities that access healthcare, workers who providethem, and government and management (public or private) that control thedelivery systems must develop a consultative process and structure so that aneffective, affordable system can be monitored and built. This structure orcommittee must meet at regular intervals and produce a public report of findingsand decisions.

Certain areas need to be better understood so that constructive solutions canbe found. For example, issues of (1) shocking infrastructure, (2) maintenanceand repair of equipment, (3) availability of supplies, (4) contractualisation, (5)political influence and intervention in hospital management, have emergedthrough the study.

Research and analysis of budgeting, revenue allocation and expenditure reportsand an awareness of the local political system of the Legislative Assembly arecrucial for understanding the pressures that give rise to these issues. Thisshould be undertaken again through a collaboration of healthcare workers,patients, and administration.

The end outcome can be a set of public standards, arrived at through the

Recommendations

Tripartite DelhiPublic SectorHospital Hearing

TripartiteHealthcareMonitoringCommittee

Development ofPublic Standards &Accountability


tripartite system, that must be met by the hospitals. Failure to comply withthese public standards should carry consequences since healthcare is a publicservice that is funded by the public and its government.

Certain service points in hospitals are particularly rife with conflict. It is criticalto monitor these tension points at each hospital:

� Entry of patients at hospital gates

� Admission of patients in OPD and OT

� Diagnostic tests (referrals, testing, report collection)

� Drugs (availability)

� Hospital supplies (availability)

� Inpatient well-being (cleaning, nursing, medical supervision)

� Release (requirements)

A tripartite mechanism (healthcare workers, patients and management) foranalyzing and addressing the issues will allow the articulation of “Rights &Responsibilities of Patients, Workers, & Administration” which can serve as aguiding tool for improvements.

Knowledge of official versus unofficial hospital policies is important for everyoneconcerned. Accurate information will prevent confusion of arbitrary practiceswith official health policies. Regular public briefings on hospital grounds oncritical issues that emerge from the Tripartite Grievance Mechanism will improveefficiency, reduce costs and improve services.

Certain judicial trends and Constitutional frameworks, combined withinternational treaty obligations, do provide avenues to articulate thefundamental Right to Health. Coordinated and strategic multi-stakeholderplatforms and initiatives must be used as building blocks for developing amovement for the Constitutional Right to Healthcare in India.

Tripartite GrievanceMechanism forHospital Units:

Public Briefing onHospital Policies

Building aMovement for aConstitutionalRight to Healthcare

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Agyepong, Irene Akua, et.al. (2004), “Health Worker (Internal Customer)Satisfaction and Motivation in the Public Sector in Ghana”, InternationalJournal of Health Planning and Management”, Vol. 19, pp. 319-336.

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India's Healthcare in a Globalised World: Healthcare Workers’ and Patients’ Views of Delhi’s...

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