Operationalising Right to Healthcare in India

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Healthcare in India Entitlements by policy and not rights Focus on preventive and promotive care Grossly under-provided facilities Poor investments hitherto Declining public expenditures and new

investments SAPping the healthcare system

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Rural-Urban Disparities – India RURAL (per 1000

population) Hospital Beds = 0.2 Doctors = 0.6 Public Expenditures =

Rs.80,000 Out of pocket = Rs.750,000____________________ IMR = 74/1000 LB U5MR = 133/1000 LB Births Attended = 33.5% Full Immunz.=37% Median ANCs=2.5

URBAN (per 1000 population) Hospital Beds = 3.0 Doctors = 3.4 Public Expenditures =

Rs.560,000 Out of Pocket =

Rs.1,150,000____________________ IMR = 44/1000 LB U5MR = 87/1000 LB Births Attended = 73.3% Full Immunz.= 61% Median ANCs=4.2

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Expenditure Patterns Public expenditures –declining trends

LPG and growth of private capital and stagnation of public investment

Reduced public spending Out of pocket – increasing burden,

especially the poor and in rural areas

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Character of Health Expenditures Public Domain

Rural/Urban divide Preventive/Curative dichotomy Plan/Non-plan expenditures Centre, State and Local governments

Private Domain Curative only- pharma industry driving force Irrational practices, malpractice, unregulated, lack of

professional ethics Supply induced demand

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Facts & Figures - Health Spending Public Domain

Centre: Rs.35 bi (0.13% GDP) State: Rs.186 bi (0.72% GDP) Local: Rs.25 bi estimated (0.10% GDP) Social Insurance: Rs. 12 bi (0.05% GDP)

Private Domain Out-of-pocket: Rs.1200 bi (4.62% GDP) Insurance (public sector) Rs.8 bi (0.03% GDP) Pharma Industry Rs. 250 bi (0.96% GDP)

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Healthcare Financing – Rs. billion1993-94

1994-95

1995-96

1996-97

1997-98

2000-01

2002-03BE

Public

Centre 7 11 12 13 14 23 35

State 68 72 89 99 113 156 186

Total

%Govt

%GDP

75

2.91

0.87

83

2.13

0.81

101

2.98

0.86

112

2.94

0.83

127

2.70

0.83

179

2.91

0.81

221

3.17

0.85

Private

%GDP

195

2.27

279

2.75

329

2.77

373

2.73

459

3.00

982

4.46

1200

4.62Source: Public Expenditures - Finance Accounts upto 2001 and Budget for 2003; Private – CSO estimates on Consumption Expenditure 1985 series; BE = Budget Estimate

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Basic Care Framework What constitutes basic health services

Family physician services, supported by paramedics and community health workers

First level referral hospital with basic specialties and ambulance services

Epidemiological services, including information management and health education

Maternity services for safe pregnancy, abortion, delivery and postnatal care

Immunisation services against vaccine preventable diseases

Pharmaceutical and contraceptive services

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Operational Mechanism Restructuring and Reforms

Organising a system Creating an autonomous health authority Referral system Standards and regulation Structured financing

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Operational Mechanism... Priorities for making it work

An Act of Parliament - Health Authority Tackling the medical profession Licensing, registration, minimum standards Integration of systems Continuing medical education Pricing mechanisms Raising substantial additional resources Consensus building in civil society

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Financing the System Resource Requirements

Present public spending on health care is less than 1% of GDP and out-of-pocket is 4%

Reorganised system will need totally 3% of GDP Costs will be shared by governments at all levels,

employers, employees, earmarked taxes and cesses, insurance funds etc..

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Innovations in Financing Using existing resources efficiently and

effectively Decentralised governance (Panchayati Raj) Block funding or global budgeting Leads to equity in access to resources PHC level resources tripled CHC and district level resources doubled

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Innovations in Financing… Generating additional resources

Increased allocations within the existing budget Payroll taxes for health like profession tax Health cess on health degrading products, polluting

industry and luxury products Compulsory public service by those graduating

from public medical schools Social security levies on land revenues

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Consensus Building Policy level advocacy for UHC Research to develop framework Lobbying with medical profession Filing of PIL for RTHH Lobbying MPs to demand justiciability of

directive principles National and regional consultations on RTHH

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Consensus Building… Campaigns on RTHH with networks of people’s

organisation Bringing RTHH on manifestoes of political

parties Pressurising international bodies like Committee

of ESCR, WHO,UNCHR.. And national bodies like NHRC, NCW.. To monitor state obligations and demand accountability

Shadow reports on RTHH Brought to you by

Summary and Conclusions Rural – Urban disparities across the board Reduced investments and expenditures on health care in

the nineties has impacted access and health outcomes Allocative inefficiencies coupled with SAP only makes

the crises of public healthcare worse Overall health outcomes not very good because of the

worsening access to healthcare –user charges and privatisation

Lack of accountability The need for a right to healthcare perspective

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