Monalisa Minz and Manisha Das comments upon the state of health care which is an important issue in today’s scenario when on one side there are super speciality hospitals coming up while on the other side, there are people who struggle to afford basic medical facility.
A huge chunk of our population is unaware about the statutory recognition of the right to health and medical facilities enshrined under article 21 of the Constitution of the India. This Constitutional recognition has given a framework for the creation of further statutory laws. Along with these, there are judicial pronouncements which may not hold the same weight as the statutory laws but are sufficient to give legitimacy, recognition and social acceptance to various ideas which can solve the health care issues. Today most urban Indians seek health care in private facilities owing to many years of neglect and lack of staff and care in Government hospital. It works as long as one has funds to pay for the private health care varies greatly in quality of care, being unregulated and financed mostly through private payments. However, there are a large number of health workers in private health care who do not have the requisite professional knowledge or degree.[1] Medical education is imparted largely through state-owned/funded institutions at highly subsidised costs. There are 195 recognised allopathic medical colleges in the country producing over 20,000 medical graduates every year 75 per cent of whom are from public institutions.[2] However, the turnout from these institutions does not benefit the public health services because a huge chunk of the turnout from public medical schools either joins the private sector or migrates abroad. The distribution of healthcare facility generally favours the urban areas however when compared to the present population, the figures are not satisfactory. The rural areas have public healthcare centres but they mainly provide preventive services like communicable disease control program, family planning services and at times immunisation services. Curative health care in rural areas is the weakest point though there is a very high demand.
The private healthcare constitutes an influential lobby in policy making circles in India. The amount of regulation in this sector is pathetic.
The medical practice is part of the concurrent list of the Constitution, both Central as well as State Governments can pass laws concerning medical practice. The Medical Council Act, 1956 regulates the modern system of medicine; The Indian Medicine Central Council Act, 1970 regulates Indian systems of medicine including Ayurveda, Sidha and Unani systems of medicine while the Homoeopathic Central Council Act, 1973 regulates the practice of homoeopathic medicines. However lately it can be seen that the only function that medical council performs is to register the qualifying doctors and issue them the licenses to practice. There is a lack of monitoring, continued education and research in the allied field of medicines and diseases, price regulation and prescription vetting both by the medical council and the Government of India. The progressive policy initiative like that of the Hathi Committee report[3] has not been implemented and on top of it over 90 percent of the pharmaceutical formula production is in the Private sector. The Supreme Court of India in its landmark judgment in the Novartis case[4] that had been lying pending in the court since last seven years claiming patent protection is a beaming example whereby the judiciary has played its role effectively but its implementation is at the hands of the government. Though the price of the generic drugs remains affordable to a large range but will it actually be available in the Government hospitals? The question still would remain unanswered as to how many government hospitals in India provide treatment for cancer and prescribe those generic drugs.
The two major health care programs in India are the National Rural Health Mission and the Rashtriya Swasthya Bima Yojana. The recent one announced by our Prime Minister Dr Manmohan Singh is an offshoot of NRHM in the form of National Urban Health mission. The NHRM launched in 2006 has had some success in improving maternity health care under Janani Surakshya Yojana program whereas the RSBY has been effective in reducing out of pocket payment for tertiary care but in most states, it only covers people below the poverty line and that too for a selected set of tertiary care. The NUHM would look into the medical issues of the urban poor particularly those in the slums areas along with teaching the necessity of sanitation. The Supreme Court has time and again upheld cases where the right to health has been a matter of right in emergency situations or right to healthy and safe working conditions and medicare for workers. The orders for which are rarely respected. The government policy under the fourth 5-year plan mandated a civil hospital and a public health centre depending upon the population density in each block but the real situation is much different from the plan. In Alma Ata declaration[5] of the United Nations and the Bhore Committee[6] recommendations for India defined primary care and its importance. It includes a wide range of services such as preventive, curative, promotive and rehabilitative care. It has been defined that an essential health care is be based on practical, scientifically sound and socially acceptable methods and technology. It should be made universally accessible to the individuals and the family in the community through their full participation.
The discrimination of health care resources across the state also varies greatly concentrating more in urban areas leaving very little for the rural areas. This is gross inequity but there is no law at present to address this. The urban areas have additional facilities of a private hospital along with district headquarter hospitals but the primary health care centres do not even have the requisite medicines for common diseases at times. The large-scale expansion of the pharmaceutical industry aimed at regulating and ensuring rapid growth and development of drug manufacture with a view to make India self-sufficient for drugs and the essential drugs to be made available to consumers at reasonable prices.
The working sector is divided into an organised sector and unorganised sector. The organised sectors are those group of people with recognised jobs in central or state government that have social legislations in form of health insurance or medical relief payments. Others who are privileged enough are covered under private health insurance while the remaining population remains uncovered. In the first case, a person employed in a certain professional capacity are entitled to rights of protective social legislation with respect to medical. This is not available to the general population. Hence though the social legislation is positive in nature, it is discriminatory for the right is selective and not universal. Health and health care is an essential component of Right to life guaranteed under article 21 of the Indian Constitution. In the case of CERC v. Union of India[7], the Supreme Court was dealing with the rights of the workers working in an asbestos manufacturing unit. The court noted the right to health and health care of a worker as a fundamental right and went ahead to state that, “Article 39(e) charges that the policy of the State shall be to secure “the health and strength of the workers”. Article 42 mandates that the States shall make provision, statutory or executive “to secure just and humane conditions of work”. Article 43 directs that the Slate shall “endeavour to secure to all workers, by suitable legislation or economic organisation or any other way to ensure a decent standard of life and full enjoyment of leisure and social and cultural opportunities to the workers”.[8] Similarly in another case State of Punjab vs. Mohinder Singh Chawla[9], the right to medical treatment of Government employees was upheld by the Supreme Court. It stated that “The right to health is integral to the right to life. The government has a constitutional obligation to provide the health facilities. If the Government servant has suffered an ailment which requires treatment at a specialised approved hospital and on reference whereas the Government servant had undergone such treatment therein, it is but the duty of the State to bear the expenditure incurred by the Government servant. Expenditure, thus, incurred requires to be reimbursed by the State to the employee. The High Court was, therefore, right in giving direction to reimburse the expenses incurred towards room rent by the respondent during his stay in the hospital as an inpatient.”[10]
When the right to health care is guaranteed by the Constitution, it means proper health care with all the facilities and services of a knowledgeable and qualified doctor. The adequacy and quality of medical care cannot be compromised in this situation. The Allahabad High Court in S.K. Garg vs. The State of U.P.[11] dealt with conditions of public hospitals. The Petition had been filed raising concerns about the pitiable nature of services available in public hospitals in Allahabad. Complaints were made concerning inadequacy of blood banks, worn down X- ray equipment, unavailability of essential drugs and unhygienic conditions. The Court appointed a Committee to go into these aspects and report back to the Court. Though the committee was set up to look into the matters pertaining Government Hospitals in Uttar Pradesh but the situation is no different in other states. The Court looked into the matter and ordered necessary steps to improve upon the conditions and it would have been a boon for the as a matter of fact for every one if the necessary steps were followed for government hospital all across the nations. In the Paschim Banga Khet Mazdoor v. State of West Bengal[12], the Supreme Court was primarily dealing with the issue lackadaisical nature of the administrative authorities because of which a poor labourer was forced to take recourse to expensive private medical care. Thus Supreme Court held that lack of finance cannot be a reason for the state to be unable to fulfil its duty as a welfare state which includes providing adequate medical care. In the case of People’s Union of Civil Liberties v. Union of India, a PIL was filed against the Government from backing out of a project that involved building of a psychiatric hospital cum medical college. The plan was approved but then backed out when it was found that the project would cost more than 40 Crores. The Supreme Court held that the hospital cum college was need of the hour and that funding should not be an issue. Thus central government and Delhi administration was ordered to resume the project. The pathetic conditions of the Government hospital makes people shift towards private hospitals. But these shifting are only but those who could afford them. Those who could not afford are left to die. And had it been the situation that the services and quality of Government Hospitals would have been as per the standard of what the committees recommend, even the ones who could afford private health care would go for the state run health care. Prior to the era of privatization, every person in sickness visited the government hospitals but as the state of those hospitals deteriorated, people are forced to shift to private health care which is not only expensive but also uneconomical in the long run, even for those who could afford it.
The growth of cities has always been accompanied by the growth of slums. Urbanization has broken down those traditional family and community [13]structures because of which the working class in particular is pushed to the brink of destitution in a crisis such as an epidemic or a natural calamity. The condition of urban poor is much worse than that of the rural poor because the urban poor has technology at his door step only he does not have means to make use of that technology. They are typically driven to the margins of the urban space, where living conditions are the most degraded and of little economic value.[14] No wonder why they are the ones who contact diseases like malaria, dengue, hepatitis, cholera and other viral and bacterial diseases which due to lack of proper treatment results to severe consequences. Even in case of emergency situations like road acc. There is a need for a comprehensive policy for primary healthcare for urban areas, which takes into account the special concerns of the poor. Such a policy would aim, first, to address the absolute deprivation of basic necessities— food, housing, water supply and sanitation that the urban poor experience. Second, there is a need to create an adequate and functional network of free services that are non-discriminatory and reach out to all sections of the population. Finally, an urban health policy would need to address the problem of social inequality in a proactive manner. The urban poor will continue to depend on the market, not merely for healthcare but for all aspects of daily life, including employment and survival needs. The state must recognize its obligation to protect the poor against the vagaries of the market. The economic disparity in a country like India cannot be ignored. A country where inequality in every form exists be it religion, economy, educational qualification, professional expertise, intellectual capacity, the mind set of every person in India inherently different. A person is forced to believe that one is better than other even if that would not be the case. The very reason why a fresh medical graduate migrates abroad or joins a private hospital is because of these various forms of inequality. A country that produces so many good doctors falling short of medical expertise is a shame. One could not pick and choose when there is scarcity and as we know the good old proverb that says practise makes a man perfect, we should make use of every help available. The medical students could be trained from the beginning in the form of medical camps under the guidance of experienced doctors to an extent that there would not be a scope for errors. There is no use of degrees if it is not for the service of one who needs it. It is the need of the moment to make the country realise that medical care is a need it should not be marketed openly.
By: Monalisa Minz and Manisha Das
[1] Healthcare in India: A Call for Innovative Reform – An Interview with Victoria Fan (NBR), retrieved from http://www.cgdev.org/article/healthcare-india-call-innovative-reform-interview-victoria-fan-nbr on 13.7.13, December 21, 2012
[2]Adv. Mihir Desai and Adv Kamayani Bali Mahabal, Health Care Case Law in India, Aug 2007
[3] Hathi Committee Report 1975
[4] (2007) 4 MLJ 1153
[5] The Alma Ata declaration adopted at the international Conference on Primary Health Care 1978.
[6] Bhore Committee 1943
[7] 1995 (3)SCC 42
[8] Ibid
[9] 1997 (2)SCC 83
[10] Ibid
[11] S.K.Garg v. State of U.P. decided on 21.12.1998
[12] 1996 SCC (4) 37
[13]Neha Madhiwalla, Health care in Urban Slums in India, National Medical Journal of India, Vol 20 No. 3, 2007, retrieved from http://www.nmji.in/archives/Volume_20_3_May_June/editorial/Editorial_2.pdf on 14.7.2013
[14] Health of the Urban poor in India, Issues, Challenges and the way forward., report of panel discussion on March 29, 2007 http://www.hss.iitm.ac.in/rt-ppp/Urban%20Health/Reports/Health%20of%20the%20urban%20poor%20in%20india-%20USAID.pdf on 14.7.2013
