The story of the vision and reality of Health for All in India during the last quarter of a century is a fascinating and inspiring, yet disturbing story. It is the story of emergence of the radical approach of primary healthcare, linked with the manifold efforts and experiments of many dedicated pioneers and community health activists, who sought to translate the dream into reality. It is also a chronicle of governmental bureaucracy and betrayal, of double talk and dilution, which has witnessed progressive debilitation of public health systems, paralleled by the unprecedented growth of the largest privatised health system in the world. And finally, it is the story of how the dream of Health for All has refused to die, and is now rising anew in various ways, especially in the form of the local-to-global process of the Peoples Health Assembly/Movement which has given the call for Health for All NOW!
Let's look at a few recent initiatives, which have been developed to obtain healthcare as a right. These efforts relate to both demanding health rights from the public health system and working for accountability of the private medical sector. In continuation of this are attempts to develop a campaign to establish the right to Healthcare as an operational and constitutional right. The underlying idea is that Health for All, meaning the essential conditions for health for everyone, should no longer remain an object of charity or largesse, but must become a basic human right. Such an entitlement could be justly claimed and obtained by every citizen of this country.
The public health system
Our public health system has been developed with a mandate of providing basic health services to all citizens, and is there accountable to the people. However, given the widespread and recurrent failure of this system to provide adequate services, in the recent past several initiatives have emerged to demand the right to healthcare at various levels. Certain initiatives, which have been developed by peoples organisations in Maharashtra and western Madhya Pradesh, mostly in collaboration with the SATHI (Support for Advocacy and Training to Health Initiatives) a sub-group of CEHAT (Center for Enquiry Into Health and Allied Themes), are described here as examples of the emerging processes.
A rural hospital in Ajara
Lessons to learn: the Ajara struggle has displayed determination of people to secure their health rightsAjara is a hilly, forested area in Kolhapur district of Maharashtra. An organisation of dam-affected people, Dharangrasta Parishad, associated with the political organisation, Shramik Mukti Dal, has successfully struggled for and ensured proper rehabilitation of displaced people, and has also developed a community health volunteer (Arogya Sathi) programme. SATHI has given technical inputs for the health initiative. It came to the notice of the local activists that the rural hospital in Ajara was not providing required obstetric services, as the specialist obstetrician was usually unavailable even during duty hours, being busy in his private hospital. Non-availability of other specialists and lack of drugs and were also identified as problems.
The struggle began in May 2000, with a delegation to the Medical Officer of the Rural Hospital, complaining about specialist medical officers in the rural hospital not fulfilling their duties, their taking bribes from patients, inadequate drug supply, lack of outreach services from primary health centres (PHC) and other issues. When this did not yield much result, a demonstration of over 450 people marched to the office of the block development officer (BDO) on 18 September 2000. The roads of Ajara reverberated with slogans such as Raste, pani, arogya seva/Hakk amcha, amhala dyava (Roads, water and healthcare/these are our right and must be given). Health officials from the entire taluka came for a detailed discussion with the peoples representatives, which went on for over three hours. This resulted in a firm assurance of improvement in the functioning of the Rural Hospital, and the errant obstetrician promising that he would be present to give services in the hospital.
The demonstration did have some impact, and the obstetrician, who previously used to come only once or twice a week for a few hours, now began attending to the hospital work for two full days a week. Complaints of staff demanding bribes also stopped. However, certain issues such as drug supply inadequate primary health care, remained.
From 3 January 2002, about 100 villagers started an indefinite dharna (sit-in agitation) in front of the BDO office in Ajara town, to press for demands concerning improvement in public health services. This unprecedented sit-in continued for 30 hours, subsequent to which a number of demands were agreed upon. Demands which were accepted included making the outpatient timing of the Ajara rural hospital user-friendly by extending it for an hour, and ensuring that the doctors in PHCs visit the sub-centres regularly as per specified dates. Other demands accepted were that iron-folic acid tablets to treat anaemia should be routinely given to anaemic non-pregnant women too. Ante-natal check ups of pregnant women, it was assured, could be done by the auxiliary nurse-midwife during her village visit, instead of the pregnant woman travelling to the sub-centre.
One major problem remains and this is inadequate drug supply in the Rural Hospital. The solution to this problem lies not with the local authorities, but needs to be tackled at the state level by increasing financial allocations for public health supplies. However, the Ajara struggle has shown how a determined organisation can establish definite peoples rights regarding public health services.
Health calendar programme in Dahanu
In Dahanu area, a tribal area in Thane district of Maharashtra, people reported that delivery of village level health services was unsatisfactory. Government nurses or multipurpose workers visits to the tribal hamlets were infrequent, affecting key services such as immunisation, antenatal care and malaria surveillance. Keeping this in mind, initially as part of a small WHO-supported project, a simple yet innovative health calendar programme was designed to help people monitor health services at the hamlet level in 1999-2000 onwards. The programme has been implemented by the peoples organisation, Kashtakari Sanghatna, with some technical input from CEHAT.
A simple calendar with a large blank space for every date was printed and copies were supplied to every hamlet, with about 80 hamlets regularly participating in the programme. First, the visit programmes of public health functionaries (auxiliary nurse midwife, multi-purpose worker) for each village were obtained from the local health authorities along with their scheduled activities. Then, on the calendar for each village, small symbolic diagrams were pasted depicting the scheduled activity on the expected dates of visit by functionaries. For instance, a diagram of immunisation would be pasted in the calendar on the date of the nurses scheduled visit for immunisation. These calendars are displayed at a few prominent places in each hamlet.
Public information of this sort helps people to be prepared for the activity (e.g. immunisation) and helps them to collect and avail of the service more effectively. The health functionary is supposed to sign against the date after his/her visit to the village. The hamlet health volunteer puts a cross (X) on the date and marks the functionary absent if he/she does not visit the village that day. Once in three months, there would be a meeting in the primary health centre, where hamlet health committee members come with their calendars and meet the medical officer and the field staff. Each hamlet presents its experience of health services in the last few months, points out when functionaries have been absent based on the calendar record, and discuss how the services can be improved.
This simple device markedly improved the frequency of service provision by public nurse-midwives in most hamlets. A year after the commencement of the programme, a survey of 56 hamlets showed that the visits of auxiliary nurse midwives to hamlets doubled after the calendar programme started. For the first time, people felt that they had a tool to ensure accountability of the health staff, and at the same time, their utilisation of services and communication with the staff also improved. This simple tool has helped people to avail of their right to village level health services.
Accountability of the private medical sector
Today, over three-fourths of outpatients care and more than half of inpatients care in India is provided by the private medical sector. However, while the public health system has an acknowledged commitment to provide basic services to all, private doctors can refuse any patient who may not be able to afford their fees. What is more, as of now the private medical sector is largely unregulated regarding basic standards of care. There is great variation in the quality and rationality of care provided by various private practitioners and nursing homes. In this context, ensuring basic accountability of private doctors and hospitals regarding standards of care is a very important but complex and somewhat neglected task. However, some attempts have been made in this direction, and the need for regulation of this sector is now recognised even by health policy makers. A couple of examples, one at the local level and another at the state level, would help illustrate the dimensions of this issue.
Health education to doctors
The overuse and often unnecessary administration of injections and saline infusions by certain doctors in order to be able to charge more is a common feature in rural areas. The irrational practice is not only exploitative, since poor patients have to pay much more for the unwarranted powerful injection or saline bottle, but may also lead to various adverse health consequences. The ignorance of patients as well as fallacious beliefs facilitates this common form of medical malpractice. Considering the need to curb this irrational practice, in early 2000 in Dahanu, activists of Kashtakari Sanghatna and health activists from CEHAT decided to help create mass consciousness about this issue.
A "Dear Doctor" letter was drafted requesting doctors to not give unnecessary injections or saline infusions. Posters explaining the situations where injections or saline are genuinely needed, as also when they are not required, were printed by CEHAT. Activists of the Sanghatna held meetings in nearly a hundred hamlets, explaining the issue, put up and explained posters and took signatures of people who agreed to the letter. Over 3,000 signatures and thumb impressions of people requesting doctors not to give unnecessary injections and saline were collected. On 19 May 2000, more than 200 adivasi people marched through the main roads of Dahanu town, raising rather unusual slogans: What is saline? Salty water. Stop cheating by unnecessary injections. Healthcare is our right. They visited each private doctor on the two main roads of the town. Some of the unqualified doctors closed their clinics and vanished. Those who did not were confronted by the people and were asked to publicly declare that they will not give unnecessary injections and saline, and were asked to put up the posters against irrational use of injection and saline prominently outside their clinic or hospital. Some doctors were sympathetic and addressed the people expressing their support, while others were defensive yet agreed that unnecessary injections and saline should be avoided.
This procession had been preceded by a similar, but smaller demonstration in Kasa on 17 May where a similar dialogue took place with private doctors, and in a few cases doctors with doubtful qualifications were requested to show their degrees. As expected, these demonstrations created a flutter among the local medical community and on the night of 19 May itself, the Indian Medical Association (IMA), Dahanu called an emergency meeting. Health activists and members of Kashtakari Sanghatna were asked to come for a discussion. While the IMA doctors expressed their displeasure with the manner in which this issue had been raised, ultimately they conceded the genuineness of the issue and expressed their support for the move against irrational use of injections and saline.
Regulating clinical establishments
Lack of regulation of standards for care has long been recognised as a problem with the private medical sector. Attempts to remedy this situation started in Maharashtra in 1991, when activists of Medico Friends Circle, Mumbai filed a public interest litigation in Mumbai high court based on a case of fatal medical negligence in a private nursing home in the city. The High Court formed a committee to look into the larger issue of standards of care, and ordered a study of private nursing homes and hospitals in the eastern suburbs of Mumbai. The study revealed dismal physical infrastructure and lack of appropriate trained personnel in many private establishments even in a city like Mumbai. The Court castigated the authorities for lack of implementing even the existing Bombay Nursing Homes Regulation Act, 1949 (BNHR).
This litigation gave a boost to a subsequent process of studying the private medical sector and advocacy for basic regulation of standards in such institutions. CEHAT and other organisations played a seminal role in these subsequent efforts. The health department of Maharashtra realised that the existing BNHRA was grossly inadequate to effectively regulate standards in private medical establishments, and as part of its Maharashtra Health Systems Development Project began a process to modify this Act in 2000. With significant inputs from a senior researcher who had been involved in studying the private medical sector in Maharashtra, the department formulated a draft for modified BNHR Act.
Besides laying down clear definitions and prescribing the need for standards, an important feature of this proposed modification was the stipulation of representative bodies at district and state levels (including representatives of government, private doctors and hospitals along with health non-government organisations and consumer organisations) to deal with administration of various provisions of the Act. The draft Act was discussed in a unique state level consultation in July 2001 organised by the health department and attended by representatives of private doctors and hospitals associations, health sector non-government organisations and consumer organisations. This led to a large number of suggestions regarding the formulation of the modified Act. While this process resulted in a significantly modified draft, a need was felt to elicit further inputs from private doctors associations and take care of various objections.
Jan Swasthya Abhiyan, Maharashtra, took the initiative to organise further discussions on the draft Act in March and April 2002, involving health non-government organisations and consumer groups on the one hand, along with organisations such as the Association of Medical Consultants on the other. The Department conducted another consultation with various stakeholders in July 2002, and the formulation of a significantly improved draft of the modified Act. This Act, which would lead to formulation of minimum standards for infrastructure and humanpower in private clinical establishments along with standard treatment guidelines, has been a pioneering and participatory effort in regulation of such establishments. The draft modified Act is expected to be tabled soon in the Maharashtra Assembly, which would become landmark legislation for ensuring accountability of the private medical sector.
National Campaign for healthcare as a fundamental right
Jan Swasthya Abhiyan in various states has begun a process of documenting cases of denial of healthcare. Information is being collected with the help of a specific protocol, and cases where denial of health services has led to the loss of life, physical damage or severe financial loss to patients are the focus. These case studies depict the real status of provision of the primary health services by the government, and strengthen the demand for the right to public health services.
Several case studies were recently presented to the National Human Rights Commission (NHRC), on a National Public Consultation on right to healthcare on held on 6 September 2003 at Mumbai. The day was the 25th anniversary of the Health for All declaration (the Alma Ata conference commenced on 6 September 1978). Justice Anand, the chairperson of NHRC, agreed that health care must be established as a human right. The JSA aims to build a national social consensus on this issue, in an effort to establish it as a legal right and the operational entitlement of basic health services. This may necessitate making the right to healthcare a fundamental (constitutional) right.
While the journey ahead is difficult and uncertain, is it sure that the dream of Health for All will be kept alive, and the veterans of this movement will be joined by ranks of active citizens, renewing everyone.