Healthcare Opportunities for Right to Health in India

Introduction

Right to health is primarily not just a call for consigning legal status of a human aspiration. It has much more to do with the civilisational preference of a nation state. It may be a sign of the value attached to the lives of citizens or an intrinsic priority towards welfare of the people who are instrumental to the progress and growth of a society. A modern state that invests heavily in creating and maintaining tangible assets, infrastructure, institutions, etc. can ill-afford to leave its people out of the health safety net. Acknowledging the health care as a human right implies a moral and constitutional commitment for the states to ensure equity, affordability and ubiquity in its availability for citizens. It is an important constituent of internationally agreed principles of human rights, inalienable from other similar canons that the comity of nations has proposed for itself. Achieving of other accepted rights like life, food, education, livelihood and shelter, etc. is largely crucial and dependent on realisation of right to health. This includes not only medical and clinical acre but also preventive measures and services like hygiene, sanitation, safe drinking water, food, nutrition, education and sensitisation on health issues. An essential concern of rights-based approach to health entails that due prioritisation is ensured for the health care needs of the poor, deprived and marginalised groups of society in the policies and programmes. 

The principle has been echoed in the recently adopted 2030 Agenda for Sustainable Development and Universal Health Coverage, which lays down that we must achieve universal health coverage and access to quality health care. No one must be left behind. 

Health Care as Social Objective

For human beings, Mental and Physical wellness is the very basis of healthcare that shapes their personality. The human race, over the ages has progressed and survived by safeguarding health and well-being. Diseases and mishaps must have had their grip over humans ever since they came into existence. The multiple causes behind such agonies are both external and internal which range from nature's wrath to lack of proper hygiene. The government agencies and professional health facilities are better equipped to prevent the multiple health hazards and deal with the ailments in an easier, effective and dependable manner. Every sovereign state concerned with the welfare of her citizens takes necessary steps for promoting well-being, health, peace, morals, education and public order among the people along with the efforts to augment wealth and prosperity. Being indispensable to the very physical existence of the community, maintenance of highest standards of public health care is one of the major social objectives in today’s world.

Talking about our country, India’s rank in the Human Development Index Report 2018 (130 out of 189 countries) issued by the United Nations Development Programme (UNDP) depicts the level of ignorance of the health sector in a country like India. Being the fastest growing economies of the world, the very essential components of primary health care is promotion of food supply, proper nutrition, availability of safe water and basic sanitation provisions for quality health information. But to our dismay, the lack of access to healthcare services, mis-provision of essential medicines and scarcity of doctors are other bottlenecks in the primary health care scenario that needs to be addressed due to noticeable differences in quality between public and private health care. 

Meaning and Nature of Health

Health has been defined to mean a state of absolute mental, physical and social well being; and therefore is not only restricted to merely absence of diseases. World Health Organization (WHO) defines Health, as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. This definition has been further simplified to include ability to lead economically as well as socially productive life. This led to the expansion of the dimensions and scope of right to health which has multiple effects on the duty and responsibility of the health professionals along with their relationship with the society at large.

Health is a causative factor that affects country’s aggregate level of economic growth. Since development is a consequence of good health, even the poorest developing countries should make it a priority to invest in the health sector. Unfortunately, health has been poorly invested in by countries with low human development, and the health sector still remains largely untapped and continues to suffer neglect. 

Right to Health 

Right to Health being an issue of fundamental importance in the Indian society, refers to the most attainable levels of health that every human being is entitled to. Health has been much regarded as the basic and fundamental human right by the international community under international human rights law. In contrast to all the other human rights, the right to health creates an obligation upon the states to ensure that the right to health is respected, protected and fulfilled, and is duly entitled to all its citizens. The responsibility to protect, respect and fulfill the right to health lies not only with the medical profession but also with public functionaries such as administrators and judges. The traditional notion of healthcare has now tended to be individual-centric and has focused on aspects such as access to medical treatment, medicines and procedures. The field of professional ethics in the medical profession has accordingly dealt with doctor patient relationship and the expansion of facilities for curative treatment. In such a context health care at collective level was largely identified with statistical determinants such as life expectancy, mortality rates and access to modern pharmaceuticals and procedures. It is evident that such conception does not convey a wholesome picture of all aspects of the protection and promotion of health in society. There is an obvious intersection between health care at the individual as well as societal level and the provision of nutrition, clothing and shelter. Also the term health has an inter-relationship with aspects such as the provision of a clean living environment, protections against hazardous working conditions, education about disease prevention and social security measures in respect of disability, unemployment, sickness and injury. More than half a century’s experience of waiting for the policy route to assure respect, protection and fulfillment for healthcare is now behind us. The right to healthcare is primarily a claim to an entitlement, a positive right, not a protective fence.

The emphasis thus needs to shift from ‘respect’ and ‘protect’ to focus more on ‘fulfill’. For the right to be effective optimal resources that are needed to fulfill the core obligations have to be made available and utilized effectively. Further, using a human rights approach also implies that the entitlement is universal. This means there is no exclusion from the provisions made to assure healthcare on any grounds whether purchasing power, employment status, residence, religion, caste, gender, disability, and any other basis of discrimination.

Ever since it was established as the specialized UN agency the World Health Organisation (WHO) has committed itself to the cause of mainstreaming health care programmes and policies as an integral part of human rights structure across the world. The Organisation has relentlessly pursued this commitment through a comprehensive approach to health and human rights by providing moral, political and technical leadership to this mission. It has supplanted the human rights rhetoric by strongly advocating integration of human health issue into this agenda besides furthering the right to health in the discourses on international law and international development activities. This integrated approach offers an opportunity to broaden context of human rights to include health along with other emerging concerns like gender equality and equity. This advocacy has helped build an awareness and mechanisms for realisation of universal health care as a matter of right.

Evolution and International Standards Pertaining to Right to Health

The origination of the right to health dates as back as 1946 when the first international organisation, World Health Organization (WHO) came into existence to formulate health terms as human right. And even prior to the coming of World Health Organization, there were several countries that have been in the phase of granting of health as a fundamental right. The movement owes its existence to the industrial revolutions also wherein the workers were treated as commodity and the employers paid no heed to the insanitary conditions of working areas. Subsequently, the demand for health grew to the extent that it came to be treated as one of the important aspect of the fundamental and basic human rights that any human being having his/her existence on earth is entitled to.

Presently, the international organisation working towards the highest attainment of Right to Health is the World Health Organization (WHO). Within this, there is a World Health Organisation Indicatory Metadata Registry (IMR) that acts as a central source of meta-data and lays down certain indicators for the highest attainment of standards ensuring right to health. These standards are followed by WHO as well as other organisations also. Now, the general question which arises is as to what does these indicators include. The indicators are actually inclusive of all the definitions, the methods of estimation, data sources and certain other information that provide a better understanding of the interests. As many as 100 indicators have been prioritized by the global community that provides crisp information on the existing health situation, trends and rebuttals at the global and national level. The indicators are majorly classified into four heads: Health status, Risk factors, Service coverage, and Health systems.

Healthcare Origin in India

India is a country with rich, centuries-old heritage of medical and health sciences. The approach of the ancient Indian medical system was one of holistic treatment. The history of healthcare in India can be traced to the Vedic times (5000 BCE), in which a description of the Dhanwanthari, the Hindu god of medicine, emerged. Atharvaveda, one of the four Vedas, is considered to have developed into Ayurveda, a traditional Indian form of holistic medicine. The philosophy of Ayurveda, “Charaka Samhita” (the famous treatise on Medicine compiled by Charaka), and the surgical skill enunciated by Sushrutha, the father of Indian surgery, bear testimony to the ancient tradition of scientific healthcare amongst the Indian people. Historically, the most outstanding hospitals in India were those built by King Ashoka (273-232 BCE). Medicine based on Indian medical principles was taught in the Universities of Taxila and Nalanda.

During the 17th and 18th centuries, there was a slow and steady growth of the modern system of medicine in India, starting with the arrival of European Christian missionaries in South India in the 17th century. In 1664 at Chennai, the British opened the first modern hospital for soldiers and, in 1688, another for the civilian population. Organised medical training began with the opening of the first medical college in Calcutta in 1835, followed by a school in Mumbai in 1845 and one in Chennai in 1850. (Jawahar)

Need of Right to Health in India-Current Metrics

According to the latest National Health Profile (NHP) 2018, India is among the countries with the least public health spending. India, the world’s second-most populous nation and its sixth-largest economy spends less on healthcare than poorer nations, retarding growth. The Indian government plans to live up to its promise of 'health assurance to all Indians' with a health spending of just Rs. three per person per day that counts for 1.02 per cent of the GDP. (India's Health Crisis)

• India is one of the countries with the lowest public health spending. Even lower-income countries like Bhutan, Sri Lanka and Nepal spend 2.5 per cent, 1.6 per cent and 1.1 per cent of the GDP respectively on their people’s health.

• The statistics by WHO's health financing profile for 2017 shows 67.78 per cent of total expenditure on health in India was paid out of pocket, while the world average is just 18.2per cent.

• India's per capita public expenditure on health increased from Rs 621 in 2009-10 to Rs 1,112 (around $16 at current exchange rate) in 2015-16. However, as compared with other countries, Switzerland spends $6,944 on health per capita, the United States spends $4,802 and UK $3,500.

• One of the central problems has been the low levels of public spending on health, and as a, result the poor access to affordable and good quality healthcare for the majority of India’s population. The National Crime Records Bureau says that 0.38 million people committed suicide in India between 2001 and 2015 due to the lack of treatment facilities. This is 21 per cent of the total suicides in that time. According to National Sample Survey Office (NSSO), outstanding loans for health reasons doubled between 2002 and 2012. In India, low health spending is pushing people towards the private sector for their healthcare needs since India stands sixth in the out-of-pocket (OOP) health spending among the low-middle income group of 50 nations.

• Seven per cent of Indians fall below the poverty line just because of indebtedness due to health expenditure. This figure hasn’t changed much in a decade. As a result about 23 per cent of the sick can't afford healthcare.

• The result of that about 55 million Indians were pushed into poverty in a single year because of having to fund their own healthcare and 38 million of them fell below the poverty line due to spending on medicines alone.

• More than half (51 per cent) of our population seeks care in private sector because the public-healthcare system is overwhelmed and delivers poor care. Yet, more expensive care does not lead to better health outcomes, with 1.6 million Indians dying due to poor quality of healthcare. India ranked 145 out of 195 on 2018 global healthcare quality and access index. 

The above scenario is reason enough for a right based approach to health care so that the inadequacies of several kinds may be considered and negotiated within a uniform policy framework throughout the country. The present health care policy framework in the country merits a closer analysis before we evaluate its effectiveness or the lack of it in meeting the quantitative as well as qualitative demands of health sector. This framework need to, not only, ensure basic health infrastructure, particularly in backward and less developed regions of the country, but also prescribe minimum standards of medical and health care facilities besides a robust regulatory mechanism for private health care providers. It is the private sector, mainly, which pockets major share of out-of-pocket expense incurred by the people on medical facilities. 

The Constitution of India and Right to Health 

The Right to health has not been explicitly incorporated as a fundamental right in the Constitution of India. However, the framers and the founding fathers of the Constitution in their vision for welfare of citizens made it obligatory on state, through the Directive Principles of State Policy, under Part IV of the Constitution wherein it's the responsibility of the state to uphold social and economic justice to its citizens. Therefore, a general inference is that Part IV of the Constitution directly or indirectly relates to the general public policy in terms of health.

Article 38 of the Constitution assigns the state the responsibility to secure social order and promote general welfare by necessary provisions for public health. Article 39 clause (e) pertains to the protection of health of the workers. Article 41 relates to providing public assistance by the state in special circumstances like sickness, disability, adulthood, etc. Article 42 protects the health of the infant and therefore the mothers, by implication ensuring maternity benefit. Article 47 imposes a primary duty of the state in improvement of public health, in securing of justice, providing humane conditions of labor for the workers, extension of advantages pertaining to sickness, disability, adulthood and maternity benefits. In addition to the present, the state is under an obligation to ban the consumption of liquor within the interest of the general public good. Article 48A states the duty of the state towards providing of an honest and healthy pollution free environment. However, these Directive Principles of State Policy are in the nature of guiding principles which do not imply any legal entitlement and hence non-justiciable, i.e. they are not enforceable in the court of law.

The Constitution incorporates provisions guaranteeing everyone’s right to the highest attainable standard of physical and mental health. Article 21 of the Constitution guarantees protection of life and personal liberty to every citizen. The Supreme Court has held that the right to live with human dignity, enshrined in Article 21, derives from the directive principles of state policy and therefore includes protection of health. Further, it has also been held that the right to health is integral to the right to life and the government has a constitutional obligation to provide health facilities. Failure of a government hospital to provide a patient timely medical treatment results in violation of the patient’s right to life. Similarly, the Court has upheld the state’s obligation to maintain health services. Public interest petitions have been filed under Article 21 in response to violations of the right to health. They have been filed to provide special treatment to children in jail; on pollution hazards; against hazardous drugs; against inhuman conditions in after-care homes; on the health rights of mentally ill patients ; on the rights of patients in cataract surgery camps; for immediate medical aid to injured persons ; on conditions in tuberculosis hospitals; on occupational health hazards; on the regulation of blood banks and availability of blood products ; on passive smoking in public places ; and in an appeal filed by a person with HIV on the rights of HIV/AIDS patients.

Judicial Pronouncements on the Right to Health under Part III of the Constitution

The Directive Principles holding being of only persuasive value and not enforceable as a matter of right, the state has not been able to fulfill its duty, responsibility and liabilities in providing and protecting health of the common public to the level expected of it. Therefore, the Hon’ble Supreme came to the rescue and brought the right under the purview of Article 21 of the Constitution of India. The scope of Article 21 has, thus, been widened. Article 21 ensures the right of life and liberty to each individual, citizens or non-citizens. The concept of personal liberty is meant to include rights that may or may not be directly linked to the life and liberty of a person; which now includes right to health as well. 

The initiation of the period of progressive jurisprudence following recognition of fundamental right was lately during the litigation pertaining to human rights in Keshwanand Bharti v. State of Kerala, (1973) 4 SCC 225. And around the same time, the standing rules were relaxed pertaining to the promoting of Public Interest Limited, and access to justice. There further led to a steep rise in the health related litigation. 

Subsequently, there were further developments including establishment of the consumer courts and secondly, the recognition of health care as fundamental right. This is because, the Supreme Court allowed individuals to approach directly for the protection of human rights. 

Right to life under Article 21 of the Constitution has been liberally interpreted to mean something more than merely human existence and includes the right to live with dignity and decency. 

In 1995, the Hon’ble Supreme Court of India in the case of Parmanand Katra v. Union of India, AIR 1989 SC 2039 held that those who are indulged into the profession of medical are in charge of public health and have an inherent obligation to protect the same so that those who are innocent can be protected and the guilty be punished.

In yet another case of Spring Meadow Hospital v. Harijol Ahluwaliya, AIR 1998 SC 180, the court held that there is need for sensitization of relevant law pertaining to the content of the right to health. An act to deal with legal prohibition of commercialized transplantation has further animated the right to health.

Therefore, the recognition of dignity and fundamental right to life led to recognizing of the importance of health. In another case of Bandhua Mukti Morcha v. Union of India AIR 1984 SC 812, the court held that although the Directive Principles of State Policy hold persuasive value, yet they should be duly implemented by the state; and it was in this case also that the court had interpreted the dignity and health within the ambit of life and liberty under Article 21 of the Constitution of India. 

In Consumer Education and Research Centre v. Union of India, the court had expressly opined that right to health was also an integral factor to lead a meaningful life and for the right to life under Part III. And the court also stated that health includes the access to medical care for the highest attainment of living standards.

In State of Punjab v. Ram Lubhaya Bagg (1998) a, while examining the revolving around the issue of right to health under Article 21, 41 and 47 of the Constitution of India, the court observed that right of one correlates with the duty of another. Hence, the right entrusted under Article 21 imposes a parallel duty on the state which is further reinforced as under Article 47. Even though several schools and hospitals are set up by the government but the duty is not fulfilled until they can be in reach of the general public. It is pertinent to note that the Hon’ble Court in this case regarded health to be a sacrosanct, sacred and valuable right. 

Further, in Paschim Banga Khet Mazdoor Samity & Ors. v. State of West Bengal, (1996) 4 SCC 37 case, the scope of Article 21 was further widened; herein the court held that it is the responsibility of the government to provide adequate medical aid to every person and to work for the welfare of the general public. Moreover, Article 21 imposes obligation on the state, the state is required to protect and safeguard right of every person. 

In T. Ramakrishna Rao v. Hyderabad Development Authority case, the Hon’ble High Court gave the observation that protecting environment is duty of both citizens and the state. Article 21 also embraces the protection and preservation of the environment for the reason that the environmental pollution is a slow death and therefore, it is violation of Article 21 of the Constitution of India. 

In the famous case of Ratlam Municipal Council v. Vardichand, Air 1980 SC 1622 case, the court held that it is the primary duty of the state under Article 47 of the Constitution to ensure the living conditions of the people are healthy and enforce this duty against any governmental body or authority who defaults in doing so irrespective of the financial resources it has. 

The Hon’ble Supreme Court in another case, CESC Ltd. v. Subash Chandra Bose, AIR 1992 SC 573 held that health is a fundamental right and is not restricted to merely absence of diseases or sickness. The medical and health facilities are sort of incentive for the workers’ to work with best productivity both in physical and mental terms. Conclusively, medical facilities are also part of the social security. 

Present Scenario of Healthcare in India

In the federal classification of various services and responsibilities in the Constitution, health care has been retained as a state subject. This might have been done to ensure its availability through the administrative reach of the state governments across the width and depth of the respective states. 

This arrangement makes every state responsible for "raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties". The Indian health care system is susceptible and too vulnerable to withstand a major health crisis became evident when it had a brush with the Covid-19 pandemic. Major questions are being asked as to what could have prevented, mitigated and lessened the misery and helplessness experienced during the catastrophe. Is it the country’s low expenditure on public health? Or, the citizens could be saved by a statutory framework that warrants right to health as a fundamental right? How does it make a difference? The answer lies in building health care capacities and facilities at the grassroots level mandated by the rights framework. Citizens’ right to health cannot be achieved just by its inclusion in the rights framework, it is dependent on how evenly we proliferate medical infrastructure, budgetary and financial allocations, strengthen life sustaining and supporting systems through other essentials wherewithal for human well-being. The major health related programmes and strategies launched by the federal government are: 

National Health Policy

The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002, have served well in guiding the approach for the health sector in the Five-Year Plans. Now, the Policy again got updated in 2017 and changes were made in four major ways. First, the health priorities are changing. Although maternal and child mortality have rapidly declined, there is growing burden on account of non-communicable diseases and some infectious diseases. The second important change is the emergence of a robust health care industry estimated to be growing at double digit. The third change is the growing incidences of catastrophic expenditure due to health care costs, which are presently estimated to be one of the major contributors to poverty. Fourth, a rising economic growth enables enhanced fiscal capacity. Therefore, a new health policy responsive to these contextual changes is required.

The primary aim of the National Health Policy, 2017, is to inform, clarify, strengthen and prioritize the role of the Government in shaping health systems in all its dimensions- investments in health, organisation of healthcare services, prevention of diseases and promotion of good health through cross-sectoral actions, access to technologies, developing human resources, encouraging medical pluralism, building knowledge base, developing better financial protection strategies, strengthening regulation and health assurance. 

The policy envisages as its goal the attainment of the highest possible level of health and well-being for all at all ages, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence. 

This would be achieved through increasing access, improving quality and lowering the cost of healthcare delivery. The policy recognizes the pivotal importance of Sustainable Development Goals (SDGs). An indicative list of time bound quantitative goals aligned to ongoing national efforts as well as the global strategic directions is detailed at the end of this section. 

The Key Policy Principles of National Health Policy are:

i. Professionalism, Integrity and Ethics: The health policy commits itself to the highest professional standards, integrity and ethics to be maintained in the entire system of health care in the country, supported by a credible, transparent and responsible regulatory environment.

ii. Equity: Reducing inequity would mean affirmative action to reach the poorest. It would mean minimizing disparity on account of gender, poverty, caste, disability, other forms of social exclusion and geographical barriers. It would imply greater investments and financial protection for the poor who suffer the largest burden of disease. 

iii. Affordability: As costs of care increases, affordability, as distinct from equity, requires emphasis. Catastrophic household health care expenditures defined as health expenditure exceeding 10 per cent of its total monthly consumption expenditure or 40 per cent of its monthly non-food consumption expenditure, are unacceptable. 

iv. Universality: Prevention of exclusions on social, economic or on grounds of current health status. In this backdrop, systems and services are envisaged to be designed to cater to the entire population- including special groups.

v. Patient-centered and Quality of Care: Gender sensitive, effective, safe, and convenient healthcare services to be provided with dignity and confidentiality. There is need to evolve and disseminate standards and guidelines for all levels of facilities and a system to ensure that the quality of healthcare is not compromised. 

vi. Accountability: Financial and performance accountability, transparency in decision making, and elimination of corruption in health care systems, both in public and private.

vii. Inclusive Partnerships: A multi-stakeholder approach with partnership & participation of all non-health ministries and communities. This approach would include partnerships with academic institutions, not for profit agencies, and health care industry as well. 

viii. Pluralism: Patients who so choose and when appropriate, would have access to AYUSH care providers based on documented and validated local, home and community based practices. 

ix. These systems, inter alia, would also have Government support in research and supervision to develop and enrich their contribution to meeting the national health goals and objectives through integrative practices. 

x. Decentralisation: Decentralisation of decision making to a level as is consistent with practical considerations and institutional capacity. Community participation in health planning processes, also to be promoted side by side. 

xi. Dynamism and Adaptiveness: constantly improving dynamic organisation of healthcare based on new knowledge and evidence with learning from the communities and from national and international knowledge partners is designed.

National Health Mission

The National Health Mission (NHM) encompasses its two Sub-Missions, the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM). The main programmatic components include Health System Strengthening, Reproductive-Maternal- Neonatal-Child and Adolescent Health (RMNCH+A), and Communicable and Non-Communicable Diseases. The NHM envisages achievement of universal access to equitable, affordable & quality healthcare services that are accountable and responsive to people’s needs.

The Union Cabinet vide its decision dated 1st May 2013 has approved the launch of National Urban Health Mission (NUHM) as a Sub-mission of an over-arching National Health Mission (NHM), with National Rural Health Mission (NRHM) being the other Sub-mission of National Health Mission. 

National Urban Health Mission (NUHM) seeks to improve the health status of the urban population particularly slum dwellers and other vulnerable sections by facilitating their access to quality primary healthcare. NUHM would cover all state capitals, district headquarters and other cities/towns with a population of 50,000 and above (as per census 2011) in a phased manner. Cities and towns with population below 50,000 will be covered under NRHM. 

National Rural Health Mission (NRHM) seeks to provide equitable, affordable and quality health care to the rural population, especially the vulnerable groups. Under the NRHM, the Empowered Action Group (EAG) States as well as North Eastern States, Jammu and Kashmir and Himachal Pradesh have been given special focus. The thrust of the mission is on establishing a fully functional, community owned, decentralised health delivery system with inter-sectoral convergence at all levels, to ensure simultaneous action on a wide range of determinants of health such as water, sanitation, education, nutrition, social and gender equality. Institutional integration within the fragmented health sector was expected to provide a focus on outcomes, measured against Indian Public Health Standards for all health facilities.

Under the National Health Mission, the government has launched several schemes like:

1. Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) 

2. Rashtriya Bal Swasthya Karyakram (RBSK)

3. The Rashtriya Kishor Swasthya Karyakram

4. Janani Shishu Suraksha Karyakaram 

5. National AIDS Control Organisation 

6. Revised National TB Control Programme 

7. National Leprosy Eradication Programme 

8. Mission Indradhanush 

9. National Mental Health Programme

10. Pulse Polio 

11. Pradhan Mantri Swasthya Suraksha Yojana (PMSSY): 

12. Rashtriya Arogya Nidhi

13. National Tobacco Control Programme 

14. Integrated Child Development Service

15. Rashtriya Swasthya Bima Yojana 

16. Ayushman Bharat Yojana or Pradhan Mantri Jan Arogya Yojana (PMJAY) or National Health Protection Scheme 

Challenges

For a meaningful and realistic implementation of universal health care as a matter of constitutional right all the available resources need to be pooled into a nationwide organised structure that can address primary issues like equity, availability and affordability. Much more than the legislative support a sustainable and definitive model, based on financial, human and scientific resources needs to be developed. Besides laying down parameters for health service norms and financial requirements there is a huge requirement of qualified human resources, access to medical equipment, medicine, pathological lab network and preventive measures like vaccination. Private health care sector, which at present has a crucial role and decisive presence, will have to be integrated into this model. Still, it remains to be seen how all this adds up to meet the challenge.

Financial Challenge

Although several forms of health financing exist in India, most of the country’s health expenditure is supported by private spending, primarily Out of Pocket (OOP), with public funds constituting an insufficient amount. Despite several government initiatives in social protection, such as the Employees’ State Insurance Scheme and the Central Government Health Scheme, only about one fourth of the population is covered by some form of health insurance.

The projected cost of Universal health care in India way back in 2001-02 came to be 2.98% of GDP. (Calculations done on population base of 1 billion and GDP of Rs. 20,000 billion; $1 = Rs.45, that is $13.24 billion). Presently this requires over 3.5 per cent of GDP as expenditure on health care.

The financial requirements need to be met mainly by tax-based public financing, and marginally by a possible social health insurance mechanism. The latter being an uncertain and relatively lesser quantum in view of small fraction of employment in the formal sector. In 2009, India’s total health expenditure as a percentage of the GDP was 4.2 per cent. The picture, however, changes dramatically when we examine levels of per capita health expenditures at PPP$132 per capita. The proportion of public spending on health by India is significantly low, not because India is poor but principally due to the very low per cent of public spending that Indian governments devote to health – typically in a range of 3-4 per cent - amongst the lowest of any country in the world. This reflects the very low priority that, historically, governments in India have accorded to the health sector. This was due to the dramatically lower allocation priority that Indian governments devoted to health.

Infrastructure

As per the present population norms for the health centres, India’s population for the year 2022 will require staffing for 3.14 lakh SHCs, over 50,000 PHCs, over 12,500 CHCs, as well as close to 5,000 sub-district hospitals, 642 district hospitals and over 500 medical colleges (under the 2 beds per 1,000 population norm (see Chapter on Health Service Norms). The staffing requirements for these facilities, have been assessed at 45.7 lakhs.

Human resource requirements for the year 2022 are estimated at close to 64 per cent for rural health facilities, i.e. SHCs, PHCs and CHCs. These requirements for various categories come to almost 12.6 lakh (25%) at SHCs; over 12 lakhs (24%) at PHCs; roughly 6.9 lakhs (14%) at CHCs, which are designated as the first referral units for rural areas; close to 11.3 lakhs (23%) at the sub- district hospitals for secondary level care and the remaining 6.8 lakhs (14%) for tertiary care at district and medical college hospitals.

Human Resource

Bhore Committee Report, which is still in reckoning with the Ministry of Health and Family Welfare, Government of India, laid down the agenda for universal health care for India, way back in 1946. It had recommended following levels of availability of human resources for a national health service: 

• one doctor per 1600 persons  

• one nurse per 600 persons  

• one health visitor per 5000 persons  

• one midwife per 100 births  

• one pharmacist per 3 doctors  

• one dentist per 4000 persons 

• one hospital bed per 175 persons 

• one PHC per 10 to 20 thousand population depending on population density and geographical area covered 

• 15 per cent of total government expenditure to be committed to health care, which at that time was about 2 per cent of GDP 

During the past eleven Five Year plans, India has substantially upgraded and increased her health facilities. The country presently has 1,47,069 Sub Health Centres (SHCs), 23,673 Primary Health Centres (PHCs), 4,535 Community Health Centres (CHCs)1 and 12,760 hospitals in the Government sector. The evidence on the actual functionality of these facilities, however, is mixed. As per the District Level Household and Facility Survey -III (DLHS 2007-2008), 62 per cent of PHCs are conducting less than 10 deliveries in a month, 10 per cent of CHCs do not provide 24x7 normal delivery services, 34 per cent of CHCs do not have operation theatre facilities, only 19 per cent of CHCs offer caesarean section deliveries, only 9 per cent of CHCs have blood storage facilities3 and of the 4,535 CHCs, 754 only are functional as per IPHS norms.

Findings suggest that in 2011-2012, there were 2.5 million health workers (density of 20.9 workers per 10 000 population) in India. However, 56.4 per cent of all health workers were unqualified, including 42.3 per cent of allopathic doctors, 27.5 per cent of dentists, 56.1 per cent of Ayurveda, yoga and naturopathy, Unani, Siddha and homoeopathy (AYUSH) practitioners, 58.4 per cent of nurses and midwives and 69.2 per cent of health associates. By cadre, there were 3.3 qualified allopathic doctors and 3.1 nurses and midwives per 10 000 population; this is around one quarter of the World Health Organization benchmark of 22.8 doctors, nurses and midwives per 10 000 population. Out of all qualified workers, 77.4 per cent were located in urban areas, even though the urban population is only 31 per cent of the total population of the country. This urban-rural difference was higher for allopathic doctors (density 11.4 times higher in urban areas) compared to nurses and midwives (5.5 times higher in urban areas). 

As per the figures reported in the World Health Statistics Report (2011), the density of doctors in India is 6 for a population of 10,000 and that of nurses and midwives is 13 per 10,000, which represents 19 health workers for a population of 10,000.

Based on the analysis of two sources of data: (i) National Health Workforce Account (NHWA) 2018 and (ii) Periodic Labour Force Survey 2017-2018 of the National Sample Survey Office (NSSO) a study by Anup Karal, et al. collated comparable estimates of different categories of health workers in India, density of health workforce and skill-mix at the all India and state levels.

The study estimated (from NHWA 2018) a total stock of 5.76 million health workers which included allopathic doctors (1.16 million), nurses/midwives (2.34 million), pharmacist (1.20 million), dentists (0.27 million), and traditional medical practitioner (AYUSH 0.79 million). However, the active health workforce size estimated (NSSO 2017-2018) is much lower (3.12 million) with allopathic doctors and nurses/midwives estimated as 0.80 million and 1.40 million, respectively. Stock density of doctor and nurses/midwives are 8.8 and 17.7, respectively, per 10,000 persons as per NHWA. However, active health workers' density (estimated from NSSO) of doctor and nurses/midwives are estimated to be 6.1 and 10.6, respectively. The numbers further drop to 5.0 and 6.0, respectively, after accounting for the adequate qualifications. All these estimates are well below the WHO threshold of 44.5 doctor, nurses and midwives per 10,000 population. The results reflected highly skewed distribution of health workforce across states, rural-urban and public-private sectors. A substantial proportion of active health worker were found not adequately qualified on the one hand and on the other more than 20% of qualified health professionals are not active in labor markets.

An analysis of health care spending from 1990 to 2007 shows that the State health care budgets have declined, while the Central Government's health spending has registered a consistent increase especially after the launch of National Rural Health Mission (NRHM) in 2005. 

To overcome these challenges some backend homework, like maintenance of national health data and disease surveillance in known and potential hotbeds are as important as mustering of financial and human resources. Institutions of local self-governance have task cut out in enforcing public health regulations to lessen the demand on medical resources.

Till such time minimum standards of services and human resources are achieved, optimum consolidation of available resources need to be equitably distributed particularly in urban slums, rural and remote areas. To this end, in the procedures adopted through the Ayushman Bharat scheme, private health care providers are involved by setting quality, cost and service benchmarks. The fact remains that Concurrently, the government should progressively and proactively commit itself to a minimum of four per cent of GDP to health sector.

Conclusion

There is no explicit guarantee in the Indian Constitution on health being a fundamental right. But various suggestions and mentions about the role and responsibility of government towards healthcare provision to citizens, supported by the rulings from the country’s higher courts promise enough ground for its rational adoption in the charter of constitutional rights. India being a federation, the roles and responsibilities of both Central as well as state governments have to be understood with full clarity and responsibility. A robust legal framework can become functional only on the strength of unflinching sincerity and commitment from both the principal stakeholders. Shifting the health from the ‘state list’ to ‘concurrent list’ is one logical step in this direction. On the ground enough preparations need to be made for bringing health care—both clinical and preventive—to the grassroots level. Apart from pooling the considerably vast resources of private service providers, a new thrust has to be placed on bridging crucial existing gaps like doctor-patient ratio, patient-bed ratio, nurses-patient ratio, etc. 

The recent experience of fighting with the Covid-19 epidemic has exposed the weaknesses of systems, infrastructure and procedures and on the other hand shown the potential of Centre-state solidarity in medical crisis management. The chinks in functioning of private and corporate health care providers’ and medical insurers have been exposed unambiguously. This needs to be addressed at the policy level to pave way for universal and uniform right based health care.

Alongside, the failing nature of better health outcomes can be reversed with higher fund allocation to this sector, induction of latest diagnostic technologies, support to pharmaceutical industry and due emphasis on augmenting human resources at various levels. Progressively, India has inched forward to a regimen closer to the principle of right to health by providing universal access to health care by the recently launched Ayushman Bharat scheme. For India, Universal Health Coverage is a Journey of partnerships engaging not for profit, and private sectors, universities, research agencies, policy fora, think tanks, and civil society organisations. The focus for people's participation is by leveraging self-help groups, community collectives, and local self-government representatives. The continuous implementations are being enabled by research, learning, adapting and sustaining progress.

References

1. India's Health Crisis  <https://www.downtoearth.org.in/dte-infographics/india_s_health_crisis/index.html>

2. National Health Profile 2018 (13th Issue) <http://www.indiaenvironmentportal.org.in/files/file/NHP%202018.pdf>

3. Changing pattern of public expenditure on health in India, Issues and Challenges, <http://isid.org.in/pdf/WP154.pdf>

4. Health as a apart of Fundamental Right under Article 21: A pursuit by India <http://www.legalserviceindia.com/legal/article-450-health-as-a-part-of-fundamental-right-under-article-21-a-pursuit-by-india.html>

5. Healthcare Scenario in India, ICU Management & Practice, ICU Volume 6 - Issue 4 - Winter 2006/2007 <  https://healthmanagement.org/c/icu/issuearticle/healthcare-scenario-in-india>

6. An 11-Step Guide To Improving The Public Health System In India  https://www.youthkiawaaz.com/2018/07/how-we-can-improve-public-health-system-in-indiahealth-for-all/>