India Together: Healthcare : Eyes on the prize – 01 October 2003

01 October 2003 –

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 People’s 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 people’s 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 rights

Ajara 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 people’s 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 people’s 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 people’s 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 nurse’s 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

The Jan Swasthya Abhiyan is currently documenting cases of denial of healthcare in various states. Loss of life, physical damage or severe financial loss to patients are the focus.

In 2000, a unique process of mobilisation and awareness generation developed
around the world, reminding governments of their unfulfilled promise of ‘Health
for All by 2000 AD’. The People’s Health Assembly process raised the demand of
‘Health for All – NOW!’. It formulated a People’s Charter for Health at the
global level and a parallel People’s Health Charter in India. This process
culminated in a 2,000-strong National Health Assembly in Kolkata and the historic
global People’s Health Assembly in Dhaka, with 1,350 representatives from 92
countries. The unique coalition developed during this process continues in the
form of the People’s Health Movement at the international level, and as Jan
Swasthya Abhiyan in India. Among a range of other activities at state and national
levels, Jan Swasthya Abhiyan is now involved in developing a national campaign on
the issue of right to healthcare.

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.