PHM-Exch> PHM INDIA ON UNIVERSAL HEALTH CARE ON THE OCCASION OF WORLD HEALTH DAY

[Claudio Schuftan]

From: *Ravi Narayan* <chcravi at gmail.com>

>From <rakhal.gaitonde at gmail.com>



PHM India is calling for national debate on design of proposed
system for 'Universal Health Care', to ensure quality, free health care for
all as a right, to give priority to expansion and improvement of public
health services, and to regulate the private health sector.

*Released on the occasion of World Health Day -- April 7/2012 and in
preparation for PHA3.*

OUR VISION

We believe and reiterate that Health is a fundamental human right - that
the government is responsible for the provision of health care, as well as
an enabling environment for the realization of the right to health, which
includes the right to having control over the social determinants of
health. As noted by the Special Rapporteur for the Right to Health, the
Right to health includes the Right of people to participate in all
decisions related to health, the implementation of these policies, as well
as their monitoring and evaluation.

Our starting principles continue to be the Right to Health and the Social
Determinants of Health, and equally, i.e.,  the principles of Comprehensive
Primary Health Care as enunciated in Alma Ata.

We believe and reiterate that Health Care is only one of the many
determinants of health. Mere access to health care, even if universal, will
have no meaning unless the larger social determinants of health are
squarely addressed and issues of ethnicity, caste, class and gender are
engaged-with as a society. We believe that the goal of Health for ALL! will
definitely be furthered significantly with the introduction of Universal
Health Care. However, we believe that *what* needs to be universalized
needs to be reflected upon. We do not believe that a mere extension of
access to the present technology and industry-driven, commodified,
irrational and impersonal form of medicine that is dominant in today's
world is the answer. In fact, we fear that a superficial and hurried
attempt at universalizing an "essential health package" in the present
un-regulated situation in which there is absolutely no accountability of
the system to the people would be beset with two problems: First, it will
be an inefficient, wasteful way of spending the taxpayers' money. Second,
it will create new problems for the people and increase inequity.  We
believe that Health is a fundamental Right of the people and health care
needs to be available based on people's needs rather than as part of a
"purchased package". With regards to health, we also believe that the
private sector should play only a supplementary and never a complementary
or competitive role.

-PHM India emphasizes the concept of "universal" over the earlier dominant
"selective" or "cost- effective" packages concept.
-It emphasizes tax-based financing of the health system.
-It completely rejects user fees in the health system.
-It is committed to "Free Medicines for ALL" in the Public Health System.
-It calls for the enforcement of price regulation and the application of
price controls on
all formulations in the Essential Drug List.
-It calls for the strengthening of public sector vaccine production
capacity and the
protection of the indigenous capacity even in the private sector.
-It calls for the protection of safeguards provided by the national patent
laws and the TRIPs Agreement to protect the country's ability to produce
essential drugs.
-It brings the critical issue of human resources to the center of the
table.
-It specially welcomes the focus on strengthening the village level
resources with the suggestion of additional community health workers,
strengthening the very local level, giving priority to the CHWs and the
nursing cadres; it suggests HRH management systems that establish clear
career paths.
-It suggests strengthening and expanding the public sector and the
earmarking of the necessary budget, and especially the establishment of a
reliable urban health care system.
-It clearly states it is against the use of private insurance in the
financing of health care.
-It highlights the need and urgency of private sector regulation, as well
as outlining a potential regulatory structure.
-It brings community-based accountability mechanisms to the center stage.
-It insists any government report must undertake some consultation with a
wide range of groups including civil society, international experts,
academics and industry.                   -It thinks that clear
recommendations for regulation of the private sector need to have a
substantive critique of the rapidly growing, unregulated private health
system, especially the emergence of the corporate health care as a dominant
entity in the last two decades.
-It objects health care needs being something that can be packaged, and the
flaws of the current health system as something that can be rectified by
tax based purchasing of
services.

                                                         -It
insists recommendations include a) the size and scale of health care
financing required for universal health care expressed as % of GDP, and b)
an estimation of the funds required for a 'Medicines for All' program.
-It welcomes the fact that government takes up the issue of the social
determinants of health. But recommendations to address this challenge need
to be made in concrete.        -It believes that a new way of looking at
health and the health system is needed. This means making the current set
of institutions more people centered rather than developing another slew of
"expert" driven bodies with complicated lines of accountability to the
people.
-It worries that top-down reports have many faulty interpretations of the
reality concerning issues that are likely to completely defeat the purpose
and spirit behind any evolving process for Universal Health Care.
-It believes that any minimalist Essential Health Package will nothing but
show the very contracted nature of the vision of health planners. This in
no way can be considered as a universal health package.
-It believes the operational autonomy of public health facilities concept
for any health facility (accountability frameworks, financial autonomy)
actually means leaving the public sector to "fend for themselves". In the
present environment, it will merely mean the death knell of this system and
jeopardizing any hopes for a Universal System.
-In the present situation of a historically neglected and dilapidated
public health
system and a private sector that has received encouragement (and has an
unregulated growth enabling it to reap huge and obscene levels of profit)
inequity has vastly increased. Under these circumstances, the concept of
"provider choice" is highly problematic.           -It believes that the
private sector should never play a competing/complementary role, but only a
supplementary role under a strengthened public health system accountable to
the people.
-It rejects the failure to focus on strengthening the district health level
that does not have the capacity or the robustness of governance needed for
the task.
-It believes that cost escalation being contained by sticking to standard
treatment guidelines, without questioning the basic commodification of
health care, again questions the vision of access to universal health care.
-It suggests that piloting district health models should be initiated only
after full discussion and public debate.

PHM INDIA's VISION FOR A UNIVERSAL HEALTH CARE SYSTEM

Health Care provision:

We firmly believe that the public health system has to be the back bone
of any universal health system. In its present state it definitely cannot
be so. The public health system has suffered years of neglect due to lack
of funding, poor governance and active encouragement of the private sector.

It is also true that in order to cover the complete population with all
the services the involvement of the private providers in some form may
be necessary. However we hasten to add that the degree, form and content
of the engagement can not be at the expense of the three critical steps:
-Strengthening of the Public Health system and especially the primary
level of care with more health workers and encouraging and building
up the capacity of self-care, and especially preventive and promotive care.
-Bringing the public sector up to its full functional capacity and
expanding it to the level at which it is supposed to be including
population coverage and infrastructure norms.
-A detailed mapping and assessment be done for each district of the actual
needs for curative health care at each of primary, secondary and tertiary
care level after taking into account a fully strengthened primary level
(including curative, preventive and promotive). This, to decide on the need
for contracting in the private sector the needs they can bring in
respecting the terms of health as a public good. The integration of the
public and private sector is not seen only in terms of provision and
financing, but most crucially in terms of an integration of the "logic" of
the health system, with corporate profit not being allowed to lead or
define health provision. The health system has to be strictly and
transparently regulated with its primary goal being the people's welfare
rather than private profit. It is only under such conditions that we can
develop a system that will truly serve the needs of the people equitably.

Health Care Financing:
There is little doubt that the most widely successful way is through,
tax-based financing. The key challenge to financing then becomes the
problem of resource allocation - to districts, and within districts,
such that it reflects the needs of equity, access and quality of care.
This needs to be in an environment of good governance and transparent
financing systems so that there are no leakages and quality of care and
efficient use of resources is ensured whether it is by public providers
or in the form of contracting private providers. While a number of
countries
have provided models worth studying, each country needs to chart out its
own
course. For sure, one thing is that what one should be aiming for is health
security and universal coverage and NOT the currently fashionable and
politically convenient "insurance schemes for tertiary illnesses" or
limited hospital based coverage. Using a  single capitation fee to be paid
to an integrated care provider as part of a "managed care" model is
untested and potentially fraught with problems of denial of care, which
would be particularly difficult to monitor when it is a private provider.
We point out that in the current social and economic context, the only
possible integrated care provider other than the government is corporate
entities, and given international and national experience with
these, this is totally not desirable.

We would limit private sector participation to essentially roles that are
supplementary to the public system, where costs and quality of care are
subject to monitoring and equity considerations are respected.

The concept of "choice of provider " is also problematic as the public
sector has many functions to perform, is very busy and it would be wrong
for it to turn away patients who have chosen it. In such a circumstance,
users would register with a private sector provider as an alternative to
the free or low cost care in principle available in the public sector. In a
situation where the private sector has historically grown using unjustified
public subsidies and encouragement; it is ridden with conflicts of
interests in referrals and in ownership; it is not competing on fair terms
thus risking to undermine the public sector. We believe that the private
sector should never play a competing, but only a
complementary/supplementary role thus strengthening the public health
system that is accountable to the people.

Governance:

Whatever the provisioning and the financing mechanisms, unless the
governance of the whole health system is firmly people-centered and
rights-based, these arrangements are likely to be exploited by the dominant
and corporte private sector. We envisage a community-led and focused
process. We further visualize institutionalizing a process of
community-based monitoring, planning and action for health. This process
needs to evolve from the learnings from the ongoing experiences in a number
of countries where PHM has partners.

In addition to this, we believe that there needs to be greater internal
democracy. The public health system is ridden with hierarchies and power
centralization. The private sector is driven by the need of extracting
profit from people in their weakest moment; it  is further characterized by
irrational and unnecessary interventions (both diagnostic and
therapeutic). These issues need to be addressed comprehensively as well.

A regulatory framework for private health facilities needs to be
strengthened. The system should be developed to give sufficient power to
regulatory bodies.

IN CONCLUSION

We welcome any national attention and emerging policy level commitment
to health care by government authorities. Always  call for the following:

-A national public debate on the contours of any proposed universal health
care system. Such an important issue cannot be rushed through and its
various strands need to be understood, discussed and commented upon widely
by the people.

-Definition of a clear, transparent and time-bound road map for
strengthening and expanding the public health system is a must while
improving its functioning and accountability; this must include allocation
of adequate, increased budgets.

-Enactment of adequate laws guaranteeing the right to health, including
National and State Health acts that lay down the framework for regulation
of the health system particularly relevant for private medical providers.
Providing entitlements must
be accompanied by a clear framework for accountability and grievance
redressal.

-While developing and operationalizing the universal health care system,
highest priority must be given to significant expansion and improvement of
public health services. Regulated private providers should not be competing
with public providers for common
resources, rather they may be in-sourced to provide services, but never as
a substitute to the public sector.

-Ensuring fora are provided for participation of community members,
community based groups and civil society organizations along with elected
representatives and public health officers at various levels for planning,
monitoring and reviewing the functioning of the universal health care
system.

-Organizing a process of mapping and estimating the pattern of health care
services required in each district and within each district in areas with
special needs. This process must be transparent and widely discussed by
people in each district.

-We must be aware that the direction of developing universal health care
anywhere must be towards strengthening the public health system and the
socialization of health care, rather than promoting further expansion
of  unregulated,
profit-oriented private medical care. Hence a national debate is essential
and there should be no haste in rolling out these
concepts; even the looming of the general elections should not become an
excuse for the government to short circuit and distort the concept of
Universal Health Care for narrow political gains.


Contact:

Dr Rakhal Gaitonde  _rakhal at sochara.org_
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