PHM-Exch> ][PHM NEWS] PHM-India Manifesto on Right to health and Healthcare in advance of Indian general elections 2024

[Claudio Schuftan]

From: Dr Abhay Shukla <abhayshukla1 at gmail.com>

*Jan Swasthya Abhiyan (PHM-India): People’s Manifesto on Right to Health
and Healthcare - 2024*



*Addressing the health system crisis - Urgent need to advance people’s *

*Right to health and healthcare through transformation of health systems*

As India approaches the 2024 Lok Sabha elections, Jan Swasthya Abhiyan
(People's Health Movement - India) circulates this memorandum with a
charter of policy proposals, appealing to all the political parties and
independents in the election fray to commit to these by incorporating them
in their election manifesto.  This is essential because of the critical
state of our country's health system, since more than 80 crore people of
this country who today depend on free ration also require protection for
their health related vulnerabilities. Despite the COVID experience,
people’s health still remains very low on priority for the Union
government. Increasing commercialisation and decrease in the government’s
role has placed quality healthcare out of reach of the majority of Indians.

The Union government's handling of the COVID pandemic was marked by serious
mismanagement on various fronts, exacerbating an already critical
situation. Although the pandemic underlined the outstanding need for
stronger public health systems, the Union government’s spending on health
remains dismal. It continues to restrict funds, along with neglecting the
National Health Mission, while eroding federalism and imposing
hyper-centralised decision making. Refusal to regulate profiteering by the
commercialised private healthcare sector, accelerated privatisation of
health services, and failures of the much-hyped PMJAY health insurance
scheme have further worsened the situation, leaving the vast majority of
the population, especially marginalised communities at risk.



*Key Demands Concerning Right to Health and Healthcare*

*1.      **Our Health, Our Right! - Right to Healthcare legislation must be
passed to ensure guaranteed availability of free quality treatment of all
conditions, in close proximity to place of residence. Expand, improve &
strengthen public healthcare infrastructure to provide such essential care.
Denial, delay and incomplete treatment to be strictly prevented.*

*2.      **Increase Budgetary Allocation for Health – Increase Health
Spending to 3.5% of GDP, with 1% of GDP coming from Centre; States should
get special financial envelopes for raised health expenditure. *

*3.      **No one should face financial hardship due to Out-of-Pocket (OOP)
Spending on health – Reduce OOP to less than 25% of Total Health
Expenditure.*

*4.      **Fill Vacant Posts and Ensure Justice to Health workers  – No
health facility should have a vacant position. No public health
establishment should engage contractual staff, it is essential to
regularise all scheme based and contractual health workers. Ensure adequate
wages and protection under labour laws. A Human resources for health policy
would be enforced to ensure these measures. *

*5.      **Devolve administrative and financial powers to local bodies and
state governments to enable them to conceptualise and manage health systems
in their jurisdictions, with support from national and regional bodies.*

*6.      **Immediately reverse the rebranding of Health and Wellness
Centres as ‘Arogya mandirs’, in keeping with the constitutional values of
secularism and inclusivity.*

*7.      **Ensure availability of affordable and quality essential drugs &
diagnostics – Implement effective and rational price control; return to
cost-based pricing. Ensure availability of medicines as per the NLEM 2022,
eliminate all irrational medicines and Fixed Dose Combinations (FDCs).  *

*8.      **Healthcare is primarily the government’s responsibility – Phase
out Government-funded health insurance schemes such as PMJAY and Public
Private Partnerships.*

*9.      **Regulate Private healthcare sector by ensuring effective
implementation of an improved Clinical Establishment Act. All states must
ensure effective regulation of private healthcare while implementing the
Patients Rights Charter, along with transparency and regulation of rates,
and grievance redressal systems for patients. *

*10.  **Stop Commercialisation of Medical Education – Review & reform
National Medical Commission and National Eligibility cum Entrance Test
(NEET). Ensure highest standard of medical, nursing and other allied
medical services education and one common uniform system of admissions and
fee structures*

*11.  **Protect Workers’ Health – Properly implement National Policy on
Safety, Health and Environment at Work. Ensure effective implementation of
laws and related measures to prevent serious diseases like silicosis caused
due to hazardous occupations, ensure full rehabilitation of families
affected by ailments. Strengthen, reform and expand the ESI system. *

*12.  **A public-centred system for universal health care, ensuring a
common system to provide health care for all residents of India, must be
developed in the foreseeable future.*



*Jan Swasthya Abhiyan (PHM-India) proposes the following range of policy
actions in the health sector*, which should be committed to by all
political parties and candidates in context of upcoming Lok Sabha
elections. JSA will mobilize and campaign among different sections of the
people around these proposals, and call upon all social movements, civil
society organisations and people to build a consensus around these actions,
which must become the highest political priority in India today.



*I.      **Make the Right to healthcare a justiciable right through the
enactment of appropriate legislations at Union and State levels. Retain
health services as a state subject with strong emphasis on federalism*

There is a need to ensure all-encompassing healthcare access from primary
to tertiary services, for the entire population by enacting Right to
healthcare legislations at State level. This should be supported by an
appropriate legal, financial and operational framework at national level.
In a complementary manner, public health laws must secure access to health
determinants, protecting people’s health from various influences. The
overall direction should be to establish healthcare as a fundamental right
in the Indian Constitution. Health services should remain with the State
List as enshrined in the Constitution and should not be made part of the
concurrent list.



*II.      **Rapidly increase public expenditure on Healthcare to reach 3.5%
of GDP, with at least 1% of GDP being spent by the Union Government. *

Overall public health expenditure must be majorly increased to reach 3.5%
in the short term. While enabling this, the Union government should transfer
a much larger share of resources to states through the Finance Commission
(FC), and a special financial envelope for states should be created for
implementation of Right to Health and Healthcare under the XVI Finance
Commission. Special grants under XV FC to local bodies should be augmented
further, to foster decentralised governance and delivery of healthcare
services. Allocation towards the National Health Mission should be enhanced
to facilitate upgradation and expansion of rural and urban health services,
and dealing with communicable as well as non-communicable diseases and
climate related health challenges. Greater flexibility should be accorded
to states to decide on the priorities within NHM and the process of
participatory, decentralised planning should be strengthened.



*III.      **Out-of-pocket expenditure on health must be minimised and
brought down to below 25% of health spending in next five years*

Out-of-pocket (OOP) spending on healthcare should be minimised so that no
one is pushed into poverty, or faces catastrophic health spending and
indebtedness due to healthcare expenses. Current decline in utilisation of
health services due to high spending by households is unacceptable and must
be reversed to ensure that no one has to forgo healthcare due to
unaffordable costs. The objective of reducing OOP to less than 25% of
health spending should be adopted as a national goal.



*IV.      **Expand and strengthen the public healthcare system to ensure
free availability of quality health care at all levels, including entire
range of medicines, diagnostics and vaccines*

Strengthen and enable public health systems at all levels in rural and
urban areas to provide free comprehensive services, essential drugs and
diagnostics, expanding both quantity and quality based on health services
standards. This would require upgradation of public health facilities, with
matching human resource policy and improved governance and management.
Combined with this, it is important to ensure nationwide access to
essential medicines and diagnostics in all public facilities, based on
models of successful state level schemes such as those operating in Tamil
Nadu, Kerala and Rajasthan. Along with ensuring genuinely autonomous public
corporations with adequate and competent staff and various measures for
transparency and responsiveness, public budgets on medicines must be
substantially
upscaled to meet the requirements. The government must provide all
essential medicines, diagnostics, and medical devices, free of charge, in
publicly run hospitals for life-threatening diseases, in order to fulfill
its constitutional obligations under Article 21. Ensure regular, adequate
availability of essential vaccines through the public health system.



*V.      **Eliminate corruption, ensure community accountability and
democratise the health system*

It is essential to ensure transparency and social accountability while
eradicating corruption in the Public health system, based on processes for
broad based participation and democratisation. Ensure empowered
participation of people through generalisation of community-based planning
and monitoring, with involvement of public representatives, people’s
organizations, women's groups and health sector CSOs at all levels from
village to state. Develop a community-driven health system with active,
diversified participation and strong grievance redressal mechanisms.



*VI.      **Replace Government funded health insurance schemes with a
Public centred system for Universal Health Care, eliminate PPPs and
privatisation of health services*

Phase out the Pradhan Mantri Jan Arogya Yojana - based on the discredited
insurance model - in a phased manner, and replace this with a Public
centred system for Universal Health Care. In the interim, all admissions
under the scheme in private facilities must be based on gatekeeping by
public health facilities, regarding those conditions where services are not
available within the public system. There is clear need as well as
potential to develop a public centred system for Universal Health Care,
based on major expansion and strengthening of public services, while
engaging regulated private providers to address current gaps. This system
will provide ready access to quality healthcare, which will be available
free of charge to everyone. Eliminate existing PPPs which weaken public
services, abolish privatization of government health services, no
government hospitals or services should be handed over to private
companies.



*VII.      **Reverse the rebranding of Health and Wellness Centres as
‘Arogya mandirs’*

Without any significant expansion in number of SCs and HWCs and augmenting
the provision of services in those facilities, the Union government has
arbitrarily renamed these public institutions built over the last several
decades, as ‘*Arogya mandirs’* with religious connotations. This is clearly
a violation of principles of secularism enshrined under the constitution,
and must be immediately reversed. It must be ensured that public
institutions remain secular and inclusive, focusing on the overall
well-being of all citizens. Instead of making such negative and superficial
changes, efforts should be made to substantially strengthen and upgrade the
Sub-centres and PHCs now designated as HWCs, to provide comprehensive
primary care.



*VIII.     **Ensure justice for all health workers, upgrading and
regulating training of health force *

All scheme based and contractual health workers, including ASHAs and
Anganwadi workers, must be regularised while ensuring them adequate wages
and protection under labour laws. The policy of contractualisation must be
replaced by systematic regularisation of all types of contractual employees
in health services. All vacancies in Health Departments must be filled and
new posts created as per requirement. All health workers including ANMs,
Nurses, Doctors and Paramedics must be paid decent wages while working in a
supportive environment. There must be complete transparency in the
processes of recruitment, transfers and promotions of officers and
employees in the health system. Increase public investment in health
professional education and training and regulate private institutions
providing training for healthcare personnel.



*IX.     **Need for major reforms in medical education and National Medical
Council*

   There is an urgent need to control commercialized private medical
colleges, while not sanctioning further such private colleges and mandating
their fees to be not higher than government medical colleges. There is need
for independent, multi-stakeholder review and reform of the structure and
functioning of the National Medical Commission, which has come under major
criticism for lack of representation of diverse stakeholders, promoting
high degree of centralisation in decision-making with erosion of state
autonomy, and promotion of further commercialisation of medical education.
There is a particular need to review and restructure the National
Eligibility cum Entrance Test (NEET) which tends to place candidates from
rural areas, those from non-English medium schools and less privileged
backgrounds at a disadvantage. NEET encroaches on the autonomy of states in
determining their own medical admission processes, and the imposition of
NEET is perceived as an infringement on state level educational policies.



*X.     **Adopt a people-centred, rational pharmaceutical policy and make
medicines affordable for all*

A pro-people pharmaceutical policy must be implemented which would bring
all essential medicines and devices under effective and rational price
control. The comprehensive price control regime should restore cost-based
pricing for all medicines, along with banning irrational drugs and
combinations, regulating pharma marketing practices, and promoting generic
medicine outlets. It is important to implement a comprehensive generic
medicine policy, which covers labelling as well as prescribing of all
medicines.

Resist dilution of Patent Law provisions that protect national interests
and use public health safeguards in the Indian Patent Act. Reject
provisions being pushed through Free Trade Agreements which affect the
production of low-cost generic drugs. Utilize compulsory licensing
provisions to reduce the costs of high-cost treatments for diseases such as
cancer and rare diseases. Additionally, address regulatory barriers to the
entry of costly biosimilar medicines. Monitor online medicine trade, and
effectively promote fair-priced drug outlets.

Strengthen public pharmaceutical industries and public sector vaccine
production units, while rolling back their privatisation. Addressing
Intellectual Property Rights (IPR) issues, coupled with scaling up
production through Indian public sector companies would enhance vaccine
accessibility. Reinstate funding for Open-Source Drug Discovery (OSDD)
initiatives, promoting collaborative research for affordable and accessible
medications. It is also recommended to abolish GST imposed on sale of
medicines, as part of the wider spectrum of measures required to ensure
affordability of medicines, which are essential life-saving products.

*XI.     **Protect workers health*

Ensure health protection for all workers in unorganised as well as
organised sectors. Formulate and enforce a comprehensive occupational
health and safety (OHS) policy, while integrating OHS into the medical
curriculum. Properly implement the National policy on safety, health and
environment at work (2009), adopt all ILO conventions concerning workers
health and safety. It is important to integrate occupational health
services with general health services at all levels. Strictly implement
laws and related measures to prevent occupational diseases like silicosis
and other occupational lung diseases. Ensure full rehabilitation of
families affected by these ailments as done in the instance of the Bonded
Labour System Abolition Act. Implement health impact assessments for all
corporate projects, ensuring transparency and participation. Majorly
strengthen and reform the ESI system, expanding this system to provide
healthcare protection for all workers in both organized and unorganized
sectors.



*XII.     **Regulate the Private healthcare sector and safeguard patients’
rights*

Effectively regulate the private healthcare sector by amending the Clinical
Establishment Act-2010, towards ensuring patient rights, quality of care,
transparency and standardisation of rates. To check irrational and
unnecessary interventions, treatment practices need to be more
standardised, with these measures people will not have to pay huge bills in
private hospitals. States should adopt such improved regulation or should
enact their own acts with similar positive provisions. It is important to
establish well-staffed, dedicated mechanisms for effective implementation
of these regulations, which include people’s representation. The complete
'Patient Rights Charter' must be strictly enforced in all hospitals and
health facilities, display of indicative rates will be mandatory and
user-friendly grievance redressal system should be operationalised. Rates
for diagnostics also must be regulated, and “cut practice” should be
effectively banned. It is also important to implement a publicly managed
admission system for charitable hospital beds, so that referrals from
government facilities to charitable trust hospitals can optimize
utilisation of beds for economically weaker sections.



*XIII.     **Promote medical pluralism and AYUSH systems of healing*

It is necessary to support medical pluralism so that people have a choice
to access non-allopathic systems of healing, including safe home-based
birthing practices. Substantial encouragement and funds must be given to
research and documentation, to promote evidence-based use of AYUSH and
traditional community-based systems of healing. At the same time, certain
commercialised Ayurvedic companies have been found to make exaggerated
health claims about their products, although these claims may not be
demonstrated. There have also been concerns about some Ayurvedic products
related to quality control and safety issues. Hence there is need for
effective, appropriate regulatory oversight of Ayurvedic and other AYUSH
systems of medicine in context of growing commercialisation and certain
kind of political patronage to specific companies.





*XIV.     **Ensure gender sensitive health services and social support
systems*

Recognize gender-based violence as an important public health concern,
providing prompt rescue, comprehensive medical care, and sustained support.
Address gender-based violence and harassment concerning health workers
urgently. Ensure equitable, quality healthcare for women, adolescents,
children, and LGBTQ individuals from all backgrounds, including those
experiencing violence. Universalize maternity benefits for all, including
contractual and daily wage workers, and provide workplace creche and
restrooms for working mothers with small children.



*XV.     **Ensure comprehensive healthcare for vulnerable groups and
sections with special health needs, eliminate all forms of discrimination
and exclusion in health care *

Implement special measures to provide comprehensive, quality health
services for vulnerable populations and those with special needs,
addressing vulnerabilities related to social background, health status,
lifecycle position, occupation and other factors. This must address the
health needs of women, dalits, adivasis, Muslims and minority communities,
particularly vulnerable tribal groups, LGBTQ persons, refugee and migrant
populations, people in conflict areas, people living with HIV, manual
scavengers, waste  pickers, differently abled persons, children and elderly
persons, and all other vulnerable groups. Urgently eliminate all forms of
discrimination including caste, community, religion, tribe, or
ethnicity-based discrimination in the health sector, while ensuring the
right to healthcare for all with dignity. Remove mandatory Aadhar linking
for accessing health services, and ensure access to healthcare for all
without barriers based on state domicile, citizenship proof, etc.



*XVI.     **Address mental health in comprehensive manner, upgrade disease
control and preventive health programmes*

Ensure comprehensive treatment for mental health problems,
community-oriented care and wider promotion of mental health, through
enhanced implementation of an expanded District Mental Health Programme
within the National Mental Health Policy framework. Address inadequacies in
dealing with major diseases, like HIV-AIDS and Tuberculosis through
expanded and reoriented health programs. Upgrade preventive health
programmes and enhance mechanisms to handle communicable diseases based on
a review of current systems.



*XVII.     **Regulation of clinical trials, promoting people-oriented
health research*

Implement strict regulation and fair compensation for clinical trial
participants, which would be effectively monitored by CDSCO. Develop a
justiciable charter of rights for clinical trial participants. Upgrade
public health research capacity, while facilitating the use of findings to
guide action and improve health systems. Ensure effective regulation of
conflicts of interest, ensure adequate national sources of funding for
Indian research institutions to prevent dependence on transnational
agencies and corporations.



*XVIII.     **Multi-dimensional initiatives to ensure social determinants
of health*

Enhance the capacity of the Public health system to monitor and advocate
for multi-pronged action on social determinants of health, involving
various concerned departments. Foster inter-sectoral coordination to
improve social determinants, considering factors like food security,
nutrition, sanitation, environmental pollution, climate change, working
conditions, road safety, substance abuse, and violence. Ensure effective
implementation and amendment of various laws for people's rights and gender
justice. Universalize and expand ICDS to cover under-3 children and
establish community-owned programs and daycare services for majorly
improved nutrition, health and well-being of women and children.



*Reclaiming public health as part of the broader movement for defending
democracy*

Today India faces a critical juncture in our history, with democracy coming
under unprecedented attack, growing communalisation and social exclusion,
and an aggressively pro-corporate political economy. Expanding democracy
and overturning the pro-corporate policy framework is now crucial to ensure
people’s health rights and strengthen public health systems. As Jan
Swasthya Abhiyan we resolve to integrate our actions for advancing public
health with various broader movements for defending and expanding democracy
and secularism, while promoting peace and social harmony in India and our
region.



*We strongly appeal to all political parties believing in democracy and
social justice, *

*to place Right to health and healthcare centrally on their agenda for
elections in 2024!*
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