1. Operationalising Right to Healthcare in India Paper presented at the 10 th Canadian Conference on International Health Ottawa 28 th October 2003 Ravi Duggal Centre for Enquiry into Health and Allied Themes www.cehat.org

2. Healthcare in India Entitlements by policy and not rights Focus on preventive and promotive care Grossly under-provided facilities Poor investments hitherto Declining public expenditures and new investments SAPping the healthcare system

3. Rural-Urban Disparities – India RURAL (per 1000 population) Hospital Beds = 0.2 Doctors = 0.6 Public Expenditures = Rs.80,000 Out of pocket = Rs.750,000 ____________________ IMR = 74/1000 LB U5MR = 133/1000 LB Births Attended = 33.5% Full Immunz.=37% Median ANCs=2.5 URBAN (per 1000 population) Hospital Beds = 3.0 Doctors = 3.4 Public Expenditures = Rs.560,000 Out of Pocket = Rs.1,150,000 ____________________ IMR = 44/1000 LB U5MR = 87/1000 LB Births Attended = 73.3% Full Immunz.= 61% Median ANCs=4.2

4. Expenditure Patterns Public expenditures –declining trends LPG and growth of private capital and stagnation of public investment Reduced public spending Out of pocket – increasing burden, especially the poor and in rural areas

5. Character of Health Expenditures Public Domain Rural/Urban divide Preventive/Curative dichotomy Plan/Non-plan expenditures Centre, State and Local governments Private Domain Curative only- pharma industry driving force Irrational practices, malpractice, unregulated, lack of professional ethics Supply induced demand

6. Facts & Figures - Health Spending Public Domain Centre: Rs.35 bi (0.13% GDP) State: Rs.186 bi (0.72% GDP) Local: Rs.25 bi estimated (0.10% GDP) Social Insurance: Rs. 12 bi (0.05% GDP) Private Domain Out-of-pocket: Rs.1200 bi (4.62% GDP) Insurance (public sector) Rs.8 bi (0.03% GDP) Pharma Industry Rs. 250 bi (0.96% GDP)

7. Healthcare Financing – Rs. billion 1993 -94 1994- 95 1995- 96 1996- 97 1997- 98 2000- 01 2002- 03BE Public Centre7111213142335 State68728999113156186 Total %Govt %GDP 75 2.91 0.87 83 2.13 0.81 101 2.98 0.86 112 2.94 0.83 127 2.70 0.83 179 2.91 0.81 221 3.17 0.85 Private %GDP 195 2.27 279 2.75 329 2.77 373 2.73 459 3.00 982 4.46 1200 4.62 Source: Public Expenditures - Finance Accounts upto 2001 and Budget for 2003; Private – CSO estimates on Consumption Expenditure 1985 series; BE = Budget Estimate

8. Basic Care Framework What constitutes basic health services Family physician services, supported by paramedics and community health workers First level referral hospital with basic specialties and ambulance services Epidemiological services, including information management and health education Maternity services for safe pregnancy, abortion, delivery and postnatal care Immunisation services against vaccine preventable diseases Pharmaceutical and contraceptive services

9. Operational Mechanism Restructuring and Reforms Organising a system Creating an autonomous health authority Referral system Standards and regulation Structured financing

10. Operational Mechanism... Priorities for making it work An Act of Parliament - Health Authority Tackling the medical profession Licensing, registration, minimum standards Integration of systems Continuing medical education Pricing mechanisms Raising substantial additional resources Consensus building in civil society

11. Financing the System Resource Requirements Present public spending on health care is less than 1% of GDP and out-of-pocket is 4% Reorganised system will need totally 3% of GDP Costs will be shared by governments at all levels, employers, employees, earmarked taxes and cesses, insurance funds etc..

12. Innovations in Financing Using existing resources efficiently and effectively Decentralised governance (Panchayati Raj) Block funding or global budgeting Leads to equity in access to resources PHC level resources tripled CHC and district level resources doubled

13. Innovations in Financing… Generating additional resources Increased allocations within the existing budget Payroll taxes for health like profession tax Health cess on health degrading products, polluting industry and luxury products Compulsory public service by those graduating from public medical schools Social security levies on land revenues

14. Consensus Building Policy level advocacy for UHC Research to develop framework Lobbying with medical profession Filing of PIL for RTHH Lobbying MPs to demand justiciability of directive principles National and regional consultations on RTHH involving civil society

15. Consensus Building… Campaigns on RTHH with networks of people’s organisation Bringing RTHH on manifestoes of political parties Pressurising international bodies like Committee of ESCR, WHO,UNCHR.. And national bodies like NHRC, NCW.. To monitor state obligations and demand accountability Shadow reports on RTHH

16. Summary and Conclusions Rural – Urban disparities across the board Reduced investments and expenditures on health care in the nineties has impacted access and health outcomes Allocative inefficiencies coupled with SAP only makes the crises of public healthcare worse Overall health outcomes not very good because of the worsening access to healthcare –user charges and privatisation Lack of accountability The need for a right to healthcare perspective