RIGHT TO HEALTH AS FUNDAMENTAL DEMOCRATIC RIGHT
Health should find a prime place. No one has the right to commodify it.
We have gathered here to discuss the issue of democratic rights movements. Democratic rights or Human rights, the basic human rights to life, liberty, freedom of thought and speech and others, as we know, came to the frame of human life and thinking with the age of Enlightenment. Almost constitution of every state since then recognizes the democratic rights of its citizens, at least on paper if not in practice. The Constitution of India is no exception; state of India also recognizes democratic rights of its citizens, though mostly on paper, not in practice like many other bourgeois states especially third world post-colonial countries. Different dimensions of this issue have been or will be discussed in this seminar, in my presentation I will focus on the right to health as the democratic right of people.
Right to Health was first formally recognized as basic human rights in the declaration of UN in late 1940’s. If one examines the Universal Declaration of Human Rights of the United Nations, one can see that there are two kinds of rights that are discussed. Although any right can be stated in either negative or positive terms, it still makes some sense to refer to these two types of rights as negative and positive.
The negative rights basically have to do with the right to be left alone by the government. The idea here is that so long as I am not infringing on the rights of others, what I do or say is not the government’s business. The negative rights are put in place to protect individuals from the unwarranted intrusion of the government.
Positive rights, on the other hand, have to do with what the government is expected to provide to the citizens under its jurisdiction. The right to at least an elementary education is perhaps the most universally agreed upon positive right, similarly a right to health, to a clean environment and to all the physical necessities for a tolerable life is the fundamental positive right of the people and the people are in full capacity and fully justified in demanding this right of theirs’ from the state. So there should be no confusion regarding the status of right to health as fundamental right.
Indian constitution on the Right to health
Part IV of the Indian constitution through articles 36-51 of the Indian constitution covers the directive principles for the state. Article 37 declares that the directive principles are the prime basis of the governance and during law making & planning, these principles must be followed by the state, it will be the obligation of the govt.
“Duty of the State to raise the level of nutrition and the standard of living and to improve public health- The State shall regard he raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties and, in particular, the State shall endeavor to bring about prohibition of the consumption, except for medicinal purposes, of intoxicating drinks and of drugs which are injurious to health”1
Article 21 of the Indian Constitution states the Fundamental right of life, guaranties to the individual her/his life or personal liberty except by a procedure established by law.
Later on different occasions, Indian judiciary has clearly stated that:
“It is now a settled law that right to health is integral to right to life. Government has a constitutional obligation to provide health facilities.”2
“The State and its machineries (in the instant case, the Municipal Corporation) are bound to assure hygienic conditions of living and therefore, health.”3
Many more examples can be given to assert that the right to health is firmly recognized by the Indian constitution and it’s the obligations of govt. to provide Healthcare to its people. But, from the directive principles, there don’t arise any legal rights from these directive principles, so non-compliance with these directive principles give no option of availing any legal remedy and nor they provide the legislature any powers. More than this, no law can be overruled if it does not show compliance to the directive principles.
India’s Public Health Scenario
India was the member of Alma Ata declaration which envisioned the global goal of ‘Health for All’ in 1978. But leave apart some progress towards these inflated and pompous declarations; conditions have even worsened. There remains nothing much to say about the scandalous public health care situation of India if we look at the different healthcare indices of India.
Infant Mortality rate (per 1000 live births) – 54
Under 5 Mortality rate (per 1000 live births) – 72
Adult Mortality rate (per 1000 live births) – 215
Maternal Mortality rate (per 100,000 live births) – 450
(Source – World Health Statistics, 2009)
And much more is there to say, prevalence of Tuberculosis is 312.2 in India which is less than 10 in developed countries, 150 million Indians are blind of which most could have been seeing this world like us if timely care could have given, there are still more than one lac cases of Leprosy in India, 58% of under 2 years age children receive incomplete vaccination 24% of whom don’t receive no vaccination at all.
No. of Physicians (per 10,000 population) – 6
No. of Nursing and Midwifery staff (per 10,000 population) – 13
No. of hospital beds (per 10,000 population) – 7
No. of Dentistry personnel (per 10,000 population) – 1
(Source – World Health Statistics, 2009)
According to CEHAT (Centre for Enquiry into Health and Allied themes) only 38% PHCs have critical staff, 80% have no obstetric care kit, only 34% of them offer delivery services, 80% have no child specialist and 70% have no obstetrician. In another survey, it has come out that 31% PHCs have no bed, only 20% have telephone and worse, only 12% ‘enjoy’ regular maintenance.
Even assuming these figures as such, these are one of the worst in the world including poorest countries of the world and sub-Saharan countries, still these are only tip of the iceberg.
But what is more glaring is that these figures are just national averages, these do not show the complete picture. There is vast gap between low income population and high income population, rural-urban areas and further divide within the urban areas where on one side are the avenues, model towns, urban estates whereas on the other side are slums, ghettos. Still further there are gaps between different communities, castes, tribes, states. If we take into consideration these differences then emerges the real motion picture. The IMR among the poorest 20% population is 20 times higher than the richest 20% population, similar differences exist in other health indices. Similarly in case of healthcare infrastructure, 75% of it is concentrated in urban areas. 80% doctors and 75% hospitals are in urban areas and hospitals with advanced facilities are only in urban areas, ratio of hospital beds to population is 15 times lower in rural areas than urban areas, and despite this govt.’s health expenditure is seven times lower in rural than urban areas. One more thing, having an eye on these data one can feel that atleast in urban areas everything is green, but it’s not the case. In urban areas, only few areas are green with lush green health palaces (hospitals), majority of population there too lives in horrible conditions of healthcare which does not need any data, though if one is interested can collect.
All this is happening when India is facing another gruesome reality. According to National Nutrition Monitoring Bureau, BMI (Body Mass Index) of 37% males and 39% females is less than 18.5. Further, 50% ST, 60% SC & >40% people in state of Orissa have BMI equal or less than 18.5. According to WHO criteria, if 40% or more population of country or community is equal or less than 18.5 is equivalent to a chronic famine.
Health Expenditure in India
Looking at the above figures, one can easily assume that the govt. of such country will set its topmost agenda as improvement of healthcare services and improving public health as a whole. But this is not the case with Indian state, like all other states promoting neo-liberalism, its bulwarks are busy in increasing the profits of capitalists and ‘nurturing’ of top 10-15% of the population.
Total expenditure on Healthcare in India is only 5% of the GDP, of which 75% comes from the pockets of people directly making it one of the highest proportions of private health spending found anywhere in the world. Centre and state govts’ combined share is only 20% of total expenses. Now if we keep this figure in front of another horrendous fact that 77% of India’s population lives on either on Rs. 20/day or less, then one can realize what is happening with the lives of the majority ¾ of the population. In the recent Union budget, health sector found only a meager amount of 26,760 crores out of total budgetary estimate of 89.90 lac crore rupees making it only 0.29% of total budget. In the same budget, tax exemptions of worth 5.12 lac crore were given directly or indirectly to the capitalists whose profits passed above 8 lac crores in year 2010. It is not a isolated year, rather it is trend now, of decreased share for health sector by centre and state govts, 1.3% in 1990, 0.9% in 1999 and 0.8% in 2005.
The conditions are further worsening because of dominance of private sector in healthcare and rising medicine prices. At the time of independence, private sector accounted for 5-10% of total patient care, but it has already touched 80% in year 2010. 70% hospitals are owned by private players and it accounts for 82% of OPD visits. Even for population of BPL, the private sector accounts for 40% hospital days. Private sector’s success is less attributable to its own efficiency but more to the failure of govt.
According to WHO World Medicine Situation Report of 2004, India has the largest number of people, an estimate of 639 million i.e. nearly two-third of population who are without regular access to essential medicines. This is because of poor availability in public sector and poor affordability in private sector. And according to 55th round of NSS, two-third of outpatients’ expenses is towards medicines. In yet another study, it came out that in developing countries like India, 80-90% expenditure by people for getting healthcare goes towards procuring medicines. So it simply means that whether a person can or can’t avail health facility, purely depends upon the fact that whether he can or can’t purchase medicines. If we see the figures of income and poverty in India, then it is easy to see how much big proportion of the population is practically not in position of having any health care facility, that such a larger portion of people are denied their basic human right.
Because of the just mentioned fact, I think we need to discuss the issue of pharmaceutics in little more detail to know how systematically the govts and profit-hungry companies are denying the people their rights.
Medicines, another Arena of Profit-hunting Madness
At the time of independence, India was completely dependent on imports for medicines. First public sector Medicine Company was developed in Pimpri in 1954 with the help of WHO & UNICEF. Later with the help of Soviets, larger public sector units were established under Indian Drug and Pharmaceutical Company (IDPL) in Rishikesh, Hyderabad and Chennai. Plant at Rishikesh was biggest at that time in Asia. In 1970, Indian Patent Act was implemented which stressed that any chemical entity used as medicine was not allowed to be patented. In 1978, Drug Policy was announced stressing the priority to public sector production and compelling the MNCs to produce medicines in bulk. This resulted in lowering of prices of Medicines in 1980’s as compared to 70’s. In 1979, by Drug Price Control Order, Govt. put 378 medicines under price control measure.
MNCs opposed these measures vehemently. Domestic capitalism also proliferated much and it started rolling out its wings to reap the rich profits from the manufacture of drugs. Neo-liberal policies of 1991 were almost victory for them. The small gains of 70-80’s were diluted systematically in favor of national and international capital. By the time of declaration of Drug policy of 2002, public sector companies were almost sealed. IDPL remain closed since 1996 and the other one named HAL (Hindustan Antibiotics Ltd.) is in dire condition. Number of drugs under price control was slashed down to 74 in 1995 from 378 in 1979 which was further reduced to only 30 in 2002. With these anti-people and pro-capital measures, the field of medicine production has been left open for corporate grab on poor peoples’ pocket which was further enhanced by the signing of TRIPS agreement which led to total control of medicine production in hands of few monopolies. This resulted in dramatic rise in prices of medicines. The portion of world population not having regular access to medicines was less than half of total in 1975 which has gone up to more than two-third now. India is also no exception to this worldwide phenomenon.
Corporate monopoly has not only affected the prices of medicines but has also made the field of research profit oriented instead of human need oriented. The research has shifted its attention from ‘essential drugs’ to ‘lifestyle drugs’ which target illusory ailments of riches; instead of ‘orphan drugs’, the new mantra of corporates is ‘Blockbuster drugs’ like Paxil and Neurotin. Less than 10% of $56 billion spent globally on medical research is aimed at Health problems of 90% of the world population. Some drugs developed earlier for diseases of tropical areas of world have started to disappear because they are seldom or never needed by those who have the capacity to pay.
Attitude of Medical Profession towards People
Capitalism has not only turned upside down the policies of govts and given rise to blood sucking jokes in form of MNCs, it has made deep inroads in the medical education and attitude of medical professionals especially doctors. Now a day, talk of ethics can earn you a tag of eccentric, psycho and many more like these. Instead of ideas of ensuring equity and justice during the provision of heath services, now fashioned words are marketised healthcare, medical tourism, evidence-based medicine etc. Much more is happening that can make a sensitive person feel ashamed like tariff wars in doctors e.g. in Association of Medical Consultants in Maharashtra leave apart the commonly known ‘cut practice’ in medical profession.
Above it is the net of pharma companies which can break any ‘taboo’ of medical professionals to maximize their sales. Gifts ranging from the pen, diaries, mobile sets, laptops, costly dinners to luxury cars & holiday packs for families are there to take care of ‘needs’ of doctors. So doctors are dancing to tune of companies. Diseases which are mostly due to lifestyle like obesity are now subjected to ‘obesity surgeries’ and more & more human intellect is being drained to refine these surgeries to ‘perfection’. Psychiatry has now become a chemotherapy based medical branch and common behavioral variations have been labeled ‘illnesses’ amenable only to drugs.
Poor people are getting their loved ones discharged from hospitals, both govt. and private, as LAMA (Left against medical Advice) because they are not able to bear the expenses towards the treatment. But what is more shameful, is that poor people are asked to sign or give thumb-prints for their willingness and consent in taking their patients to home for which they are not at all willing, after all who wants to lose his or her dear ones. But capitalism has made this possible, poor people are now signing the consents for deaths of their own fathers, mothers, brothers, sisters, children, wives and husbands. This is the height of insensitivity and violation of human rights. And corporate houses are reaping profits and doctors are purchasing Audis, Mercedes, building villas. Result is popular dissatisfaction and anger towards medical professionals leading to attacks on doctors and ransacking of hospitals. Doctors instead of looking in there own house, are staging & celebrating ‘major victories’ like ‘Violence against doctors’ bill of Maharashtra.
But yet there is another dimension to this commoditization of health services, a large section of health workers is also being thrown before the bloody crabs of market. This section includes mainly paramedics like nursing staff & technicians and less qualified doctors who can be thrown out of the hospitals at any time and are made to work on meager amounts.
‘Right to Health’ as centre of mass Democratic Movements
With this plagued condition of ‘Right to health’ it is clear that there is gross violation of vast majority of peoples’ basic right to live. So if any movement for democratic rights with broad mass base and support is being envisioned, then the fight for ‘Right to health’ with mass education & involvement can play and will play a central role in building such a movement.
Right to health has a special character which connects it directly to many other basic democratic human rights. Right to health immediately brings into fore the right to food as right to health is meaningless without adequate balanced food. It brings into the arena the ‘right for proper housing’ and ‘right for healthy & humane conditions at workplace’. It also connects to the ‘Right to minimum basic education’.
For making people to participate in fight for health as a Right and in more broad movements for democratic rights, there needs to be the recognition of peoples’ potential which may be underdeveloped at present but can become an invincible force in reckoning if they are properly educated about their rights. This needs a closely knit network of interaction between intellectuals, democratic rights activists & organizations and masses. There is need of building mechanisms to ignite the public consciousness and involve & mobilize the masses.
They need to learn why their governments spend so much on military hardware and so little on human needs. They need to know why the leaders they elect systematically roll back socially progressive policies, and why they deregulate the practices of giant corporations at the people’s expense. They need to question why the newspapers proclaim economic prosperity, when daily wages buy less and less. People should let know that there is no scarcity of resources. A recent study4 by Gupta et al has shown that providing free essential medicines to all citizens of India will cost central and state govts nearly 30,000 crore Rs., which will be there if the central govt. increases the share of health allocation in union budget from 0.29% to nearly 0.7% i.e. raising health sector allocation in absolute amounts from 26,760 crore of present allocation to 56,760 crore Rs. So people should be educated that it is not matter of availability of resources but what is missing is the political will of the country’s ruling class: that relatively small, elite minority who control most of the resources and decision-making power.
Here are some suggestions in form of demands that can be raised and taken to the people to fight for as part of struggle for ‘Right to Health’. These are unfinished thoughts that can be further refined or modified.
- State should make arrangements for provision of free primary healthcare services to every citizen immediately. The services should not only be free but also easily available and near the doorsteps of the people.
In the long run, the state should build a health care system that will be able to give comprehensive health care services free of cost to the people. The state should also fix a time-frame for doing this.
- State should immediate act to fulfill the requirements of medical personnel and equipments & infrastructure, and also stop privatization of healthcare services. Existing private healthcare should be nationalized and future entry of private players in healthcare should be banned constitutionally.
- State should take the production and distribution of medicines and other healthcare related equipments, instruments under its own control, every form of profit-making and private production should be ousted from pharmaceutics.
- As the Alma Ata declaration made clear (of which India is a part), people not only have the right to health, but have the right to participate in the planning and implementation of Health care system. This is an important aspect of the larger right to participate meaningfully in all the decision making patterns. It is even more important when there is striking inequalities in terms of economic & social parameters and rural-urban divide.
- Bureaucracy of healthcare department and doctors should be made directly answerable to people and brought under direct control of the people. This control should include periodic evaluation of their work towards the concerned section of people by the people themselves and even suspend or terminate their services by popular vote of the area concerned.
- Medical research, similar to the planning and implementation of healthcare should be brought under public eye. People should know where and for what research the money is going, is it being spent taking into account the particular population group or not?
- Medical education should be brought exclusively under govt control and should be designed, enhanced depending upon the needs of population.
- Right to Health is meaningless if the people don’t get enough of balanced diet, proper housing, and minimum basic education, proper and humane conditions at workplace. The state should make sure to provide these basic amenities to all citizens.
- State should make special provisions for looking after of Health of children and of persons in old age so that children can grow up as healthy adults and elderly can lead their life with human dignity.
- Right to Health along with other rights like Right to food, Right to Education, Right to proper housing and healthy & humane conditions at workplace should be made a fundamental right of all citizens of India instead of just a directive principle by an Amendment in the constitution. Constitution should provide provision for the citizens to sue the state and its machinery & concerned persons including the head of state in the court of Law and have criminal proceeding started if neglect & violation of these rights is done.
Conclusion: Health is not for sale!
In summary, it can be stressed that if health is ever to be a human right, it must cease to be a commercial product, bought and sold in the marketplace. Medical research and development should be guided not by the profit motive, but by what ails or endangers the largest number of people. It is unethical for pharmaceutical companies to reap huge profits through legalized price-fixing of life-saving drugs. In last analysis, to assure health as a human right, the whole market system with its byproduct of increased poverty and ill-health needs to be reexamined and eventually replaced with a better one, so that well-being of the people and the planet becomes a top priority.
- Part IV, Constitution of India adopted on 26thNovember 1949
- State of Punjab and Others v. Mohinder Singh, AIR 1997 SC 1225
- In Mahendra Pratap Singh v. State of Orissa, AIR 1997 Ori 37
- Narendra Gupta (2010-11): “What It Costs to Provide Medicines to All Sick Persons in India”, MFC Bulletin, August-January, Issue 342-43.