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.
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.
Dr Rakhal Gaitonde [email protected]_