A Crucial Indicator of a Nation’s Progress

DOES RIGHT TO LIFE INCLUDE HEALTH AND WELL BEING?

A Crucial Indicator of a Nation’s Progress

Swapna Jha*

Though the Constitution of India does not expressly recognise the right to health as a fundamental right it has several provisions that deal with the health of the public at large. A silver lining, however, comes from the Supreme Court of India, which has established, through judicial interpretation, that the right to health is indeed a fundamental right under Article 21 which guarantees right to life and personal liberty. The apex court has repeatedly observed that under Article 21, “life” means a life with human dignity and not mere survival or animal existence.

In the case of Paschim Banga Khet Mazoor Samity v. State of West Bengal (1996) 4 SCC 37, the scope of Article 21 was further widened, as the court held that it is the responsibility of the Government to provide adequate medical aid to every person and to strive for the welfare of the public at large.

The right to health encompasses various factors crucial for a good quality of life, extending beyond mere survival. It involves access to healthcare, sanitation, nutrition, and overall wellbeing. In modern society, the pursuit of a better quality of life is intricately tied to maintaining and improving health.

However, the right to health is still an illusion for most of the country’s marginalised population. As per data released by the Health Ministry, under the National Health Profile, on June 19, 2018, there is one government allopathic doctor per 11,082 population, one government hospital bed per 1,844 population and one state-run hospital for 55,591 population.

The WHO Constitution and the Universal Declaration of Human Rights in the forties were the first international instruments to endorse health as a fundamental right of every human being. The right to the highest attainable standard of physical and mental health was subsequently incorporated into

The right to health encompasses various factors crucial for a good quality of life, extending beyond mere survival. It involves access to healthcare, sanitation, nutrition, and overall well-being.

the International Covenant on Economic, Social and Cultural Rights (1966). In international human rights law, the right to health is an inclusive right, extending beyond healthcare to the underlying determinants of health, such as access to potable water, sanitation, adequate food, nutrition and housing, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health.

The normative scope and content of the right to health (i.e., the standard for the human right to health) comprise four interrelated elements which require that public health and healthcare facilities, goods, services and programmers, in addition to the underlying determinants of health, be Available, Accessible, Acceptable and of a reasonable Quality. The right to health for all people means that everyone should have access to the health services they need, when and where they need them, without suffering financial hardship. It also imposes obligations of immediate effect on states including the guarantee of non-discrimination, and the obligation to take deliberate, concrete and targeted steps towards realising the right

to health for all.1 No one should get sick and die just because they are poor, or because they cannot access the health services they need.2

Defining Health

There is no proper legal definition of health. The most widely accepted definition is given by the WHO, which defines ‘health’ as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’

Health is a crucial factor in national development. Unfortunately, healthcare is one of the most neglected aspects of development in India. According to a study by the World Bank, 50% of the economic growth differentials between developing and developed nations are attributed to poor health and low life expectancy. The healthier the citizens of a country, the more effective the workforce; the better the health of their children, the fewer births, and hence the fewer dependents. Ensuring the health and wellbeing of all is essential to poverty eradication efforts and achieving sustainable development, contributing to economic growth and prosperous communities.3

It is also a key indicator of a country’s progress: a nation with a healthy population is more likely to experience sustained growth. Good health is also essential for the stability of entire regions, as pandemics, which transcend borders, can have severe social and economic impacts on families and communities, and can put increased pressure on health systems.

Although global health has improved significantly in recent decades, this benefit has not been shared evenly within and among nations. Several hundred million people across the globe continue to go without basic health services, especially in rural areas and in the most impoverished communities. More than six million children die each year and nearly 300,000 women die in pregnancy or childbirth, many from preventable causes.4

Government Policies and Efforts

Public spending on health as a percentage of GDP is an indicator of the priority accorded to health in the planning process of any nation. Policy documents like the approach paper to the 12th Five Year Plan (2012 to 2017), the High-Level Expert Group for Universal health coverage, the program implementation framework of the NRHM and the report of the National Commission on Macroeconomics and Health have all endorsed the need to raise the level of public spending on health in India from around 1% to 2-3% of GDP.

In India public expenditure on health is incurred by three tiers of the government, the central government, the state government and the local bodies. The central government spends directly on health and also provides grants in aid to state governments who, in addition to spending out of the grants in aid received from the center, incur health expenditure directly out of the resources available with them. Their health expenditure also includes transfers to rural and urban local bodies for health spending while the local bodies too incur health expenditure from the resources available with them. The sum total of health expenditure by each of these three tiers of government provides an estimate of public spending on health in India. In 2009- 2010 and 2010 -2011 public expenditure on health in India was around 1.1% of GDP and in the financial year 2023 it is estimated to be 2.1%.

The increased spending has resulted in an important initiative by the government. National Health Mission (NHM) is Government‘s largest public health programme, which aims rather ambitiously to achieve universal access to quality healthcare. It consists of two sub-missions, the National Rural Health Mission (NRHM); and the National Urban Health Mission (NUHM). While public health services in India have improved slowly over the years they are nowhere near the minimum norms prescribed by WHO. This applies to things like government hospital beds per thousand people and population wise number of allopathic doctors. The situation varies from state to state with some states being vastly ahead of others. Same is the story of the primary and community health centres, Accredited Social Health Activists (Asha), doctors and nursing staff.

However, it must be noted that the successive government initiatives have resulted in reducing the country’s average death rate. In 2020, communicable diseases accounted for 12,271 deaths in India, which was 10 per cent lower than the corresponding figure for the previous year. Acute respiratory infections and pneumonia accounted for the majority of deaths in 2020. Vector-borne diseases accounted for 4 per cent of total communicable diseases related deaths in 2020. This figure stood at 8 per cent in 20195 . The figures show some improvement but the outcomes in India are nowhere close to the international standards.

India’s Progress on Sustainable Development Goals

The WHO’s Sustainable Development Goal (SDG) number 3 is “good health and wellbeing for all at all ages”. There has been some progress on improving global health in recent years. For example, 146 out of 200 countries or areas have already met or are on track to meet the SDG target on under-5 mortality. Effective HIV treatment has cut global AIDS-related deaths by 52 per cent since 2010 and at least one neglected tropical disease has been eliminated in 47 countries. However, insufficient progress has been made in other and more fundamental areas, such as on reducing maternal mortality

“While India is way behind in achieving Universal Health Coverage, the government has been trying to intervene through nationwide schemes like the Ayushman Bharat and Pradhan Mantri Jan Arogya Yojana (PMJAY) launched in 2018.”

rate (MMR) and expanding universal health coverage. Globally, approximately 800 women died every day from pregnancy or childbirth in 2020. As many as 381 million people were pushed or further pushed into extreme poverty in 2019 due to very high out-of-pocket expenditure on health.6

While India is way behind in achieving Universal Health Coverage, the government has been trying to intervene through nationwide schemes like the Ayushman Bharat and Pradhan Mantri Jan Arogya Yojana (PMJAY) launched in 2018. It aimed to empanel more healthcare providers, especially in small towns, towards the aim of having 1.5 lakh Health and Wellness Centers and covering at least 50 crores beneficiaries from 10 crores financially vulnerable families under Rs. 5 lakh per family, per year coverage in secondary and tertiary care hospitalisation, by 2022. With an aim to bring low-cost treatment close to people’s homes while targeting non-communicable diseases, maternal and child health as well as to provide essential drugs and diagnostic services at affordable prices, the government regulations are paving the way for better infrastructure and health facilities throughout the country.

Launched on September 23, 2018, PMJAY has been designed to provide financial risk protection against catastrophic health expenditure that impoverishes an estimated 6 crores people every year. The number of individual beneficiaries verified under PMJAY stands at more than 21.90 crores. Over 26,031 hospitals have been empaneled under the scheme till date. This has facilitated over 4.07 hospitalisations as on January 5, 2023, saving beneficiaries over Rs. 47,055 crores in outof-pocket medical expenditure. It is estimated that PMJAY has contributed in curtailing outof-pocket expenditure to the tune of 1.5 to 2 times the actual expenditure recorded under the scheme.

Another important initiative, the National Digital Health Mission (NDHM) is being rolled out to create an integrated nationwide database of health services and providers. The mission aims to create a management mechanism to process digital health data and facilitate its seamless exchange; develop registries of public and private facilities, health service providers, laboratories and pharmacies; and to support clinical decisionmaking as well as offer services like telemedicine.

The NDHM has the potential to make the health system more evidence-based, transparent and efficient. This will immensely help the government in its efforts to prioritise policies and programs that resonate with the targets set in SDGs.7

“In many countries, some if not most physicians work simultaneously for the public sector and in private practice. This means the public sector ends up subsidizing unofficial private practice.”

Findings of the World Health Reports

The WHO carried out the first-ever analysis of the world’s health systems in “The World Health Report 2000 – Health systems: Improving performance”8 . The main message from this report, according to WHO DirectorGeneral Dr Gro Harlem Brundtland, “… is that the health and well-being of people around the world depend critically on the performance of the health systems that serve them. Yet there is wide variation in performance, even among countries with similar levels of income and health expenditure. It is essential for decision-makers to understand the underlying reasons so that system performance, and hence the health of populations, can be improved.”

Some of the noteworthy findings of the World Health Report are:

Many health ministries’ focus on the public sector and often disregard the frequently much larger private sector healthcare.

In many countries, some if not most physicians work simultaneously for the public sector and in private practice. This means the public sector ends up subsidizing unofficial private practice.

Many governments fail to prevent a “black market” in health, where widespread corruption, bribery, “moonlighting” and other illegal practices flourish. The black markets, which themselves are caused by malfunctioning health systems, and low income of health workers, further undermine those systems.

Many health ministries fail to enforce regulations that they themselves have created or are supposed to implement in the public interest.

While private health expenses in industrial countries now average only some 25 percent because of universal health coverage (except in the United States, where it is 56%), in India, families typically pay 80 percent of their health care costs as “out-of- pocket” expenses when they receive health care.9

India is ranked fifth from the bottom in terms of public spending on health globally and 155th out of 167 countries on hospital bed availability. It has one of the highest out-of-pocket spending levels on health in the world. Out-of-pocket spending as a proportion of total health spending is a leading cause of impoverishment in India. The hospital industry accounts for 80% of India’s total healthcare market; it is expected to be valued at USD 132 billion by 2023. Despite its huge role, regulation of the private sector is weak.10 It is time we start following best practices from across the world, allocate a higher percentage of our GDP towards healthcare and ensure a better public delivery system to achieve the SDG goal of universal healthcare within a reasonable time frame.

Endnotes

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