Draft People’s Health Manifesto, 2018

The Jan SwasthyaAbhiyan staunchly upholds the Right to Health and Health Care for all people of India.We are opposed to anti-people steps being taken by the current Government in the health sector. We strongly oppose various negative policy trends such as:

• the recent national health budgets being reduced in real terms,
• downgrading of public health services;
• various retrograde steps concerning the National Health Mission;
• launching of the ‘Ayushman Bharat’ scheme based on the discredited ‘insurance model’ despite massive evidence against the effectiveness of such insurance based schemes involving major participation of the private sector in service delivery;
• moves for privatisation of district hospitals and other public health services;
• continued refusal to ensure effective regulation of the private medical sector,allowing this sectorto continue massive profiteering at the cost of patients, especially by corporate hospitals;
• lack of comprehensive price control for all essential medicines and unwillingness to regulate unethical marketing practices by the pharmaceutical industry;
• ongoing exclusion and marginalisation of wide sections of the population related to health services

All these steps point to an ominous direction. We oppose the trend of pushing neoliberal policies in the realm of health care, which weakens public systems and leads to rampant marketisation of health services. To realise the right to health for all, requires ensuring a wide range of social determinants of health, along with universalising health care, where a strengthened, accountable, democratized public health system acts as the backbone and leader.

In this context, we propose the following policy actions, especially in the context of various upcoming state assembly elections, and parliamentary elections likely in 2019, to be acted uponby all political parties and candidates. This is with the expectation that the parties which come to power should implement these policy measures, and those which serve in the opposition should continue to raise these proposals and demands in all available forums within and outside elected bodies. The Jan SwasthyaAbhiyan will concurrent mobilize and campaign among different sections of the people to build a consensus around the urgent actions we propose.

1. Make the right to health care a justiciable right through the enactment of appropriate legislations both at Central and State levels. Such legislations should ensures universal access to good quality and comprehensive universal health care including the entire range of primary, secondary and tertiary services for the entire population. This must be accompanied by a public health legislation which ensures people’s access to a range of health determinants and protection from health harming influences. These should contribute to the process of making Health and Health care fundamental rights in the Indian Constitution.
2. Increase substantially the public expenditureon Health, financed primarily through general taxation, to 3.5% of GDP (this would be annually around Rs. 4,000 per capita at current rates) in the short term, and 5% of GDP in the medium term, with at least one-third being the contribution from the Centre. Since health is a state subject, and the contribution of states is at the centre much higher than the central contribution, all states should establish a system to monitor expenditure and implementation of activities supported through the state health budget. Further ensure that out of pocket spending on health, which is currently obnoxiously high, is rapidly reduced and becomes less than one-fourth of total health care expenditure. Because of the centralization of fiscal powers at the Centre states have serious financial constraints and this must be addressed by much greater decentralization of fiscal relations between the Centre and States. For example, contrary to claims, an additional 1200 crores has not been allotted for the Health and Wellness Centres and this amount will be deducted from the budget for the National Health Mission, and states will have bear the additional financial burden for these proposed centres.
3. Stop all forms of privatization of Public Health Services. Expand and strengthen the public health care system to ensure quality and availability of health care appropriate to primary, secondary and tertiary level, entirely free of user fees. Ensure that no private practice is undertaken by government doctors at the time of their work as part of public health services.
4. Build and actively promote a predominantly public health system based framework for Universal Health Care(NOT ‘Coverage’). Major expansion and strengthening of public health services could be combined with some in-sourcing of regulated private providers, as an interim mechanism, to cover the current gaps in provisioning.  While doing so the goal would be to maximize the extent and reach of public provisioning over time, while socializing and majorly transforming involved private providers, who would be individual, small and charitable providers, and not corporate hospitals. The direction would be of selectively using private health care resources to strengthen public systems, contrary to the approach of the proposed Ayushman Bharat program of indiscriminately using public resources to strengthen private health care providers.
5. Abandon plans for the ‘Ayushman Bharat’ scheme based on the discredited ‘insurance model’. The projected annual outlay of Rs.12,000-50,000 crores, as per different estimates would be much better utilized by investment in expansion of public facilities and creation of permanent public assets. Absorb existing publicly funded health insurance schemes (RSBY and different state health insurance schemes) into the public health system, supplemented by selective in-sourcingof private providers for filling of service gaps.
6. Regularise all Health Scheme workers and ensure that they receive protection from the entire range of labour laws. All levels of public health system staff shall be provided with adequate skill training, fair wages and placement and all provisions of social security and decent working conditions.
7. Formulate and implement a comprehensive policy on occupational health and safety. Ensure accountability and stringent action against violations. All projects by corporations that can potentially affect health should first receive a ‘health clearance’.
8. Increase public investment in education and trainingof the entire range of health personnelto ensurecapacity building in government run colleges. Establish a well-governed and adequate public health workforce by creating adequate numbers of permanent posts. Put in place stringent mechanisms for regulation of all existing private institutions, such as medical and nursing colleges, in a transparent manner and place a moratorium on the establishment on new private medical colleges.Overhaul the Medical Council of India and the Nursing Council of India along democratic lines to eliminate corruption and unethical practices.
9. The Government of India, with active involvement of all State governments, should without any delayguarantee access to all essential and life saving medicines and diagnostics in all public facilities across the country. The scope and coverage of this scheme should be no less than the ongoing schemes in Tamilnadu, Kerala and Rajasthan, which would ensure free access to thefull range of essential medicines and medical investigations provided through all levels of health facilities. Revive existing public sector units and establish new public sector drug production units towards self reliant medicine production in the country. Provide adequate funding to all public sector medicine research institutions.
10. Bring all essential medicines under price control through a system of price fixation based on manufacturing cost.Ban all irrational medicines and irrational combinations. Effectively regulate and eliminate unethical marketing practices by Pharmaceutical companies. Promote opening of generic medicine outlets in adequate numbers.The government should prepare a generic medicine policy and make mandatory use of generic names in prescriptions while ensuring easy availability of generic medicines.Use the public health safeguards in the Indian Patent Act to promote access to medicines, and actively promote indigenous manufacture of most drugs and devices. Protection should be provided against patent misuse and Compulsory Licenses should be for local manufacturer of needed medicines.

 

11. Eliminatecorruption in the Public Health System through transparent policies for appointments, promotions, transfers, procurement of goods and services and infrastructure development through a Transparency Act, and institute robust grievance redressal systems, which are adequately financed and managed with certain autonomy from the systems involvedin implementation of programs and policies.
12. UniversaliseCommunity based planning and monitoring of public health services at all levels to ensure the accountability and responsiveness of public health services. Over time, move towards a democratised, community driven health system, and a framework of health care that takes into account diverse community needs and perceptions.
13. Expand and Strengthen the ESI system. Ensure inclusion of a comprehensive system of health care protection for workers in the unorganised and organised sectors, linked with the expansion and rejuvenation of the Employees State Insurance (ESI) Act, 1948. Specifically include workers in the unorganized sector and the agricultural sector, who are currently not covered by any form of social protection mechanism.
14. Effectively regulate the Private medical sector – modify theNational Clinical Establishment Act-2010to ensure observance of patient’s rights; regulation of the rates and quality of various services; elimination of kickbacks for prescriptions, diagnostics and referrals; and grievance redressal mechanisms for patients. All states must adopt the National Act or a state specific act which incorporates all the features of the national Act. Establish a publicly managed admission system, and regular referral between government hospitals and charitable trust hospitals, to effectively utilise beds for patients from economically weaker sections in trust and private hospitals who have been given lands at highly subsidised rates and tax concessions in purchase of equipment.
15. Various types of ‘PPPs’ which weaken public health services should be eliminated. Instead, where essential to fill gaps in public provisioning, regulated private providers (especially smaller and not-for-profit facilities) should be in-sourced at standardized rates, in such a manner that they serve the larger public health goals.
16. Support medical pluralismso that people have a choice to access non-allopathic systems of healing, including safe home-based birthing practices. Substantial encouragement must be given to research and documentation related to non-allopathic systems.
17. Ensure thatvulnerable sections and sections with special needs enjoy access to health care at all levels. Vulnerability could be due to social position (e.g. women, dalits, adivasis), health status (e.g. HIV status), occupation (e.g. manual scavengers), ability, age or any other cause. Guarantee comprehensive, accessible, quality health services for all women and transgender persons for all their health needs.
18. Recognize gender based violence as a public health issue and ensure access to comprehensive health care for survivors. Adopt measures to ensure access to entire spectrum of equitable, quality health care for women from all backgrounds and in all situations.
19. Universalise Maternity benefits for all pregnant and post natal mothers, including contractual Workers, Daily Wage Workers, all workers in the Unorganized Sector and in the Agrarian Sector. Provide Crèche & Rest room for mothers small children in all work places.
20. Take immediate and effective steps to eliminate all forms ofcaste based discriminationand any discrimination or deficits based on tribe or ethnicity, in the health care sector and beyond. Take immediate steps to eliminate the heinous practice of manual scavenging.
21. Ensure rights based access to comprehensive treatment and care ofpersons with mental illness through integration of the revised District Mental Health Programme with the National Health Mission.
22. Eliminate the interference by multi-lateral and bilateral financing agencies and corporate consultancy organisations (such as the World Bank, USAID and Gates Foundation, Deloitte and McKinsey etc.) from all health policy formulation.
23. Implement strict regulation of approval and conduct ofclinical trials. Ensure that the CDSCO and the ICMR monitor the conduct of clinical trials at the trial sites. Ensure fair, timely compensation for trial participants who suffer from adverse events. Develop a justiciable charter of rights of clinical trial participants.
24. Promote appropriate health research, significantly upgrade and build capacity of department and centres for health research, so that monitoring and evaluation of health programmes can be scientific and representative. Findings of such evaluations should lead to generalisable recommendations, rather than review missions which have poor scientific rigour and limited insights.
25. Systematically plan to deal with both the traditionalsocial determinants of health like food security and nutrition, sanitation and the newer determinants like environmental pollution, occupational health, road safety, addictive substances like tobacco, alcohol etc. and violence.
26. Universalize and expand the ICDS programmeto effectively cover under-3 children and universalize community-owned CMAM (community based management of malnutrition) programmes.
27. Remove requirement for mandatory Aadhar link to access health services from all health care related schemes.
28. Integrate action on public health with broader defence and expansion of democracy and secularism at all levels.Review the health policy and existing systemsto ensure that these prevent any type of majoritarian fundamentalism, discrimination against minorities, denial of care in conflict situations, and stigmatization or denial of care for persons labeled as ‘others’ or ‘outsiders’. Ensure that health systems at all levels are maximally inclusive and equitable, and strongly project messages to propagate an ethos of democratic inclusion, secularism, humanity and peace.

We appeal to all political parties and aspiring candidates to give highest political priority to people’s health in their agenda. In the 40^th year of adoption of the Alma Ata Declaration of ‘Health for All’, as a nation we must revive the concepts of inter-sectoral action and community empowerment as being central to health. In this spirit it is imperative to prepare and implement people based plansat various levels to ensure food security, education, water supply and sanitation, land justice and agrarian regeneration,community control of natural resources, livelihood security, gender and social justice – all linked with environmentally sustainable and equitable development – which are essential for the general well being and health of the people of India.

Please send your additions/changes, if you have any by 5th October. The Manifesto will be finalised based on your inputs.