Do we consider health as a basic human right, which the Constitution of India guarantees under the Right to Life? In contrast, we believe in the World Health Organization’s (WHO) definition of health: a certain totality of health extending beyond physical fitness to the realm of mental and social well-being and happiness, and the absence of disease and disability. This means that we cannot achieve health in its broadest definition without addressing the determinants of health. This necessitates an inter-sectoral convergence beyond the medical and health departments such as women and child development, food and nutrition, agriculture and animal husbandry, civil supplies, rural water supply and sanitation, social welfare, tribal welfare, education, forestry.
We all subscribe to the slogan “Health for All by 2000”, which was proposed by Hofdan Mahler and endorsed by the World Health Assembly in 1977. The slogan had an underlying implication, i.e., “for all”, meaning universality. Thus, no one is deprived and everyone is eligible without discrimination on the basis of financial status, gender, caste, place of residence, ability to pay or any other factors. Universal health care/coverage (UHC) was enshrined as early as 1977. India committed itself to the goal of ‘Health for All’ by 2000 through its National Health Policy 1983.
focus on first aid
When and where did the partial coverage of the population and the partial responsibility of the ruling government to pay for health care come from? The International Conference on Primary Health Care at Alma Ata, 1978, listed eight components of minimum care for all citizens. It mandated all health promotion activities, and the prevention of diseases, including vaccination and treatment of minor illnesses and accidents, for all using government resources, especially for the poor. Any non-communicable disease, chronic illness including mental illnesses, and its diagnosis and treatment were almost excluded from primary health care. When it comes to secondary and tertiary care, it is left to the individual to get it from a limited number of public hospitals or the private sector by paying out of pocket. There were not enough government-run institutions for the poor (who could not afford exploitative and expensive private care). This abdication of responsibility, ie, by the state to provide secondary or tertiary care, ensured the dominant, unregulated, profit-making private sector and also kept the health insurance sector happy and thriving. This created a dichotomy between peripheral primary and institutional-referred specialist care at the secondary and tertiary levels.
looking ahead
Recognizing that the poor also suffer from chronic diseases and non-communicable diseases such as cardiovascular, nervous, psychiatric and metabolic disorders, and also need to be screened and managed in peripheral primary health institutions, a Primary Health Care (PHC) ) Version 2 or wider PHC defined. A sensible move, it was piloted through the National Rural Health Mission (NRHM) in India since 2013. The latter half of the last decade saw the operation of the Health and Wellness Center as a model for the implementation of comprehensive primary health care.
Everyone has the right to be healed and not have complications, disability and death. This right is only guaranteed by individualism in public health, the new global approach to UHC, where “no one is left uncounted and neglected”.
The Alma Ata Declaration of Primary Health Care can be left behind as a beautiful edifice of concepts from the past. Let us move forward with a new concept of UHC which includes primary, secondary and tertiary care to all who need it at an affordable cost without any discrimination.
Universal health coverage slogan should be avoided as it is misleading. This is because it is neither universal in its implementation nor comprehensive in its coverage of services and never assures access or affordability as its funding is conditional to insurance premiums paid by the individual or the state. The WHO should not have bowed to the pro-market reform guidelines of the World Bank and the Rockefeller Foundation during the 2004–2010 period, such as reducing state regulation and selectivity of non-economic service coverage. This backtracking from “Health for All” undermines the UHC concept. The consolation, however, is that a 2011 World Health Assembly resolution urges countries to timely finance the health sector to reduce out-of-pocket spending and the impoverishment of households resulting from catastrophic expenditures in health.
2018 Astana Declaration Calls for a “partnership” with the private sector, however, from alcohol, tobacco, ultra-processed foods, and industrial and automobile pollution by the commercial private sector are well established. Furthermore, poor countries have miserably failed or been reluctant to “deregulate the private sector”. It never addressed poverty, unemployment and poor livelihood, but praised quality PHCs only as a cornerstone of universal health coverage and neglected comprehensive universal health care.
The concept of a globally accepted health system since the Beijing Health Systems Research Conference 2012 is a multi-nodal system of specialties with different sectors, professional streams and different types of staff to provide comprehensive universal health care.
The National Health Mission is a better model of fully tax-financed Universal Health Care with concurrent inter-sectoral emphasis on Poshan Abhiyaan, National Food Security, Mahatma Gandhi National Rural Employment Guarantee Act, Jal Sanitation, Sarva Shiksha Abhiyan etc. But Ayushman Bharat Jan The Arogya Bhima scheme harms that approach.
Dr. KR Antony is Independent Monitor, National Health Mission, Government of India, Former Director, State Health Resource Centre, Chhattisgarh and Former Health and Nutrition Specialist, UNICEF, India.