Claudio Schuftan, Ho Chi Minh City.
Schuftan@gmail.com
To understand these challenges, one needs to describe the health services in the countries in the region from a historical perspective all the way to the present. Efforts at providing comprehensive health care, and in extending the infrastructure of health services need to be scrutinized to pass a human rights judgement. No such a human rights-based diagnosis has been carried out in the region. So the best contribution to this topic this paper can make is to give guidance to Asian countries on how to assess their right to health care situation. The following country-level questionnaire can be used as a guide to document with hard facts the real situation from a human rights perspective.
1. General questions
• 1.1.How has the delivery system matched the needs of the vast majority of your people?
1.2.Was there at any time a political commitment to provide affordable and easily accessible comprehensive health care services to the poorest?
1.3.Has the implementation of official national health policies been able to make a significant dent in the status of health of the poorest or in health care delivery systems to serve them?
1.4.Has there been an urban elitist bias in medical education as well as in medical services detracting from providing health care to the poor and the rural populations?
1.5.Has there been an emigration of health personnel?
1.6.Has medicine emphasized medical specialties and the development of private hospitals and clinics?
1.7.Has the trend to irrational use of non-essential drugs and of sophisticated technology increased?
1.8.Has the disease-load of the poor population continued to be unacceptably high?
1.9.Have maternal, infant and child mortality rates been improving?
1.10.How high have State allocations to the health sector been over time? How does it compare with global and other regional standards?
1.11.Have the (meagre?) allocations for health been utilised to solve the health problems of the poorest?
1.12.Has the quality of health services provided by the public sector suffered?
1.13.Do health care services tend to respond to a new ‘market demand’? Do the health needs of the poorest (the majority) figure as part of this “demand”?
2. Neoliberal Reforms: Their Impact on Health Care
• 2.1.Has your country had such reforms? If yes, did these reforms mark a major shift in the government’s policy towards social sectors like health?
2.2.Were government spending and subsidies to the social sectors cut?
2.3.Were public services privatized?
2.4.Did the State withdraw from the social sectors like health, education, food security?
2.5.Have programs for provision of clean drinking water and sanitation suffered?
2.6.Can you quantify the cuts made in the budgetary support to the health sector, e.g. in terms of percentage of the government’s investment plan, or the expenditure by the government on health as percentage of GDP?
2.7.Was the squeeze on the social sector resources of the state distributed in a fair manner?
2.8.As a result, do recurrent expenditures (especially for salaries) now tend to take up an inordinately large proportion of total expenditures? Can you quantify this in percentages over time?
2.9.Has the burden of cutbacks been increasingly placed on medicines, medical supplies and materials?
2.10.Are expenditure patterns on health care grossly skewed in favour of urban areas? Have investments correspondingly fallen on rural health services?
2.11.Overall, is the neoliberal reform process geared to restructure the economy in a certain manner and not to improve welfare measures arguing that present levels of subsidies to the social sector are unsustainable? Are prescriptions for restructuring of the health sector largely designed, not to provide the best possible health care, but to maximise outputs from greatly reduced state support?
2.12.What is the percentage of government spending in the total expenditure on health care? Has this percentage been falling thus legitimizing the further privatisation in the health sector?
2.13.Have the TB, malaria, diarrheal diseases, EPI, family planning programs seen earlier gains decrease?
3. Misplaced Emphasis on Vertical Programs
• 3.1.Are you experiencing a “resurgence of communicable diseases” in your country?
3.2.Has there been any degree of integration of vertical programs at the level of delivery? Are these programs sensitive to local conditions and responsive to local needs? To whom are these programs accountable? Has the utilisation of government health facilities decreased in many areas?
3.3.Together with a slowing down of investment by the State in these programs, have simultaneous incentives been given to the private sector in the form of soft loans, subsidies and tax exemptions?
3.4.Has the use of new medical technologies further added to the impetus of privatization with increasing participation from the corporate sector? Have multinational insurance companies entered the market more aggressively?
3.5.Does all this mean that the health needs of the poorest majority of your people are being increasingly ignored?
4. Penetration of the Private Medical Sector
• 4.1.Has the government abandoned its basic duty of providing health care facilities and enhanced the ability of the private sector to penetrate into the health sector?
4.2.Are drinking water and sanitation services provided by the private sector?
4.3.If private medical care can only survive if it is profitable, can you say that a private medical care provider stands to profit rather from ill-health? (i.e., the more people fall ill and the longer they remain ill, the larger the profit for the care provider!)
4.4.Are private providers concentrated more among the better off citizens?
4.5.Do you consider the health care in the private sector to be expensive and inefficient or does privatisation of health care lead to more efficient utilisation of resources?
4.6.Does the private sector in your country have a host of direct and indirect subsidies from the government? Does the government provide concessions to private hospitals?
4.7.Does the government provide incentives, tax holidays, and subsidies to the private pharmaceutical and medical equipment industry? Does it allow exemptions in taxes and duties in importing medical equipment and drugs, especially for expensive new medical technologies?
4.8.Is medical and pharmaceutical research and development largely carried out in public-funded institutions, but the major beneficiary is the private sector?
4.9.Are you seeing the entry of the organised corporate sector in medical care?
4.10.Is this corporate take over attempting to further push up cost of medical care by introducing high cost technologies, expensive diagnostic aids and expensive medicines?
5. National Health Policies
• 5.1.Do official documents recognize the very concept of comprehensive and universal and primary health care? Is the government committed to the principles of “Health for All”? Does it refer to the Alma Ata Declaration of 1978 in its official documents?
5.2.Do policies mention the concepts of village health workers and of good public referral services?
5.3.If policies are silent on these PHC principles, do they provide a framework for the dismantling of the whole concept of primary health care?
5.4.Is there an essential drugs policy and does it mention price controls?
5.5.Is the intersectoral approach in health planning mentioned? If mentioned, has it then been ignored?
5.6.What is said about women’s health needs? Are specific proposals made to address them?
5.7.Are child health and child nutrition distinct national programs?
5.8.What does the policy say regarding the need to create a medical education system oriented to the needs of primary health care? or, Is the system biased towards urban, hospital and specialist-based health care?
5.9.What is said about medical research? Anything said about research in public health and about ethical criteria in this regard?
5.10.Do policies say anything about equitable distribution and allocation of resources to improve health services in remote areas?
6. Top-Down Prescriptions
• 6.1.Are health policies –the whole rhetoric on community participation aside– more of a shopping list of “top down” prescriptions?
6.2.Do they recommend retaining most of the national vertical programs?
6.3.What is said about devolution of responsibilities and financial powers to districts? Are efforts of decentralisation strong?
6.4.Is the primary health care system retained as a collections-driven (fee for service) system controlled by the centre?
6.5.Do policies express the feeling that providing drugs and equipment (though an important part) is all that is needed to improve the quality of services?
7. Prescriptions for Further Privatisation
• 7.1.Do policies clear the way for further privatisation of the health care system?
7.2.Is sub-contracting of public health services to NGOs mentioned as an option?
7.3.Is it proposed to employ user fees in public hospitals –couched in the usual sugar coating of it being introduced for’ those who can pay’?
7.4.Are user fees driving out the poor and the indigent?
7.5.Is the government retreating from providing comprehensive and quality secondary and tertiary care? Is it being hinted that the private sector can occupy the space that would be left vacant?
7.6.What percentage of inpatient care is used by the poorest 20% of the population?
7.7.Do policies talk about using health facilities to attract patients from other countries? Will this “health tourism” divert your best resources to serve the interests of the global health market and create islands of brain and resource drain within the country?
7.8.Are policies critical of the public health system (justifiably so) with no criticism found of the ills of the unregulated private medical care system? Is the need to develop regulatory norms for the private sector mentioned?
8. Policy on Population Control – Targeting Women
• 8.1.Are existing family planning policies and programs paternalistic and prescriptive? Do they victimize women?
• 8.2..Do women have faith in the FP program as addressing their real concerns?
• 8.3.Is women’s health considered important primarily when women are pregnant or lactating? Do existing policies addresses women’s health in all its dimensions
and not just their wombs?
• 8.4.What percentage of deaths in women are due to childbirth?
• 8.5.Are girls <5 more likely to die than boys?
• 8.6.Has the emphasis shifted from Population Control to Reproductive and Child Health --beyond what policy says?
• 8.7.Do women have a choice, i.e., are they in a position to make decisions about their choice?
• 8.8.Are the child-sex ratios across the country a matter of concern?
9. Pharmaceutical Policy
• 9.1.Do you have a comprehensive national policy on pharmaceuticals? Has it been revised periodically?
• 9.2.Are drugs under price control? Are drugs patent protected?
• 9.3.Has the volume of pharmaceuticals under price control been reduced over time? 9.4.Have prices of essential and non-essential drugs risen importantly
in the last five years?
• 9.5.Have increases in prices resulted in the "costing out" from the market of a large number of people? Has this forced poor consumers to pay for medicines
even if they are being treated in public facilities?
• 9.6.Does the national drug policy address the issues of universal availability and affordability of essential drugs?
10. New Directions in Policy
• 10.1.What promises come out from the latest health policies regarding the issues above? Are these promises credible and likely to become reality? What
concerns are you left with?
• 10.2.Is there a trend towards moving further away from any commitment in providing comprehensive and universal health services by the government?
11. Wide Ranging Impact – Denial of Health Care at all Levels?
• 11.1.Infant and Child mortality/Maternal mortality: Have there been improvements?
• 11.2.Avoidable/preventable child deaths: How many per day? Trends improving? 11.3.Deaths from tuberculosis: How many every year? Improvements?
• 11.4.What proportion of the population cannot afford health care when they fall ill? Do you have national surveys on this? What percentage of hospitalized
patients are forced to borrow money or sell assets to cover expenses? (best estimate)
• 11.5.What percentage of your population has been pushed below the poverty line every year because of the catastrophic effect of out of pocket spending on
health care? (best estimate)
• 11.6.Are irrational medical procedures on the rise? e.g., caesarean sections?, irrational prescribing?, percentage of money spent on unnecessary prescriptions
or tests?
• 11.7.Can your population access all essential drugs that they require?
• 11.8.How big are differences between Infant Mortality Rates in the poorest 20% of the population vs that in the richest 20% of the population?
• 11.9.Is a child in minority populations more likely to die in childhood?
• 11.10.Is a girl more likely to die before reaching her fifth birthday, compared to a boy?
• 11.11.How many times more likely is a person from the poorest quintile of the population to access hospitalization compared with a person from the richest
quintile?
• 11.12.How many times less likely is a woman from the poorest quintile of the population to have her delivery attended by a medically trained person compared
with a well off mother? What about minority women?
• 11.13.What is the ratio of doctors to population in rural areas compared with the availability of doctors for the urban population?
• 11.14.What is the government per capita spending on public health in rural areas compared to the same spending in urban areas.
• 11.15.What percentage of all primary health care centers (PHCs) do not have all the critical staff? What percentage do not have all the critical supplies
(defined as 60% of critical inputs)? What percentage have no Essential Obstetric Care drug kits? What percentage do not offer delivery services?
12. Violation of Health Rights: How serious?
[This section assumes that your country has ratified the three major human rights covenants of the UN (see below). If it has not, you can still document violations to the right to health care, but your campaign may choose to lobby for ratification. This section also assumes that violations to the right to health care occur almost universally; so, to zero-in quickly, questions herebelow assume such violations do occur in your country; if this is not the case , clearly say so under the respective question].
• 12.1.Can you say there are repeated and continued violations of the Right to Health Care (RHC) in your country? Are these in sharp contrast to Constitutional or legal provisions in the country and to International Covenants signed by your country?
12.2.Does your Constitution incorporate provisions guaranteeing everyone's right to the highest attainable standard of physical and mental health? Has your
Supreme Court at any time upheld that right? Ergo, does the government have a constitutional or legal obligation to provide health care?
• 12.3.Which international covenants upholding health rights in their varied manifestations has your country ratified?
• 12.4.The Universal Declaration of Human Rights, Article 25 states: “Everyone has the right to a standard of living adequate for ... health and well-being of
himself and his family, including food, clothing, housing, medical care and the right to security in the event of ... sickness, disability.... Motherhood and
childhood are entitled to special care and assistance...” Are the state of health services and access to them an evidence of violation of the Declaration in
your country?
• 12.5.Three covenants – the International Covenant on Economic, Social and Cultural Rights (ICESCR), the United Nations Convention on the Rights of the Child
(CRC) and the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) – describe in detail obligations towards provision of
comprehensive health care services. Have you examined them to understand the extent of violation of health rights that are seen today in your country?
13. International Covenant on Economic, Social and Cultural Rights.
[The International Covenant on Economic, Social and Cultural Rights (ICESCR) is the most comprehensive international convention covering economic and social rights. Our government ratified it in 19.. (or did not). This covenant includes the Right to Health, covered by article 12: “The states parties to the present covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” This right has been elaborated upon and clarified by the General Comment 14 of the UN Committee on Economic, Social and Cultural Rights, adopted in the year 2000: “The obligation to fulfil requires States parties, inter-alia, to give sufficient recognition to the right to health in the national political and legal systems, preferably by way of legislative implementation”].
• 13.1.Is this recognized as the right to health in your country? Is there any legislative implementation of this? Is the obligation fulfilled? “..and to adopt
a national health policy with a detailed plan for realizing the right to health”.
• 13.2.Does such a plan exist in your National Health Policy or equivalent?. “States must ensure provision of health care”.
• 13.3.Do the facts reflected above represent gross deficiencies in the provision of health care by the government? “…including immunization programmes against
the major infectious diseases, and ensure equal access for all to the underlying determinants of health, such as nutritiously safe food and potable drinking
water, basic sanitation and adequate housing and living conditions.” “Public health infrastructures should provide for sexual and reproductive health
services, including safe motherhood, particularly in rural areas.”
• 13.4.Do your maternal mortality rates, your poor coverage of antenatal and delivery services indicate large scale violation of this right? “States have to
ensure the appropriate training of doctors and other medical personnel, the provision of a sufficient number of hospitals, clinics and other health-related
facilities, and the promotion and support of the establishment of institutions providing counseling and mental health services, with due regard to equitable
distribution throughout the country.”
• 13.5.Do your data show large scale inequities in the availability of doctors and hospital beds between urban and rural areas? The General Comment 14 also
clearly specifies certain Core obligations of states related to the right to health: “43 … States parties have a core obligation to ensure the satisfaction
of, at the very least, minimum essential levels of each of the rights enunciated in the Covenant, including essential primary health care.” “(a) To ensure the
right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups;”
• 13.6.Do your data show that vulnerable groups such as rural and minority populations suffer from denial of physical access to quality health services?
• 13.7.Do large sections of the population living in poverty suffer from lack of financial access concerning private medical services? and/or access to
hospitalization? “(d) To provide essential drugs, as from time to time defined under the WHO Action Programme on Essential Drugs;”
• 13.8.Are Essential drugs accessible for over 95% of the population? “(e) To ensure equitable distribution of all health facilities, goods and services;”
• 13.9.How equitable is the distribution between urban and rural areas as described earlier? “(f) To adopt and implement a national public health strategy and
plan of action, on the basis of epidemiological evidence, addressing the health concerns of the whole population; the strategy and plan of action shall be devised, and periodically reviewed, on the basis of a participatory and transparent process; they shall include methods, such as right to health indicators and benchmarks, by which progress can be closely monitored; the process by which the strategy and plan of action are devised, as well as their content, shall give particular attention to all vulnerable or marginalized groups.”
• 13.10.Is there such a national public health strategy, or are you aware of any process of participatory and transparent review? Have right to health care
indicators and benchmarks been developed? The General comment 14 clearly specifies ‘Violations of the obligation to fulfil’ as follows: “52. Violations of the obligation to fullfil occur through the failure of States parties to take all necessary steps to ensure the realization of the right to health. Examples include the failure to adopt or implement a national health policy designed to ensure the right to health for everyone; insufficient expenditure or misallocation of public resources which results in the non-enjoyment of the right to health by individuals or groups, particularly the vulnerable or marginalized; the failure to monitor the realization of the right to health at the national level, for example by identifying right to health indicators and benchmarks; the failure to take measures to reduce the inequitable distribution of health facilities, goods and services; the failure to adopt a gender-sensitive approach to health; and the failure to reduce infant and maternal mortality rates”.
• 13.11.Do these violations exist on a consistent and continued basis based on the data presented earlier? Finally, the GC 14 has specified the desirability of
a national legislation on Right to health: “56. States should consider adopting a framework law to operationalise their right to health national strategy. The
framework law should establish national mechanisms for monitoring the implementation of national health strategies and plans of action”
• 13.12.Does such legislation or framework exist in your country?
14. United Nations Convention on the Rights of the Child.
[The United Nations Convention on the Rights of the Child entered into force in 1990. It was ratified by our country in 19.. (or was not). Article 24 of CRC clearly mandates the right to health and health care for children: Article 24 “1. States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.”]
• 14.1.Do the avoidable child deaths every year documented above indicate that this right remains largely unrealized? “2. States Parties shall pursue full
implementation of this right and, in particular, shall take appropriate measures:” “(a) To diminish infant and child mortality;”
• 14.2.Did the expected declines in both IMR and CMR take place during the 1990s? At what percentage is the current annual reduction in death rates per year
estimated? If your country intends to achieve the MDGs by 2015, how much higher should be current reduction rate be? “(b) To ensure the provision of necessary
medical assistance and health care to all children with emphasis on the development of primary health care;”
• 14.3.How gross are the inequities in access to health care for children in rural areas compared to urban areas?, and for children from poor families compared
to those from well off families? “(c) To combat disease and malnutrition, including within the framework of primary health care, through, inter-alia, the application of readily available technology and through the provision of adequate nutritious foods and clean drinking-water, taking into consideration the dangers and risks of environmental pollution;”
• 14.4.What percentage of children <3 in rural areas still suffer from malnutrition? What percentage of all children under age three are not fully protected
with immunisation? How many children die each year from an ordinary illness like diarrhoea? Are safe drinking water and sanitary conditions becoming
progressively more available? “(d) To ensure appropriate pre-natal and post-natal health care for mothers;”
• 14.5.What percentage of mothers do not receive all of the recommended services during antenatal care? What percentage of births still occur at home? What
percentage of women do not receive postpartum care? “(e) To ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding, hygiene and environmental sanitation and the prevention of accidents;”
• 14.6.What percentage of infants are not exclusively breastfed and what percentage are not given timely complementary feeding? What percentage of children with
diarrhoea do not receive an Oral Rehydration Solution? “(f) To develop preventive health care, guidance for parents and family planning education and
services.”
• 14.7.Do the above mentioned sample facts illustrate deficiencies in preventive health care for children? Are health/nutrition awareness/education activities
carried out? In conclusion, what does this overview demonstrate regarding violations of the Right to Health Care in your country? Or are these violations
occasional or accidental?
15. Initiatives to Remedy the Situation
[It is obvious that a large number of initiatives are required to remedy the present situation. Check here some of the immediate steps related to the health care system that seem to be needed to be taken. Add or delete as needed to fit your national reality; this is only a sample].
• 15.1.Is a National Public Health Act mandating assured provision of basic health services needed? It would specify a set of basic health services to be
available to all as a right, including legal obligations of public and private health care providers, health rights of citizens, standards of care and certain
proportion of public funds to be earmarked for public health. All within specified time frames.
• 15.2.Is making health care a fundamental right suitable for a constitutional amendment? This includes the formulation of national legislation mandating the
Right to Health Care with a clearly defined comprehensive package of health care, along with authorization of the requisite budget being made available universally and prog ressively starting within one year. • 15.3.Does the government need to undertake a review of the national health policy (or equivalent) to bring to the foreground the Primary Health Care approach and the goal of universal access to comprehensive health care; along with the elimination of measures that promote the private medical sector?
• 15.4.Does the government need to strengthen the existing public health system with commitment to quality coverage and to equity? This, especially in rural
areas, assuring that all the required infrastructure, staff, equipment, medicines and other critical inputs are available, and result in delivery of all required services at the primary secondary and tertiary levels. These would be ensured based on clearly defined, publicly displayed and monitored norms. Health services need to be integrated and vertical programs must be progressively phased out.
• 15.5.What measures are needed to reverse the declining trend of budgetary allocations for public health? This means that budgets must be appropriately
upscaled to make optimal provision of health care in the public domain possible. Making larger resources available to rural health facilities is deemed urgent. Simultaneously, the budgetary allocation to the health sector must be increased substantially, targeting to progressively reach 5% of GDP as public expenditure on health care (as recommended by the WHO).
• 15.6.If the public health system fails to deliver, should it be treated as a legal offence, remedy for which is to be sought in the courts of law? The public
system must ensure all elements of care like drug prescriptions, diagnostic tests, child birth services, hospitalization care, etc.
• 15.7.Is there a need for a range of policy measures to eliminate discrimination, and to provide special quality and sensitive services for women, children,
elderly persons, unorganised sector workers, HIV-AIDS affected persons, disabled persons, persons with mental health problems and other vulnerable groups and minorities? Similarly, situations of conflict, displacement and migration need to be addressed with a comprehensive approach to ensure that the health rights of affected people are protected.
• 15.8.Is national legislation to regulate the private health sector, to adopt minimum standards, accreditation, standard treatment protocols, standardised
pricing of services needed? Also a mechanism is to be put in place to regulate private medical colleges (if applicable).
• 15.9.Should the government operationalise a system and set up a central fund for the procurement of essential drugs? Such a central fund could be utilised for
procurement of a set of essential drugs in all states/provinces. This fund could be matched by a decentralized essential drugs fund and a transparent,
rationalised procurement and distribution system at state level.
• 15.10.Are effective drug price controls and the promotion of rational drugs needed? Steps to be taken to impose price control on all drugs of the National
Essential Drug List in a phased manner.
• 15.11.Should the government introduce a new community-anchored health worker scheme and implement it in a phased manner with involvement of people’s
organizations in both rural and urban areas? First contact primary care and health/nutrition education can thus be ensured. If they already exist, all state level coercive population control policies, disincentives and orders should be removed and disproportionate financial allocation for population control activity should not be allowed to skew funding from other important public health priorities.
• 15.12.Finally, streamlining of health education to form basic, community-oriented health professionals and technicians is needed to ensure a wider outreach
and improvement of access to health care services in all areas.