Health Workshop for AIDWA activists – strengthening the fight for our right to health care
AIDWA took the initiative to organize a two day workshop on health related issues for activists from the Hindi speaking states. The growing challenge to achieving the right to health care, in a context where government policy was increasingly promoting the private corporate sector in health services at the expense of the public health system was the subject of a Commission in AIDWA’s 10th National Conference in Bodh Gaya. The discussions had concluded that our interventions on health had to increase at multiple levels.
Accordingly the broad objectives of the workshop were (a) to strengthen campaigns and struggles around health related issues at the local level, (b) help activists to evolve demands around these concerns, linked to an understanding of policy trends and (c) facilitate a gendered perspective towards health concerns.
AIDWA Vice President, Sudha Sundararaman welcomed the 27 participants from Bihar, Delhi, Haryana, Himachal Pradesh, Jharkhand, MP, Rajasthan, UP, Maharashtra, and W. Bengal. She also introduced members from the People’s Health Resource Network (PHRN) which was facilitating and supporting the workshop. AIDWA President, Malini Bhattacharya introduced the two day programme, and chaired the session.
Strengthening the Public Health System
The first session on Strengthening the Public Health System was conducted by Dr. T. Sundararaman. A majority of the participants had taken up local issues related to the public health services, mostly in public hospitals, and found them either lacking essential services, overcrowded, unfriendly or even unaffordable. In fact many participants had themselves only used the private sector in the last six months, or were using both. Only a minority had used the public system exclusively. However they did point out that most of the people in that area wanted to use the public services, if only they were made available, and accessible.
Taking off from these experiences, Dr Sundararaman placed the fundamental premise that the right to health care means the right to free care provided by efficient, effective, good quality public health care facilities and the need of the hour was to ensure this as a political task. Without taking up the specific demands to strengthen the public health services, our struggle for the right to health is in danger of being diverted through policy changes to benefiting and expanding the private sector through insurance and other public funding schemes.
It was necessary to understand why public services were ineffective, to formulate demands for action. Hospital services had to be built upon the underlying primary care services where a large number of basic health problems could be handled. The lack of comprehensive and quality primary care facilities at the level of the PHC and CHC, in turn linked to and supported by the efficient secondary level public hospitals through a referral system, were major factors for the failure of the public health system. Under the pressure of the World Bank, public primary health system had been limited to providing only selective services like family planning and immunisation, and offered treatment for very few diseases. Even the priority being given to pregnancy care and safe delivery for women, which were very crucial to reduce maternal and child mortality, ultimately took care of only 10% of the illnesses and conditions for which women needed health care.
Therefore, local level struggles would need to focus on the nearest public health facility such as the PHC in rural areas and demand services that provided effective treatment for all common illnesses of the area. ( provided in the NRHM list of services). Effective treatment should include a) free drugs, b) free ambulance service, c) free diagnostic services, etc. Though a doctor was desirable and must be pushed for, a wide range of services can be provided in the PHC even with well trained nurses and paramedicals. Moreover, drugs for chronic illness should be dispensed at the local PHC or sub-center, so that the patient need not go all the way to the district hospital every week, just to collect drugs. The government must pay if there was a referral to a private service.
In addition, campaigns should also raise demands for : a) improved quality of services, that ensured satisfactory treatment outcomes, b) safe treatment, and c) privacy and dignity of the patient. These should be monitored through grievance redressal mechanisms, users committees, village health and sanitation committees, district health society etc. Representatives of womens organizations should be members of these committees.
In the urban areas, there is no equivalent network of primary care services and the demands related to this need to be evolved. It is essential that every individual has a health record maintained by the nearest PHC and that this entitles them to a basic set of preventive, promotive and curative services.
The policy of low government funding on health ( amongst the lowest in the world) was strongly criticized by Dr. Sundararaman. Distorted expenditure, less allocation for necessary services, deliberate policy of understaffing, increased use of contractual and commission based employees, lack of measures to train and motivate doctors and staff to work in rural and remote areas, and undue influence of international aid agencies in policy making were also pointed out as faulty policy measures.
After the presentation the participants divided into groups to discuss the demands that they would like to raise in their states, and this was followed by a lively discussion.
Dangers of privatisation in health sector
The second session on Understanding the Private Sector in Health was divided into two sub-sessions. Sonya Gill dealt with the adverse consequences of privatisation for health of people as a major source of indebtedness and poverty. The growing presence of the private sector in health was the outcome of government policy which had subsidised the private sector and under-funded the public sector. Post 1990s, the policy trend actively supported the expansion of the private sector through public private partnerships, promotion of insurance schemes, privatisation of medical education, failure to regulate the private sector and disallow private practice by government doctors.
In parallel, the health sector reforms led to further reduction in government health spending and raising user fees in public hospitals. Since health care as an industry put profitability above health, corruption and exploitative practices were rampant. A campaign had to be taken up for the regulation of the private sector with a focus on protecting patient rights. Every state should have a private clinical establishments act in place with rules to provide for a minimum of nine safeguards for patients. This would have to be backed by grievance redressal mechanism in every hospital and legal aid for patients denied health care or subjected to exploitation.
Understanding Health Insurance Schemes
Dr. Indranil addressed the issue of insurance schemes. Insurance schemes are meant to protect the patient from the costs of treatment but in reality the reimbursed amount is very small and payment is often denied by the insurance company on a number of technical grounds. Rashtriya Swasthya Bima Yojana (RSBY) was the main scheme that the participants were aware of. This scheme had problems both in its design and implementation. The enrolment of the beneficiaries, and the provision of the card was often faulty. Out of pocket expenditure had not decreased as spending on primary care was borne by families. Girl children or elderly women were often excluded due to the targeted approach. One study showed that though hospitalization was to be provided free to those with the card, only 12% of those who had the card and needed hospitalization could get this benefit. The participants had many questions about the RSBY and several demands were pinpointed to make the scheme more accessible for peoples.
Overall, the session concluded that insurance schemes fundamentally helped to expand the private sector. Therefore, only where the public hospital is unable to provide treatment, referral to private hospitals may be made. Insurance payment could be reoriented to support public health services by covering other costs such as transport, attendant care, compensation for loss of wages, as well as incentives for the staff.
AIDWA General Secretary, Jagmati Sangwan concluded the first day of the workshop by emphasizing the importance of mobilizing around health issues, and appreciated the inputs given by PHRN which would strengthen AIDWA’s interventions.
Women and Health
The third session on Women and Health began with a thought provoking presentation by Dr Bhagat from Sarthak on the impact of social devaluation on women’s mental and physical health and well being. It was helpful for participants to understand and cope with the stress that they themselves experienced as women activists.
The subsequent presentation by Dr Vandana Prasad followed this up with a detailed analysis of the range of discriminations faced by women, arising from the social roles prescribed for them and the narrow focus on reproductive health to the exclusion of other health needs in public health policy. The starting point for raising women’s health issues was to assert that health was women’s fundamental right. The existing policy with a selective, targeted approach had to be changed and the totality of women’s health needs had to be given importance in the health care services. The local level struggles would need to focus on availability of free services that could address women’s common health conditions, anaemia and malnutrition, violence related problems and safe contraception, along with RCH services. Quality of care based on sensitivity and respect for the patient must be ensured. She pointed out that the patriarchal gender construct was placing numerous health care responsibilities on women based on their traditional roles but male responsibility was never emphasized. She touched on clinical drug trials, and the lack of safety in health sector research, which especially affected women.
The final session on making common cause with the large number of women who were involved in providing health care to the people by the Government, but who were themselves being discriminated against, and denied their rights as workers was dealt with by Malini Bhattacharya, and Sudha Sundararaman. They explained the divisive tactics that were being employed to split the unity of women from poorer sections. For instance, the vulnerable ASHA worker is forced to bear the burden of an ineffective and often corrupt health system. There was an active discussion, at the end of which it was decided that AIDWA would move for better co ordination with organizations and unions that were taking up the problems of ASHAs, anganwadi workers, helpers, and other health service providers at the community level.
The workshop concluded with a recap, and a brief session to decide on future action programmes within the states around some of the issues that had emerged. The participants were greatly enthused by the workshop, and resolved to hold similar programmes, and to intensify struggles around health issues in their respective states.