India is looking for good final outcomes for various inputs in health care sector. Final outcomes are defined in terms of goals like equity, efficiency, improvement in health levels, good quality of health care, reduction in catastrophic consequences of disease, improvement in accessibility and affordability in health care. To achieve these final goals, India has taken various initiatives for last 30 years such as National Health Policy 1983, 73rd and 74th Constitutional Amendments for decentralisation in 1992, National Nutritional Policy 1993, National Health Policy 2002 and more recently National Rural Health Mission 2005.(WHO-India 2012)
When we try to combine all the expected final outcomes, they indicate towards "Health for all". National Health Policy 1983 was specially targeted towards "Health for all by 2000 A.D.". But it failed to meet its goal. In India, access to health care, good quality of health care and health care according to the needs are seems to be major problems to achieve this goal. Access to good quality of health care as per the needs is the core factor of right to health and health care for all. (Wilkinson and Marmot 2003).
Health care for all is certainly a different concept than health for all. It not only addresses the medical care but also consider all aspects of pro-preventive care. Health care for all includes universal access to health care, fair distribution of health care and lastly inclusion of marginalised and vulnerable groups in the coverage of health care. That means only availability of health care can never be sufficient to achieve health for all. It should be supported with accessibility, acceptability and adaptability i.e. realisation of right to health. It is responsibility of each and every state to realise people about right to health and implement policies and programmes addressing right to health (Srinivasan 2006).
So, this paper highlights the current situation and initiative taken by government regarding with availability, accessibility, acceptability and adaptability in the health sector. And also looks after the implementation of policies and programmes, whether they are in a way to realise the "Right to Health" and "Health Care for All" or not.
METHODS
Articles and reports were searched from Web of science, The Lancet, Oxford University Press, Economic and Political Weekly, Indian Journal of Community Health and Google Scholar for publications related with implementation of policies and programmes in India, barriers in the implementation process and realisation of right to health and health care for all. The official websites of World Health Organisation, Ministry of Health and Family Welfare of India, World Bank and Planning Commission are referred for various statistics. To ensure up-to-date knowledge, search of the articles were restricted to the past 12 years.
RESULT
Extracted articles identified previous as well as current scenario of implementation of policies and programmes in India. Many policies failed to achieve the goals. Even National Health Policy 1983 failed to achieve "Health for all by 2000 A.D.". Government consistently failed to raise its expenditure on health. Also health sector is suffering from human resource crisis. Government failed to make health service available, accessible, acceptable and adaptable. But certain initiatives by government show some positive responses. Overview of some constitutional rights show that government is now addressing towards increasing health facilities, equal access to health care and non-discriminatory health services, which are the key ingredients of right to health and health care for all.
DISCUSSION
Availability, accessibility, acceptability and adaptability are the basic pillars of the right to health and health care for all. So, above points are discussed under two headings i.e. current situation and government initiatives to address them.
CURRENT SITUATION-
Health transition in India is becoming a driving force for policies and programmes. It includes:
Demographic transition i.e. shifting from high level of mortality and fertility to level.
Epidemiological transition i.e. shifting from acute diseases like communicable diseases to chronic like non-communicable one.
Social transition i.e. shifting from low knowledge of health system to high.
(Peters et al 2003)
This changing pattern in the health leads to improvement in the health status indicators. Life expectancy at birth rose from 49 years in 1970 to 64 years in 2010. Also infant mortality is reduced from 129 in 1970 to 52 in 2010 (WHO World health statistics 2010). But still promise made by government in 1983 to achieve "Health for all by 2000 A.D." is pending. In addition to that goals set in National Health Policy 2002 such as eradication of polio and yaws by 2005, elimination of leprosy by 2005, elimination of kala-azar by 2010, achieve the zero level growth of HIV/AIDS by 2007, reduction in infant mortality up to 30 per 1000 live births by 2010, increase in the utilisation of public health facilities from less than 20% to more than 75% by 2010 and many more are hardly completed (National Health Policy 2002).
In terms of health expenditure also government is far lagging behind private. General government expenditure on health is only 26.20 % of the total expenditure on health in 2001, while private expenditure on health is far higher i.e. 73.80% of total health expenditure. This public expenditure on health is very less as compared to other countries, as mentioned in the following table :( WHO World health statistics 2010). Due to low public expenditure, question arises on the affordability of the health care services. Privatisation in the health sector is seriously hampering the economic condition of the vulnerable groups. Around 73.80% of expenditure on health is on private sector. This out-of-pocket expenditure may drive individual or families into the trap of poverty (Caswell and O'Hara 2010). And poverty again leads to ill-health. Poor people are less likely to access preventive and curative health services than rich (Govender and Kekana 2007).
According to Bhore committee 1946, there should be 20 nurses per 10000 populations, where in 2004; India had only 7.85 nurses per 10000 populations (WHO 2006). WHO also suggests that there should be at least 23 workers (i.e. doctors, nurses and midwives) per 10000 populations. But India has only 19 health workers per 10000 populations in 2011. India is suffering from human resource crisis in health sector and is ranked 52 out of 57 countries facing human resource crisis (World health statistic report 2011). This human resource crisis in health sector leads to inequity in the distribution of health cadre. Marginalised and vulnerable population in rural, tribal and hilly areas are facing more problems due to this. For example, 26% of the total doctors practices in rural areas where around 72% of the total population lives (Rural Health Statistic Bulletin 2010). This proves the lack of availability of skilled workers in the health sector.
Both availability and affordability collectively may lead to inequities in the accessibility of health services. Untreated morbidities are higher in rural areas, in females, in scheduled castes and tribes and in lower consumption classes with respect to urban areas, males, forward castes and higher consumption classes respectively. Also women from schedule castes and tribes have poorer access to health care facilities than that of women from other castes (NSSO 2006; IIPS 2007). Also the socio-cultural distance between health service system and its users is major problem in accessing the health services. Respect to patient's dignity, confidentiality, sensitivity towards women and other vulnerable are the key findings for acceptability of health services (Simon 2008). Again health services should change accordingly with the needs as well as demographic health situations so that population should adapt the health service and use it. So, only availability and accessibility are not sufficient enough to drive health care system, they should be accompanied with acceptability and adaptability (Srinivasan 2006).
GOVERNMENT INTIATIVES-
To handle all the above problems, Government of India is taking initiatives with World Bank. World Bank is helping India to achieve its goals mentioned in 11th five year plan. World Bank lent $19 billion to India to achieve these goals (World Bank). To reduce inequalities among rural and urban areas, Government of India is targeting on primary and rural health services under RCH-2. It has been decided that the service will be provided for 24 hours and 7 days in a week at primary health centre. This will be achieved in 50% of PHC's within next five years (Ramani and Mavalankar 2006).
Out-of-expenditure is increasing due to privatisation. To reduce this and make service affordable, Government of various states started some health insurance schemes such as Yeshasvini, Arogya Bhagya Yojna, Arogya Bhadrata, Employee State Insurance Scheme etc.(Ramani and Mavalankar 2006). Tribal, rural and hilly areas, most of the time faces the problems of accessibility of health services. Government is providing ambulance facility for them. Recently, Government of India introduced the concept of telemedicine. As 75% of the treatments don't require surgical instruments, they can be treated theoretically by using telemedicine. In addition to that, government has started free helpline for women and children to address accessibility.
Acceptability and adaptability are the again major problems in the health service sector. To address these problems, government started NRHM in 2005. NRHM is going for major architectural correction in the health sector. Decentralisation is the basic theme of NRHM. Through decentralisation process local institutions like Panchyat get involved in the system. So community participation and empowerment become ease. Also to improve these unsatisfactory conditions, government has decided to raise spending on health sector from 0.9% of GDP to 2-3% of the GDP under National Common Minimum Programme (Dhingra and Dutta 2011).
Constitution states that health is a subject of State. State has an obligation to provide health facilities as well as to protect rights regarding with health. But as centre has large number of items listed in concurrent list, Central Government plays significant role in health sector. Therefore, to protect and promote the right to health and health care for all, government had had made some provisions so that vulnerable and marginalised people should exercise their rights (Desai and Mahabal 2007). Right to education, right to livelihoods, right to housing, sanitation and quality water, right to equal treatment, right to participation and many more are provisions exist in Directive Principles for the States, which collectively addresses right to health (Chatterjee and Sheoran 2007). Some more declarations are made in Universal Declaration of Human Rights such as Convention on the Elimination of All Forms of Discrimination against Women, Convention on the Elimination of All Forms of Racial Discrimination etc.
Good final outcomes in health sector could not be achieved by only right to health. It requires some more considerations of individuals' behaviours and socio-economic conditions for health. So, WHO cites "Making human rights an integral dimension of design, implementation, monitoring and programmes in all spheres, including political, economic and social." Government also addresses on the patients' rights while utilising health services. Patient should be treated with respect and dignity. They should be provided with respectful care and should be free from physical, mental, sexual and emotional harassment. They should be able to exercise right to privacy, right to equal treatment, right to information, right to food and nutrition etc. (Desai and Mahabal 2007).
CONCLUSION
India is in a stage of health transition. That means demography, pattern of diseases and knowledge regarding with health are shifting from their previous forms to new one. So, to address these changes government is targeting its policies according to change. But this doesn't mean that previous illnesses are completely eradicated. Despite of various policies and programmes, some simple and avoidable problems are still in the community. The basic reason is in the implementation of the policies and programmes. WHO's report on Social Determinants of Health suggests that policies and programmes should address social determinants of health to achieve "Health for all." Because these factors restrict people from accessing and utilising health care services. Right to health and health care for all plays an important role in removing these barriers. So, people should be promoted to exercise right to health care and health care for all and State is obliged to fulfil that right.
