As the General Elections-2019 are fast approaching, Jan Swasthya Abhiyan activists are pushing the political structures to address the issues plaguing people’s health by releasing a ‘People’s Health Manifesto-2019’

The manifesto demands increasing the public expenditure on health to 3.5 per cent of the GDP in the short-term and absorbing the Ayushman Bharat health insurance scheme—based on the discredited ‘insurance model’—under a strengthened, well-funded public health system and a right to health act which includes a patients charter.

People’s Health Manifesto, 2019 Jan Swasthya Abhiyan Remembering the 40th  anniversary of the Alma Ata Conference which proclaimed ‘Health for All’, the Jan Swasthya Abhiyan (JSA) Strongly iterates the Right to Health and Health Care for all people of India.

We express our deepest concerns regarding the anti-people steps being taken by the current Government in the health sector. We strongly oppose various negative policy trends such as:

• the failure to move a constitutional amendment to make the right to health a fundamental right in the Indian Constitution

• the recent national health budgets being reduced in real terms, • the downgrading of public health services and various retrograde steps concerning the National Health Mission;

• launching of the ‘Pradhan Mantri Jan Arogya Yojana ’ (PMJAY) or National Health Protection Scheme which is 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 privatization of district hospitals and other public health services;

• more corporatization of Medical Education giving scope for more capitation based student enrolment.

• continued refusal to ensure effective regulation of the private medical sector, allowing this sector to continue massive profiteering at the cost of patients, especially by corporate hospitals;

• unwillingness to effectively control prices of medicines, based on cost of production. Allowing marketing of hundreds of irrational and harmful Fixed Dose Drug Combinations (FDCs).

• not bringing a legal code to eliminate unethical marketing practices by the pharmaceutical industry;

• ongoing exclusion and marginalization of wide sections of the population related to access to quality health services •

In this context, we propose the following policy actions, especially in the context of 3 various upcoming state assembly elections and parliamentary elections, to be committed to by 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 JSA will concurrently mobilize and campaign among different sections of the people to build a consensus around the urgent actions we propose. •

1.Make the right to healthcare a justiciable right through the enactment of appropriate legislations both at Centre and State levels. Such legislations should ensure universal access to good quality and comprehensive 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 healthcare as fundamental rights in the Indian Constitution. •

• 2,Increase substantially the public expenditure on Health, financed primarily through general taxation,to 3.5% of GDP (this would be annually around Rs. 4,000 per capita, at current rates, as recommended by the National Health Policy-2017) in the short term, and 5% of GDP in the medium term, with at least 60% of the expenditure being borne by the Centre and 40% by states. • Further ensure that out of pocket spending on health, which is currently unreachably 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. The center must commit to contributing significantly to paying for the additional human resources. For example, contrary to claims, an additional Rs.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 (NHM), and states will have bear additional financial burden forcing more exclusion. This would betray the commitment of the National Health Policy 2017 to shift from the highly selective primary health care which was imposed as part of health sector reforms in the nineties towards a comprehensive primary health care. •

3.Expand and strengthen the public healthcare system to ensure quality and availability of health care appropriate to primary, secondary and tertiary level, entirely free of user fees and provide, universal access to the entire range of essential drugs and diagnostics at the public facility with a matching human resource policy and much better governance and management. Such strengthening may require supplementation by referral for select services to private providers, often specialists where these have not been possible to arrange in-house. Supplementation by private agencies could also be required to expand the capacity of public services to deliver certain ancillary or supportive services. The direction would be of selectively using private health care resources to strengthen public systems, contrary to the approach of the proposed Pradhan Mantri Jan Arogya Yojana (PMJAY) under Ayushman Bharat program of indiscriminately using public resources to strengthen private health care providers. •

4.Capacity of Public Sector Health System should be enhanced to monitor and analyze new elements of social determinants in order to recommend preventing and mitigating measures. Inter-sectoral coordination has to be envisaged so that Govt. departments act together at various levels to improve these social determinants of health. •

5.Ensure that no private practice is undertaken by government doctors as part of public health services. •

6.Improve, democratize radically and expand exponentially both in terms of quantity and quality, Public Health System to enable it to play a leading and regulating role in the National Health Care System.Build and actively promote a predominantly public health system based framework for Universal Health Care (NOT ‘Coverage’ or ‘Assurance’). Major expansion and strengthening of public health services could be combined with some contracting 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 provisio

7.Abandon plans for the ‘Pradhan Mantri Jan Arogya Yojana” or “National Health Protection Scheme” as part of Ayushman Bharat as this is 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 an expanded and strengthened public health system. •

8. Regularise all contractual health workers, including ASHA, Anganwadi and helpers involved in deliver y of public health services 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. •

9 . Formulate and implement a comprehensive policy on occupational health and safety.Occupational health should be included in the medical curriculum. Ensure accountability and stringent action against violations. All projects by corporations that can potentially affect health should first have a health impact assessment done in a transparent, participatory and technically sound manner, based on which they receive a ‘health clearance’. •

10. Increase public investment in education and training of the entire range of health personnel to ensure capacity building in government run colleges. Establish a well-gov- 5 erned 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 or charging of capi tation fees. Overhaul the Medical Council of India (MCI) and the Nursing Council of India along democratic lines to eliminate corruption and unethical practices. Allow state specific rules and processes for recruitment of candidates that combines merit and transparency in selection and finds appropriate candidates for working in difficult areas.

• 11.The Government of India, with active involvement of all State governments, should without any delay guarantee 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, Delhi and Rajasthan, which would ensure access to the full range of essential medicines and medical investigations, without any fees, at all levels of health facilities. Ensure availability of all appropriate, safe and cost-effective vaccines in the Public Health System. Revive existing public sector units and establish new public sector drugs and vaccine production units towards self reliant medicine production in the country. Provide adequate funding to all public sector medicine research institutions. Encourage pharmaceutical research through Open Source Drug Discovery model.     

• 12.The government must adopt a scientific pro-people pharmaceutical policy. Towards this end, it must • Bring all essential medicines and their analogues as well medical devices under price control through a system of price fixation based on manufacturing cost. • Ban all irrational medicines and irrational Fixed Dose Drug combinations • Effectively regulate and eliminate unethical marketing by adopting legal Uniform Code for Pharmaceuticals Marketing Practices. • Adopt a rational pharmaceutical policy covering drugs, vaccines, diagnostics, and medical devices and equipment. • Promote opening of generic medicine outlets in adequate numbers. The government should prepare a Generic medicine policy that would make it mandatory for manufacturers to prominently display the generic name (rather than brand) as main labelling for all products, and for doctors to use generic names in all prescriptions, while ensuring easy availability of generic medicines • Use the public health safeguards in the Indian Patent Act to promote access to medicines, Protection should be provided against patent misuse and Compulsory Licenses should be for local manufacturer of patented medicines. Build innovation eco-systems that actively promote drug and diagnostic innovation to ensure that the diagnostics and therapies required to address our changing health needs particularly for orphan 6 diseases. • Public pharmaceutical industries and vaccine manufacturing units should be strengthened, rather than being privatized.

13.Eliminate corruption 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 involved in implementation of programs and policies. Establish separate food and drug courts in the centre and states. Ban on private practice of doctors employed in Public Health Services will be strictly enforced •

14.Universalize Community 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 democratized, community driven health system, and a framework of health care that takes into account diverse community needs and perceptions. A participatory system of community-based monitoring, grievance redressal and planning will be generalized to ensure that people in every area would be able to access appropriate health services as their right with accountability mechanisms, seek effective action on complaints, and have strong voice for improved functioning of health services in their areas. •

15.Expand and Strengthen the ESI system. Ensure inclusion of a comprehensive system of health care protection for workers in the unorganized and organized 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.

16. Effectively regulate the Private medical sector – modify the National Clinical Establishment Act-2010 to 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 utilize beds for patients from economically weaker sections in trust and private hospitals who have been given lands at highly subsidized rates and tax concessions in purchase of equipment.

17.Various types of ‘PPPs’ which weaken public health services should be eliminated. Instead, where essential to fill gaps in public provisioning, services could be referred to private providers on agreed-to rates in such a manner that they serve the larger public health goals •

18.Support medical pluralismso that people have a choice to access non-allopathic systems of healing, including  safe home-based birthing practices. Substantial en- 7 couragement must be given to research and documentation related to non-allopathic systems. •

19.Adopt special measures to ensure that vulnerable populations and persons with special needs enjoy access to comprehensive, accessible, quality health services – including those having vulnerability due to social position (e.g. women, dalits, adivasis, particularly vulnerable tribal groups, refugee and migrant populations, queer and transgender persons), people in conflict areas; due to health status (e.g. HIV status), occupation (e.g. manual scavengers, rag pickers), differently abled persons, children and elderly persons, or due to any other kind of vulnerability. All forms of caste and religion-based and other forms of discrimination in health care would be eliminated through various proactive measures. • Recognize gender based violence as a public health issue and ensure access to prompt rescue and recovery care, comprehensive medical care as required and sustained support for those affected by it. Urgent steps will be introduced to address GBV experienced by health workers of all categories. Adopt measures to ensure access to the entire spectrum of equitable, sustained quality health care for women, adolescents, children, queer, trans-persons from all backgrounds and in all situations of violence.

20.Universalize 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 with small children in all work places.

• 21.Take immediate and effective steps to eliminate all forms of caste and community/religion 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.

• 22.Ensure  comprehensive treatment and care for persons with mental health issues  through strengthened implementation and integration of the revised District Mental Health Programme with the NHM within the framework of the National Mental Health Policy.

• 23.Eliminate the interference by multi-lateral and bilateral financing agencies and corporate consultancy organisations (such as the World Bank, USAID and Bill & Melinda Gates Foundation, Deloitte and McKinsey etc.) from all national health policy formulation and strategy development. Ensure that Indian research institutions have alternative national sources of funding and do not have to become dependent on them.

• 24.Implement strict regulation of approval and conduct of clinical trials will be ensured, along with ensuring fair, timely compensation for trial participants who suffer from adverse events, with the Central Drugs Standard Control Organization (CDSCO) monitoring 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.

• 25.Promote appropriate public health and health systems research: Significantly upgrade and build capacity of departments and centres for public health and health systems research. Findings of such studies should be able to guide action leading to a better understanding of social determinants and health systems and lead to innovative ways to improve the functioning of public health systems and government action. Funding and implementation of such research have to undergo strict and vigilant assessments conflict of interest.

• 26’Systematically plan to deal with both the traditional and newly recognized/ emerged pathologies in social determinants of health: this should be done by improving food security and nutrition, sanitation as well as addressing the newly evolved detriments in social determinants like environmental pollution, climate change, stressful working conditions, compromised road safety and weakened public transport systems, addictive substances like tobacco, alcohol etc. and violence including gender-based violence. Effective implementation of existing laws on these areas and necessary amendment of certain acts towards protecting people’s right.

• 27.Universalize and expand the ICDS programme to effectively cover under-3 children and universalize community-owned CMAM (community based management of malnutrition) programmes and daycare services as important to the health and wellbeing of women and children both as well as an intervention in malnutrition.”

• 28.Remove requirement for mandatory Aadhar link to access health services or any health related public services or schemes and benefits.

• 29.Integrate action on public health with broader defense and expansion of democracy and secularism at all levels. Review the health policy and existing systems to 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. Action on public health would be integrated with expansion of democracy and secularism at all levels, while promoting peace and solidarity in the region. •

• We appeal to all political parties and aspiring candidates to give highest political priority to people’s health in their agenda. In the 40th 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.