Insufficiency of medical facilities

By Abhinav Yadav

The West Bengal National University of Juridical Sciences, Kolkata

Editor’s note:

The health situation and medical facilities in India continue to be extremely dismal. Under the domain of human rights, the right to health is defined as the right to achieve the “highest attainable standard of health” not merely the absence of disease. They form a part of customary international law, and guarantees protection, healthy environment, food, housing, etc. This paper examines the role of the WHO, the State, and the terrible state of affairs of the rural healthcare system with emphasis on India. It concludes with a glance at India’s changing political economy, and some policy objectives it must work towards.

Introduction

The twenty fifth anniversary of Alma Ata Declaration was observed last year. Along with other countries, India had also formulated various targets to be achieved by the year 2000. However, the achievements were minimal even after half a century of health planning, and most of the goals could not be realized. The health situation in our country continues to be dismal.

Human rights standards address the civil, political, economic, social and cultural sphere.  Each human right, while formally belonging to one of those categories, in reality encompasses aspects of all of them. This is easily identifiable within the human right to health. Moreover, the right to health within the human rights framework is defined as the right to achieve the “highest attainable standard of health” not merely the absence of disease. Both of these aspects of human rights are consistent with a social determinant approach to health, as they take into account the wide array of factors that influence a   person’s overall health status. Finally, a human rights and health care delivery approach both have in common an assumption that the primary purpose of a health care system is preserving health, rather than addressing economic interests.

The international human rights framework is robust and authoritative. Arising out of the atrocities of World War I, human rights stand for the proposition that rights cannot be given nor taken away by government, but exist innately for all human beings. Human rights are comprised of civil, cultural, economic, political, and social rights. They are part of customary international law as evidenced by the world embracing the principles of the Universal Declaration of Human Rights (UDHR). Human rights are also part of binding and enforceable international law, as evidenced by the broad treaty obligations of the two major international covenants: the International Covenant on Economic, Social, and Cultural Rights (ICESCR), and the International Covenant on Civil and Political Rights (ICCPR). These documents contain a wide range of health-related rights including “the right to health”, medical facilities, and have been widely ratified by governments globally. Additional human rights conventions and guidelines govern the rights of women, children, religious or ethnic minorities, and persons with physical (e.g., HIV/AIDS) and mental disabilities.

What is the Human Right to Health,Health Care and medical facilities?

The human right to health means that everyone has the right to the highest attainable standard of physical and mental health, which includes access to all medical services, sanitation, adequate food, decent housing, healthy working conditions, and a clean environment.

  • The human right to health guarantees a system of health protection for all.
  • Everyone has the right to the health care they need, and to living conditions that enable us to be healthy, such as adequate food, housing, and a healthy environment.
  • Health care must be provided as a public good for all, financed publicly and equitably.

The human right to health care means that hospitals, clinics, medicines, and doctors’ services must be accessible, available, acceptable, and of good quality for everyone, on an equitable basis, where and when needed. The design of a health care system must be guided by the following key human rights standards.

Universal AccessAccess to health care must be universal, guaranteed for all on an equitable basis. Health care must be affordable and comprehensive for everyone, and physically accessible where and when needed.

Availability: Adequate health care infrastructure (e.g. hospitals, community health facilities, trained health care professionals), goods (e.g. drugs, equipment), and services (e.g. primary care, mental health) must be available in all geographical areas and to all communities.

Acceptability and Dignity: Health care institutions and providers must respect dignity, provide culturally appropriate care, be responsive to needs based on gender, age, culture, language, and different ways of life and abilities. They must respect medical ethics and protect confidentiality.

Quality: All health care must be medically appropriate and of good quality, guided by quality standards and control mechanisms, and provided in a timely, safe, and patient-centered manner.

The human right to health also entails the following procedural principles, which apply to all human rights:

Non-Discrimination: Health care must be accessible and provided without discrimination (in intent or effect) based on health status, race, ethnicity, age, sex, sexuality, disability, language, religion, national origin, income, or social status.

Transparency: Health information must be easily accessible for everyone, enabling people to protect their health and claim quality health services. Institutions that organize, finance or deliver health care must operate in a transparent way.

Participation: Individuals and communities must be able to take an active role in decisions that affect their health, including in the organization and implementation of health care services.

Accountability: Private companies and public agencies must be held accountable for protecting the right to health care through enforceable standards, regulations, and independent compliance monitoring.

Right to Health: The International Perspective

Right to health and availability of qualitative health services are issues that are relevant all over the world. Hence, these issues also form topics of debate at various international levels. The United Nations, in particular, has been active in adopting various resolutions to safeguard the interests of individuals in ensuring their health and well being. The Universal Declaration of Human Rights states that: “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing, and medical care, and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

World Health Organization:

For more than fifty years, the World Health Organization has been playing a laudable role at the international level with a view to ensure the availability of the highest standards of health care to people all over the world. The Preamble of the World Health Organization Constitution states that:

  1. The enjoyment of the highest standards of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, and economic and social condition.
  2. The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and states.

  3. The achievement of any state in the promotion and protection of health is of value to all.

  4. Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger.

  5. Healthy development of the child is of basic importance; the ability to live harmoniously in a totally changing environment is essential to such development.

  6. The extension to all people of the benefits of medical, psychological and related knowledge is essential to the fullest attainment of health.

  7. Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people.

  8. Governments have a responsibility for the health of their people, which can be fulfilled only by the provision of adequate health and social measures.

Article 2 of the same Constitution deals with functions that, directly and indirectly, require the application of legal principles, such as:

  1. To act as the directing and coordinating authority on international health work;

  2. To propose “Conventions, Agreements and Regulations”, make recommendations with respect to international health matters, and to perform such duties as may be assigned thereby to the Organization and are consistent with its objective; and

  3. To develop, establish and promote international standards with respect to food, biological, pharmaceutical and consumer products.

Several international agencies have also lent support to public participation in health care. The World Health Organization Alma Ata Declaration 1978, states that: “The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.”

Health and Health Care: National Perspective

The Constitution charges every state with “raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties”.
Health and health care have been covered both under the Constitution of India and in different legislation. The Constitution does not explicitly recognize right to health as a fundamental right. Similarly, different legislative enactments passed with regard to health and health care deal more with the regulatory aspects rather than the right to health. It can be interpreted that these statutes recognize right to health in a given context in an indirect sense.

Constitutional Provisions

Preamble to the Constitution of India categorically directs the State to initiate measures aiming at improving the health of the people. This is to be inferred from the broader parameters of social and economic justice.

Duty of the State to raise the level of nutrition and the standard of living and to improve public health: The State shall regard the raising of the level of nutrition and standard of living of its people and the improvement of public health as among its primary duties, and in particular, the State shall endeavor to bring about prohibition of the consumption except for medical purposes of intoxicating drinks and of drugs which are injurious to health. Though right to health has not been expressly incorporated in the Constitution as a fundamental right, because of innovative judicial interpretation, right to health has acquired that status. Scope for such an interpretation has been created by the dictum of Supreme Court in Meneka Gandhi v. Union of India wherein, while interpreting Article 21 the Supreme Court has unequivocally held that reasonableness, justness and fairness must form part of the procedure established by law. The State is now mandated to provide to a person all rights essential for the enjoyment of the right to life in its various perspectives. Consequently, the right to health and access to medical treatment has been brought within the fold of Article 21. It is a fact that accessible and affordable health care is still a mirage to many of our people. The position has not undergone any significant improvement, even after completing more than 50 years of governance since independence. The available health care services particularly those in the private sector are only accessible to those who can afford the cost. If not, denial of service is the consequence. Nevertheless, those who cannot afford it are driven to the private health care sector owing to the fact that the government hospitals are no longer in a position to cater adequately to the health care needs of the people. In other words, the role of the State in the context of health care is fast shrinking, at the same time, market players are experiencing phenomenal expansion.

The Shameful Frailty of the Rural Healthcare System in India

Rural India contains over 68% of India’s total population, and half of all residents of rural areas live below the poverty line, struggling for better and easy access to health care and services.  Health issues confronted by rural people are many and diverse – from severe malaria to uncontrolled diabetes, from a badly infected wound to cancer. Postpartum maternal illness is a serious problem in resource-poor settings and contributes to maternal mortality, particularly in rural India.  A study conducted in 2009 found that 43.9% of mothers reported they experienced postpartum illnesses six weeks after delivery. According to a report by the United Nations, 75% of the health infrastructure in India  – including doctors and specialists and other health resources – is concentrated in urban areas where only 27% of India’s population lives. The rural population of India is around 716 million people (72%) and yet there is a chronic lack of proper medical facilities for them. This is one of the reasons for the differences in urban and rural healthcare indicators.  The rural health care system in India has been developed as a three tier system comprising of the following:

  1. The Community Health Centre (CHC)-A 30 bed hospital/referral unit for 4 PHCs with specialist services.
  2. The Primary Heath care centre (PHC)-A referral unit for 6 (4-6 bed) sub-centers staffed by a medical  officer in charge and 14 paramedics.

3.The Sub Centre-The most peripheral point of contact between the primary health care system and the community, staffed by 1 Health Worker-Female (HM-F)/Auxiliary Nurse Midwife (ANM) and 1 Health Worker-Male (HW-M).

In the rural healthcare program in India, structured in these three tiers, there is a basic need for primary health centers (PHCs) and community health centers (CHCs). These PHCs could serve approximately 20,000 people in tribal and hilly areas and around 30,000 people in the plains, while the CHCs would serve approximately 80,000 people in tribal and hilly areas and around 120,000 people in the plains.

There is only one doctor per 1,700 citizens in India; the World Health Organization (WHO) stipulates a minimum ratio of 1:1,000. While the Union Health Ministry figures claim that there are about 6-6.5 lakh doctors available, India would need about four lakh more by 2020—50,000 for PHCs; 0.8 lakh for community health centers (CHC); 1.1 lakh for 5,642 sub-centers and another 0.5 lakh for medical college hospitals. If shortage of doctors is one problem, their unwillingness to work in the rural hinterland is another, creating artificial scarcity in the area and high concentration in another. Worse still, many doctors posted in the hospitals in the rural areas remain absent for long periods. And in the absence of doctors, patients visiting the healthcare centers are treated by stand-ins—pharmacists and even nurses.

Availability of healthcare services is skewed towards urban centers with these residents, who make up only 28% of the country’s population, enjoying access to 66% of India’s available hospital beds, while the remaining 72%, who live in rural areas, have access to just one-third of the beds. Insufficiencies in public healthcare services have driven people across socio-economic strata to private healthcare facilities leading to issues of affordability challenges. In 2012, 61% of rural patients and 69% of urban patients chose private in-patient service providers, up from 40% reported in a 1986-87 government survey. A trip to AIIMS in the national capital—the country’s top most referral hospital—at emergency hour could be heart-wrenching, if not scary. According to official data, around 7,000 patients visit the OPD everyday from various states and the number of serious cases has to be added. In the year 2008-09, the number of new cancer patients coming from Uttar Pradesh and Bihar stood at 2,403 and 1,072 which has now gone up to 2,666 and 1,243, respectively.

Little wonder that people in India now prefer to mortgage their land and gold to avail healthcare in the private sector. With the Government spending on healthcare woefully inadequate, there’s been a mushrooming of private sector hospitals, mostly high-end. It has not only put pressure on the common man’s medical healthcare bill, but also strained the supply of doctors. There’s a continuous flight of doctors to these better-paid and better-equipped private healthcare domains. This has led the private hospitals to cash in on the abysmal government health infrastructure.

But since the cost of treatment at private healthcare facilities is at least 2 to 9 times higher than at public facilities, it leads to the factor. Poor patients receiving outpatient care for chronic conditions at a private facility spent on an average 44% of their monthly household expenditure per treatment, against 23% for those using a public facility, says the study conducted by IMS (Institute for Healthcare Informatics)

The healthcare system in India is not delivering affordable, acceptable and accessible healthcare to all Indians – which must be the test of its quality, In fact, some fixes to only a part, without considering their effects on other parts of the system, can backfire as indeed some are. According to the IMS study, the lack of accessible healthcare facilities in rural areas, the difficulty in accessing transport and the loss of earnings means patients postpone treatment, or make do with facilities that may be closer but are not cost-effective or even suited to their needs.

The study, which was based on a survey of nearly 15,000 households across 12 states, says that a 40-45% reduction in out-of-pocket expenditures for both outpatient and inpatient treatments can be achieved by addressing physical accessibility of healthcare facilities, availability and capacity of needed resources; quality and functionality of service, and affordability of treatment relative to a patient’s income.

Strong connections exist between bodily health and access to basic provisions and services such as clean water, advanced sanitation, and health care. The lack of these basic amenities often leads to illness or premature death. Statistics indicate that nearly 70% of all deaths and 92% of deaths from communicable diseases occur among the poorest 20% of the population. In India, waterborne infections account for roughly 80% of illnesses, leading to an annual loss of 73 million workdays and an annual death rate of 1.5 million.  In rural areas, infectious and communicable diseases — most of them preventable — cause the majority of deaths. Indeed, the incidence of all diseases is twice as high in rural areas than in urban ones. A significant factor in rural illness and death, especially in comparison to urban contexts, is a grossly inadequate public health care system. As with other measures of development, stark disparities in health care access and resources exist across the rural-urban divide. While the level of the Indian government’s expenditure on health care has remained fairly constant over the past five years at about 5% of total expenditures, which is less than 1% of GDP, only about a fifth of health subsidies go to rural India. Three-quarters of India’s health infrastructure, medical manpower, and other health resources are concentrated in urban areas, despite the fact that only one-third of the populace live there. Only about 40% of India’s doctors, hospitals, and dispensaries are in rural areas. While India’s urban middle class have access to state-of-the-art health services, about million rural residents lack access to even rudimentary health facilities. Healthcare in India is administered through a three-tiered system comprised of Community Health Centers (“CHCs”), Primary Health Centers (“PHCs”), and Sub-Centers (“SCs”). Tertiary medical care is provided through multispecialty hospitals and medical colleges, which are concentrated almost exclusively in urban areas. Because 80% of medical specialists in India live in urban centers, rural Indians have virtually no access to specialist care.  As of May 2007, the 145,000 Sub-Centers spread across India were most rural residents’ first contact point with the health care system.  Each SC is designed to provide only essential health needs, and each is equipped with basic drugs for minor ailments. PHCs are designed to “provide an integrated curative health care to the rural population with emphasis on preventative and primitive aspects of health care.”Each CHC, the largest and most specialized health care facility in a rural area, serves as a referral center for four PHCs. In spite of this seemingly comprehensive health care delivery infrastructure, major problems remain. One government report recorded major deficiencies in implementation of health care services. Beyond the shortage of service providers, PHCs and CHCs in nine of the monitored states lacked full stocks of essential drugs, vaccines, and contraceptives.  Further, twenty-four states had not prepared required district-level annual plans, and many centers were not spending the funds allocated and disbursed for specific services.  Finally, despite the large number of SCs, PHCs, and CHCs already in place, the system still lacks significant numbers of all three types of institutions relative to need.148 India’s burgeoning population — an   increase by 130 million since the shortage was calculated — continues  to exacerbate the shortage. In 2005, the central government launched the National Rural Health Mission (“NRHM”) to “provide accessible, affordable and accountable quality health services to rural areas with emphasis on poor persons and remote areas.” The NRHM aims to better serve rural populations, especially women, children, and the poor, by improving their access to and the availability of quality health care. Its overall goal is to double or triple public expenditure from the current level of about 1% of GDP. Such increased investment would likely improve substantially the public health care system, but the extent to which it would target rural populations is unclear.  Despite some progress as measured by health indicators such as  infant mortality rate and life expectancy, the central government acknowledges uneven progress across regions. Dr. Ashok Vikhe Patil, President of the International Association of Agricultural  Medicine and Rural Health, has also criticized the government’s focus  on programs like family planning, child survival, and safe  motherhood, accusing the government of treating them as “statistical  targets [rather] than as health services.” He is especially critical of India’s approach to providing health care to rural residents, noting that “new doctors are incapable of and not inclined to meet the needs of the majority of the public.”  Ironically, in light of the poor state of health care in India, its citizens’ right to health care is constitutionally protected. The Indian Constitution explicitly recognizes the “right to life” as a fundamental  and enforceable right, a right that the central government cannot  take away or abridge. The Supreme Court of India has construed the right to life to include the right to access health care. In P.B. Khet  Mazdoor Samity v. State of West Bengal, the court held that “Article 21  (the Right to Life) imposes an obligation of the state to safeguard the  right to life of every person.” Various government hospitals denied medical assistance to the plaintiff, who suffered severe injuries after falling off a train; he eventually paid Rs 17,000 for treatment at a private hospital. The court awarded the victim Rs 25,000 in compensation and issued directions to the state of West Bengal to upgrade its health  facilities. The Supreme Court has upheld and enforced the Right to Life in several subsequent cases, including one decided in 2010.

A significant cause of deficits in India’s health care infrastructure is the means of funding, which also has legal implications. Despite the importance of public health infrastructure to the country’s development, the current funding structure deprives public health of essential funds. The constitution delegates to the state governments responsibility for providing most public health services, while requiring them to remit a high percentage of their tax revenues to the national government. The constitution thus leaves states with an essentially unfunded mandate. Further, the central government regularly requires states to co-fund new programs, which states are often unable to do. Moreover, the legislative framework for public health service provision as manifested in Public Health Acts has not been revised since the colonial era. For example, the central government passed the Model Public Health Act in 1951 and revised it in 1987, but most states have not adopted the Act. Consequently, while some municipal areas still have public health facilities and regulations in place, such infrastructure is rarer in small towns and rural locales. By failing to adopt a unified standard and permitting municipalities to retain their own regulations, less developed areas suffer health care deficits. Compounding difficulties in gaining access to health care is the fact that just one tenth of Indians have any form of health insurance. Almost 60% of the average citizen’s total annual expenditures are on medical care, and 25% of Indian people who are hospitalized become impoverished while attempting to cover their medical expenses. That is, they must borrow heavily or sell assets to cover medical costs, causing many to fall below the poverty line. A study of rural families’ health care expenditures found that “70% of families spend 60% of their annual income on health” while 93% of health care expenditures went to “curative and emergency care.” Further, because public-sector health services are “ill-equipped and unaccountable,”173 poor families must often use private services which  leave them “spending a higher percentage of their income on health  than do the rich.”

The majority of these statistics show the sad state of affairs in the rural healthcare system in India. The fact is that most people living in rural areas or small cities and towns across India don’t have access to critical medical facilities including hospitals, medicines, and doctors. Ensuring proper medical care as well as preemptive care facilities is mentioned regularly in every 5th year plan but somehow the plans all end up being shelved and every year economists come up with new death statistics. So where are we going wrong? It has assumed that for a person to have access to healthcare in India, a facility must be reachable within a 5 km and must offer available doctors, drugs and treatment options that satisfy both acceptable cost and quality-of-care standards. Even if only one of the components is missing, a patient is unlikely to receive the right treatment in the most appropriate and efficient manner. They found that in rural areas, only 37 per cent of people were able to access in-patient facilities (within the criteria stated above), and only 68 per cent were able to access out-patient department facilities. The implication of travelling long distances is the potential loss of a day’s earnings and deferment of treatment in the early stages of the disease. This would only lead to increasing the cost burden over time.

One of the most critical requirements for healthcare in rural areas is doctors. Doctors and medical specialists are an integral component of the Indian healthcare system but rural India is currently facing a 64% shortage of doctors.

Today, rural India faces a shortage of more than 12,300 specialist doctors. There are vacancies for 3,880 doctors in the rural healthcare system along with the need for an astounding 9,814 health centers.

Some of the key facts relative to the current state of the rural healthcare system in India have been highlighted in a report by the National Rural Health Mission (NHRM). They are:

  • The ratio of rural population to doctors is six times lower than in urban areas
  • The ratio of rural beds vis-à-vis the population is 15 times lower than in urban areas
  • 66 percent of the rural population in India lacks access to preventive medicines
  • 31 percent of the rural population in India has to travel over 30 km to get needed medical treatment
  • 3,660 PHCs in rural India lack either an operation theater or a lab or both
  • 50 percent of the posts for obstetricians, pediatricians, and gynecologists in PHCs or CHCs are vacant
  • There is a 70.2 percent shortfall of medical specialists in CHCs
  • 39 percent of PHCs are currently without a lab technician
  • Infectious diseases dominate the morbidity pattern in rural areas: 40% in rural areas vis-à-vis 23.5% in urban areas.

Urban areas have 4.48 hospitals, 6.16 dispensaries and 308 beds per 100,000 urban population in sharp contrast to rural areas which have 0.77 hospitals, 1.37 dispensaries, 3.2 PHCs and 44 beds per 100,000 rural population. The city hospitals and the civil hospitals are basically curative centers providing outpatient and in-patient services for primary, secondary and tertiary care. In contrast the rural institutions provide  mainly preventive and primitive services like communicable disease control programs, family planning services and immunization services; curative care in the rural health institutions are the weakest component in spite of a very high demand for such services in rural areas. As a consequence this demand is met either by the city hospitals or by private practitioners. These facts are for real, and the reasons behind the poor healthcare infrastructure can be attributed to lack of investment incentives for the private sector, gross inefficiency in public healthcare system, and a chronic lack of quality doctors and medical professionals. There are serious gaps in the Indian rural healthcare infrastructure which need to be addressed with urgency.

The Changing Political Economy

India is knocking at global markets. Since the mid-1980s India has rapidly integrated with the world economy and now faces not only the ups but also the downs as protection of the internal economy has become a thing of the past. The globalization of India was speeded up under the Structural Adjustment Program designed with World Bank’s assistance to reform India’s economy. A large part of the middle class has certainly benefited from the SAP and related initiatives but overall poverty has not declined – if at all it has added to the misery of the already impoverished masses. Health sector reforms did not stay far behind. But the question is, were they reforms in the positive or progressive sense? In the name of reforms, again under the aegis of the World Bank, and other bilateral and multilateral agencies like USAID, DFID, WHO, UNICEF etc. public health investment became even more selective and targeted at selected populations. Thus family planning and immunization services, and selective disease programs like HIV-AIDS, acquired an even more central position in public health care and other concerns like curative services, hospital care, malaria, tuberculosis, maternity services, etc lost further ground. The new priorities were not priorities determined by those who needed health care but by global agents of change who were in the business of adjusting India to the world economy!

Impact of Changing Political Economy

The changing political economy demands reduced state participation in the economic spheres both in terms of policy and intervention. One very clear impact is declining state investments in the health sector. There has been a declining trend since 1991 in social sector expenditures best reflected in compression of grants to the states for social sector expenditures. Health care expenditures too have been affected both in quantitative terms (declining real expenditures) and qualitative terms (increasing proportion of establishment costs and declining proportion on medicines, equipment, maintenance and new investments). Another very striking impact is the rapidly rising cost of medicines. With greater dependence on the private health sector even by the poor this has meant extreme hardship. With the drug price control virtually on its way out and with India having signed the WTO treaty on IPR we are moving closer to international prices of drugs. The combined effect of the above facts makes a deadly mixture that results in reduced access of the poor to health care. As stated above the historical dominance of the private health care sector in India in provision of ambulatory care and rising costs could spell disaster for the poor given the fact that the State is gradually reducing its responsibilities in providing health care. Since the poor too have been active users of private health care their dependence on it makes the case for “right to health care” an increasingly distant dream on the political agenda.

As we attempt such intervention, we may keep in mind that while the health system is usually an instrument of maintaining the hegemony of the dominant social order, it can also be an arena for asserting people’s claims for services and accountability, and hence people’s power. In this context, in the arena of health care, today two competing paradigms confront each other. The ruling paradigm may be characterized as ‘Health care as commodity / health care as safety net’ Confronting this ruling paradigm is the emergent, people’s paradigm of ‘Health care as a Human Right’. The human rights approach to health is of course not novel, since it had been implicit in various community-based and alternative approaches for health care during the last few decades.

Some Policy Objectives to Work Towards

With this perspective, it may be suggested that a policy goal we can work towards is

  1. Building adequate infrastructure, human power, services and supplies at various levels, restoring the basic functionality of the system and rebuilding public confidence. However, such rejuvenation would not be possible without bringing the public to the centre of the public health system. Mechanisms for public accountability would need to be put in place along with reorientation of staff at various levels to rebuild their motivation and responsiveness.

  2. Linked with such strengthening of the public health system, to institutionalize accountability would require a legal and constitutional framework to assure health services as a Right.

  3. Specific Health care requirements of various groups with special needs – such as women, children, and elderly persons – would need to be met through sets of special measures, sensitively delivered by the general health system.

  4. Ensuring access to essential drugs in a rights based framework, both in form of ensuring availability of the range of essential drugs free of cost in public health facilities, and stringent price control by inclusion of all essential drugs in the DPCO, are objectives to work towards in the immediate future. Promotion of generics, effective drug quality control and elimination of irrational formulations and combinations are issues already on the agenda.

The achievement of a strengthened public health system, which is more accountable to ordinary citizens, is a potentially achievable goal to fight for within the existing system. Similarly, the health movement must lend it strength and voice to movements for improving health related entitlements such as nutritional services and food security, clean drinking water, sanitation and safer environmental and working conditions, which may be achieved to certain extent.

Edited by Neerja Gurnani

One Reply to “Insufficiency of medical facilities”

  1. I want to know the procedure for transfer of a leased property in a Co-op. Society by way of gift !

    1) I hold an open plot in a Co-op. Society and as a member hold 10 shares of Rs.50/-

    2) I plot is leased to me for 999 years and the lease deed is originally registered.

    3) I wish to gift the plot to my close relative ( not a blood relation ) but allowed within the definition of Income Tax and shall be registered with requisite stamp duty.

    4) The Society had informed me the procedure to surrender the property by executing a “Surrender Deed” and the plot will be re-leased to the donee (transferee) by registering a “Lease Deed” with requisite payment of stamp duty.

    5) Since the re-lease now can be registered with payment of 5% stamp duty since it is now not allowed to register on Rs.100 stamp paper.

    6) By this procedure, even though only one transfer ( transaction ) of property takes place, the stamp duty needs to be paid twice.

    My question ?

    The Managing Committee informed me that they do not know the procedure and requested me to find it myself and they will co-operate and do the needful.

    I am told by my Income Tax consultant that I necessarily need to register the Gift Deed with requisite stamp duty to avoid any complication in future.
    Therefore, I shall appreciate your lawful advice about what procedure the society should follow so that the stamp duty need not be paid twice on single transfer of property.

    With Best Personal Regards,

    Vilas Munot.

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