Saturday, 23 July 2016 18:04

Jana Swastha Abhiyan Or Peoples’ Health Movement

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Diganta Basu

( Vice President, Tripura Bigyan Mancha, Agartala)

It is known to all that 134 countries along with WHO and UNICEF met at Alma Ata from 6th – 12th Septemberin 1978 and declared that all issues of Health would be made available to all people of the world. Its for the 1st time that health was defined in a holistic manner, which states that health means “  a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity.” 

 

This stated goal remained a distant dream and was day by day moving out of control by the people of this country and to many countries inclusive of the developed countries due to the changed economic order from 1990s, in the name of globalization.

             In this backdropPeoples’ Health Movement (PHM) developed as a response to the failure of the goal of “Health for All by the Year 2000” in the Alma‐Ata declaration to be realized. By the end of the year 2000 several international organizations, civil society movements, NGOs and women's groups organized the first People’s Health Assembly in December, 2000 Savar, Bangladesh. The PHM rose from this Assembly as a body of health rights proponents who would demand Health for All Now across the globe; a worldwide citizens movement committed to making the Alma‐Ata dream a reality. The Indian Chapter of the PHM was termed as Jana Swastha Abhiyan ( JSA ).

The PHM or JSA as it may be called adopted the following principle :

1.  It would be a global network of health activists

2.It would stives  for revitalizing primary health care

2.It would advocates  for addressing social determinants of health

3.It would struggle to empower  people to take control of their rights

4.It would campaign for   health as a right for all!

In this context it would necessarily address health issues and would not only include heath activists and peoples’ science movement (PSM) groups but would also involve all sections of the society and organizations who would go by the principles adopted by the PHM, with the slogan “ Health for all, Now’”

Tripura Vigyan Macha also adopted in its 2 day Conclave held at Agartala on 16th & 17th September endorsed to be a party to JSA, and would organize campaign to for Heath . But as it is known that , the Government of India has proposed a new National Health Policy -2015, so this policy has to be analysed and should be given proper priority. But before dealing with the issues of NHP-2015 we must go to the historical back ground of the health issues and health movement in our country.

The trajectory of the Health System in our country,  dates back to 1943.  At the then  time we find the British Government implemented a policy on health on the recommendations of  Bhore Committee (which was known as  Health Survey & Development Committee, with Sir Joseph Bhore as its Chairman)  and implemented it in 1946.The major thrust of the policy was on Curative and Preventive aspects of health  with a short term as well as a long term strategy components ( “The 3 Million Plan”).It  clearly stated that structural basis for Primary and Secondary Heal Care System that the country should have.

But unfortunately even after sixty eight years after Independence  we were unable to formulate a comprehensive  Health Policy till 1983 , five years later that too under compulsion of the Alma Ata declaration in 1978 of “Health for All by 2000”.

It is quite interesting to note that from 1950 – 1983 in absence of a formal policy in place people and organizations which were fighting for a universal health and education for the country had to go for multiple litigations against the state and central government as Heath being a State subject but important components of the system : disease control and family planning are in the Concurrent list and many acts in the health sector has been promulgated by the central government.

The science and health activists were  more and more became vocal from 1980s  which crystallized during the year 1982 – 83 and formed the AIPSAN – All India People’s Science Action Network which demanded for implementation of a Pro-people Drug Policy. As a result of which the 1st National  Health Policy was passed in  1983 as committed in the Alma Ata declaration.

            Unfortunately within a year, the Bhopal Gas Tragedy took place in December 1984. This event was an eye opener which proved  beyond any doubt that the fragility of the  Health System in our country on one hand and gave a momentum to the movements of science and health activists  in different parts of the country to make an organized effort to change the prevailing scenario of heath system. As an organized effort , in 1987, five national kala jathas  in the name of Bharat Jan Vigyan Jathas ( BJVJ) were organized which culminated in Bhopal.  The success of the campaign programme led to Peoples Science Congress at Kannur  in 1988 from where the All India Peoples’ Science Network  (AIPSN) was formed.   AIPSN with other regional and national organization brought to the forefront the issues of health and demanded that health to be acknowledged as a Fundamental Right. But it was not an easy task which was finally settled by the Supreme Court in 1997 which stated that, right to health is integral to right to life. Government has a constitutional obligation to provide health facilities.

As the international pressure was increasing so it becomes eminent that to counter these movement ‘some lollipops’ are to be advanced

In the changed legal interpretation of Health as a Right the government announced another policy in NHP-2002.

The 2002 policy had stated: "Global experience has shown that the quality of public health services, as reflected in the attainment of improved public health indices, is closely linked to the quantum and quality of investment through public funding in the primary health sector... Therefore the policy while committing additional aggregate financial resources, places strong reliance on the strengthening of the primary health structure, with which to attain improved public health outcomes on an equitable basis" (NHP-2002: pp 24-25). It further commented: "Broadly speaking, NHP-2002 focuses on the need for enhanced funding and an organisational restructuring of the national public health initiatives in order to facilitate more equitable access to the health facilities."( NHP-2002: pp35). During these years ,there has neither been a significant increase in public funding, nor an adequate population-wide expansion in the coverage and quality of primary healthcare services or enhanced equity in access to healthcare services.

Even after the Supreme Court verdict the Right to Health as a Fundamental Right still could not pave its way as a Constitutional Obligation . on the other what we experience during the period of  these two Health Policies can be summarized as follows :

(1)                            The Health Care in India is one of the most privatized in the world : More than 80% of the health-care expenditure in India is borne directly by the patients themselves; more than 80% of doctors are private practitioners. In contrast, the proportion of private expenditure to total health-care expenditure is much less in all developed countries – it ranges from the highest of 60% in U.S., to the lowest of 5% in Britain.

(2)                            (2) The private health care system is almost totally unregulated. The quality of health care, its rationality and the fees charged are totally left to the ‘market forces’. Hence a large proportion of health care is substandard, irrational, and exploitative.

(3)                            (3) Our health-care system model is hospital oriented, doctor-centric. There is no proper role for Community Health Workers and other paramedics. Doctors do the job of treating minor ailments even ‘where doctor is not needed’. This is an unnecessary luxury which a developing country like India can ill-afford.

(4)                            The Public Health Care System in India which can at least partially remedy the above three defects is too inadequate in quantity and quality : The Public Health System caters to 10-15% of patients and yet accounts for less than 3% of the total expenditure of medicines in India. There are gross, continuous shortages of even essential medicines in most Public Health facilities.

Now since the Central Government has placed before the country a draft of another national policy on health, known as National Health Policy 2015. To many it be felt that after the failures of the previous policies, the present policy will bring a paradigm shift of the health policy of the country.

So the imminent task of JSA is to critically analyse the NHP-2015 as its 1st priority followed by its mandate to organize people in support of the movement,

 through  PHM is  which is formed and guided by the following principle :

Hence, the JSA in India has to face a double challenge : 1st to address critically  the proposed NHP-2015 , then to organize in an all-out manner to involve all sections of the Indian Society to make the Declaration of Alma Ata a reality.

 

Here it is to be noted that within this period as Health was becoming dearer but the Health Indus try flourished as they have already captured the lion share as state above. This has been pointed in the proposed in the Draft of NHP-2015 in unequivocal terms . To quotes a few passages would be sufficient to established the arguments .

A few paragraphs from the NHP-2015 are placed  below for the readers to understand the above facts  :

Para 1.1 : ““The reality is straightforward. The power of existing interventions is not matched by the power of health systems to deliver them to those in greatest need, in a comprehensive way, and on an adequate scale".

1.1. Para 1.2 : “ … Now 13 years after the last health policy, the context has changed in four major ways.

a)Firstly- Health Priorities are changing. As a result of focused action over the last decade we are projected to attain Millennium Development Goals with respect to maternal and child mortality. Maternal mortality now accounts for 0.55% of all deaths and 4% of all female deaths in the 15 to 49 year age group. This is still 46,500 maternal deaths too many, and demands that the commitments to further reduction must not flag. However it also signifies a rising and unfulfilled expectation of many other health needs that currently receive little public attention. …..”

b)The second important change in context is the emergence of a robust health care industry growing at 15% compound annual growth rate (CAGR). This represents twice the rate of growth in all services and thrice the national economic growth rate”.

c)”Thirdly, incidence of catastrophic expenditure due to health care costs is growing and is now being estimated to be one of the major contributors to poverty.”

d) “The fourth and final change in context is that economic growth has increased the fiscal capacity available. Therefore, the country needs a new health policy that is responsive to these contextual changes.”    

2.10. Cost of Care and Efforts at Financial Protection: “ ……..Yet if health care costs are more impoverishing than ever before, almost all hospitalization even in public hospitals leads to catastrophic health expenditures, and over 63 million persons are faced with poverty every year due to health care costs alone, it is because there is no financial protection for the vast majority of health care needs…….”

2.12. Healthcare Industry:

Engaging and supporting the growth of the health care industry has been an important element of public policy. The private health care industry is valued at $40 billion and is projected to grow to $ 280 billion by 2020 as per market sources. The current growth rate of this perennially and most rapidly growing area of the economy, the healthcare industry, at 14% is projected to be 21% in the next decade. Even during the global recession of 2008, this sector remained relatively recession-proof.

It continues , “The Government has had an active policy in the last 25 years of building a positive economic climate for the health care industry. Amongst these measures are lower direct taxes; higher depreciation in medical equipment; Income Tax exemptions for 5 years for rural hospitals; custom duty exemptions for imported equipment that are lifesaving; Income Tax exemption for Health Insurance; and active engagement through publicly financed health insurance which now covers almost 27% of the population. Further forms of assistance are preferential and subsidized allocation of land that has been acquired under the public acquisitions Act, and the subsidized education for medical, nursing and other paramedical professional graduating from government institutions and who constitute a significant proportion of the human resources that work for the private sector; and the provision for 100% FDI. Indeed in one year alone 2012-13-as per market sources the private health care industry attracted over 2 billion dollars of FDI much of it as venture capital. For International Finance Corporation, the section of the World Bank investing in private sector, the Indian private health care industry is the second highest destination for its global investments in health….”

2.13. Private Sector in Health:  The private sector today provides nearly 80% of outpatient care and about 60% of inpatient care.

2.16. Research and Challenges: “……..There have been significant contributions made by the Department, but modest funding of less than 1 % of all public health expenditure has resulted in limited progress. ……”

2.18. Investment in Health Care:   “ …… Global evidence on health spending shows that unless a country spends at least 5–6% of its GDP on health and the major part of it is from Government expenditure, basic health care needs are seldom met.  The Government spending on healthcare in India is only 1.04% of GDP which is about 4 % of total Government expenditure, less than 30% of total health spending. This translates in absolute terms to Rs. 957 per capita at current market prices. The Central Government share of this is Rs. 325 (0.34% GDP) while State Government share translates to about Rs. 632 on per capita basis at base line scenario.

Based on the above the proposed NHP-2015 came out with its different formulations at all levels as cited below :

The  Objectives

3.3.6. Influence the growth of the private health care industry and medical technologies to ensure alignment with public health goals, and enable contribution to making health care systems more effective, efficient, rational, safe, affordable and ethical.

The Policy Directions:

4.1.1. The National Health Policy accepts and endorses the understanding that a full achievement of the goals and principles as defined would require an increased public health expenditure to 4 to 5% of the GDP. However, given that the NHP, 2002 target of 2% was not met, and taking into account the financial capacity of the country to provide this amount and the institutional capacity to utilize the increased funding in an effective manner, this policy proposes a potentially achievable target of raising public health expenditure to 2.5 % of the GDP…..”  It also notes that 40% of this would need to come from Central expenditures.( thus 60% from State implied)

4.1.2. The major source of financing would remain general taxation. …… The Government would explore the creation of a health cess on the lines of the education cess for raising the necessary resources. ( putting more burden on the people )

Principle of Re-Orientation of Public Hospitals :

4.3.3.1 An important change in policy mind-set is to move away from imagining public hospitals as social enterprises that ideally must recover the costs of their functioning, to re-imagining them as part of a tax financed single payer health care system in which, what public hospitals deliver is not free care, but rather pre-paid care (like in commercial insurance) and which is cost efficient in addressing health care needs of the population.

 

On Governance : “ ….. Further it has its obligations under a number of international conventions and treaties that is a party to. Further, disease control and family planning are in the Concurrent list and these could be defined very widely.

Finally though State ownership has been used by some states to become domain leaders and march ahead setting the example for others, the Center has a responsibility to correct uneven development and provide more resources where vulnerability is more.

The Policy Issue : 12.2 One of the fundamental policy questions of our times is whether to pass a health rights bill making health a fundamental right- in the way that was done for education. Many industrialized nations have laws that do so. Many of the developing nations that have made significant progress towards universal health coverage like Brazil and Thailand have done so and the presence of such a law was a major contributory factor. A number of international covenants to which we are joint signatories give us such a mandate- and this could be used to make a national law. Courts have also rulings that in effect see health care as a fundamental right- and a constitutional obligation flowing out of the right to life. There has been a ten-year long discussion over this without a final resolution. The policy question is whether we have reached the level of economic and health systems development as to make this a justiciable right- implying that its denial is an offense. And whether when health care is a State subject, it is desirable or useful to make a central law?

And whether such a law should mainly focus on the enforcement of public health standards on water, sanitation, food safety, air pollution etc, or on health rights- access to health care and quality of health care – i.e on what the state enforces on citizens or on what the citizen demands of the state? Or does the health policy take the position that given the existence of a large number of laws including the clinical establishments Act, and the track record on adopting them and implementing them, a Central law is neither essential nor feasible.

Finally the NHP-2015 put forward  a straight forward proposal , the demand of PHM or JSA in the following manner .

As stated in the text of NHP-2015,to break the deadlock and this vacillation and move forwards with determination- the draft national health policy proposes the following formulation-

 the Center shall enact, after due discussion and on the request of three or more States (using the same legal clause as used for the Clinical Establishments Bill) a National Health Rights Act, which will ensure health as a fundamental right, whose denial will be justiciable…….” 

Apparently this sounds well but it is this obvious gap between the rhetoric in successive health polices and the actual delivery on the promises made which leads us to question the relevance of the new policy.

            It is still useful, however, to analyse the major features and broad thrust of the draft policy of 2015. This is not an easy exercise, given that the draft itself contains a reasonable and balanced analysis of the state of healthcare services. The reasons behind the poor record of the country's health services and the consequent hardships faced by the people, in the form of financial burden and poor access to necessary services, are generally identified correctly. What is, however, significant is that the proposals to remedy the situation is located in a very clear macroeconomic vision, that needs to be read in conjunction with the government's clear neoliberal trajectory in all sectors.

Thus, for example, the draft identifies four major changes since 2002. The first change relates to the need to look beyond maternal and child health and focus on communicable diseases as well as rapidly emerging non-communicable diseases. What is, however, more revealing are the three other "changes" that are identified:

  • The emergence of a robust healthcare industry that is growing at a compound annual growth rate of 15%
  • The (growing) incidence of catastrophic expenditure due to healthcare costs; and
  • An increase in the fiscal capacity available due to economic growth.

While these changes have been identified accurately, what is revealing is that only these have been singled out for mention. Underlying all of them is a running discourse that subsumes polices on healthcare under issues of financing and markets, while the importance of a discourse on the actual content and quality of services is ignored. Thus, it is the growth of the "healthcare industry" and "increased fiscal space" that would presumably guide strategies to address the issue of catastrophic health expenditure. This provides the justification for many of the prescriptions of the NHP, which are described in the following paragraphs.

Provider–payer split and purchasing of services

The overarching premise that informs the NHP's prescriptions is what is known as the "provider-–payer split". While the government's role in financing healthcare services is acknowledged, its role as a provider of care services is circumscribed by the description of its being a "strategic purchaser" of services. While the NHP claims that the priority would be to "purchase services from public facilities and not-for-profit private facilities", it also foresees purchasing from for-profit private facilities. The policy deliberately shies away from acknowledging that the government will finance and provide services on the basis of needs and priorities. Instead, by borrowing the term "purchase" from insurance language, its underlying attempt seems to be to continue and expand insurance-based schemes.

Critiques of a model for healthcare provision led by the public sector are quick to point out that universalisation of access to care cannot be achieved unless a significant proportion of private providers and facilities are also harnessed. The issue here is not which interim steps need to be taken – these can include harnessing private providers where necessary, provided that they work within the overall logic and control of a public system. Though it needs to be mentioned that in underserved areas, where the gap in healthcare provision is the worst, the private sector just does not exist and hence, is not an option. The important issue is that of framing a plan that can progressively strengthen public services. The overall prescriptions in the draft regarding insurance schemes that rely largely on private sector provisioning in the case of secondary- and tertiary-level care (hospital care) are designed to do the opposite, i.e. further strengthen the private sector and denude the public sector.

This links with the NHP's stated objective to integrate the public-funded insurance schemes into a single-payer system, thus maintaining the possibility of purchase from private for-profit facilities. Given the past experience of public-funded insurance schemes (Rashtriya Swasthya Bima Yojana [RSBY] and others), in which the bulk of "purchasing" is done from private facilities, it is not unrealistic to apprehend that public money will be used to purchase secondary and tertiary care services from private facilities. This is not in keeping with the NHP draft's generally correct analysis of the different problems associated with the existing insurance schemes. The problems mentioned include "denial of services by private hospitals for many categories of illnesses, and over-supply of some services" and "resort[ed] to various fraudulent measures, including charging informal payments".

Incorrect vision of primary healthcare

The NHP proposes free services for all at the primary level of care. However, it erroneously claims that this is based on the "primary health care" (PHC) model. The vision of PHC, as described in the Alma Ata declaration, includes comprehensive primary healthcare services located in a national health system that integrates care at the primary, secondary and tertiary levels, with appropriate linkages and integrated networks of facilities. The NHP draft, instead, proposes a disjunction, with primary level care being provided by public facilities and secondary and tertiary services being "purchased" from an array of facilities under an insurance scheme. It is not possible to call such a schema a "system" as there are no clear linkages between the different levels of care. The NHP trivialises this vital aspect of a PHC model – which requires health systems to be networked and interlinked with clear backward and forward linkages – by proposing improved transport services to secondary and tertiary healthcare facilities as the solution. At the secondary and tertiary levels of care, the NHP does not commit itself to the provision of free services to all patients. Instead, it proposes free "emergency services".

Benevolence towards the private sector

The NHP appears to characterise the rapid growth of the private sector as a positive trend, when it says: "The second important change in context is the emergence of a robust healthcare industry growing at 15% compound annual growth rate (CAGR)." This, taken together with the claim that the growth of the private medical sector cannot be explained solely by deficiencies in the public system, illustrates a clearly benevolent outlook towards the private sector. No indication or evidence is provided of the other reasons behind the rapid expansion of the private sector, which would imply that the growth of the private sector is a natural process. This is not borne out by global evidence. It must be noted that the existence of a strong and growing private sector has an adverse impact on the public sector since it draws away human and financial resources. The draft policy identifies the number of concessions and benefits to be granted to the private sector by the government, but does not mention any concrete ideas pertaining to the private sector's obligations towards the promotion of health. The regulation of the private sector is mentioned in several places, but vague generalities are used to deal with the subject. The draft policy fails to spell out concrete measures for regulation, or even the proper implementation of the Clinical Establishments Act.

No concrete commitment to increasing financial support

The NHP correctly points out that in the case of public services, "Much of the increase in service delivery was related to select reproductive and child health services and to the national disease control programmes, and not to the wider range of healthcare services that were needed." It further states: "The budget received and the expenditure thereunder was only about 40% of what was envisaged for a full re-vitalization in the NRHM Framework." Both statements would imply that there is a need to increase financial support for the health sector by at least to 3–5 times the present levels – if comprehensive quality care is to be made available to the entire population. Further, the NHP proposes various new measures that would require additional resources, including the provision of free medicines and diagnostics in public facilities, enhanced staffing, new infrastructure and the establishment of new medical colleges. Yet, the NHP refuses to commit to a concrete roadmap for greater allocation. It states: "It would be ambitious if India could aspire to a public health expenditure of 4% of the GDP, but most expert groups have estimated 2.5% as being more realistic." It goes on to argue: "At current prices, a target of 2.5% of GDP translates to Rs 3800 per capita, representing an almost four-fold increase in five years. Thus a longer time frame may be appropriate to even reach this modest target." In other words, the NHP refuses to commit to a target of even 2.5% of the GDP as public expenditure at the end of five years from now. In the absence of such a commitment, it is inconceivable that the plans proposed in the NHP have any possibility of materialising.

Access to medicines: moving two steps back

The NHP claims that the prices of drugs are being monitored effectively, but glosses over the fact that the National Pharmaceuticals Pricing Policy of 2012 legitimised the inordinately high prices of many drugs by switching over from a "cost-based" formulation of ceiling prices on essential drugs to a "market-based" formula for fixing prices (  http://www.nppaindia.nic.in/NPPPNotification.pdf ). The NHP speaks in two voices about the availability of free drugs in public facilities. The initial part of the draft policy refers to a commitment to make free drugs and diagnostics available in private facilities. However, the latter part circumscribes this claim by the following proposal: "The drugs and diagnostics available free would include all that is needed for comprehensive primary care, including all chronic illnesses, in the assured set of services. At the tertiary care level, too, at least for in-patients and out-patients in geriatric and chronic care segments, most drugs and diagnostics should be free or subsidised with fair price selling mechanisms for most and some co-payments for the well-to-do." (NHP-2015: p 46) Clearly, the NHP is reluctant to commit to a system in which all drugs and diagnostics that are essential and life-saving would be available free in public facilities. This is, in fact, represents a regression from the system already followed in states such as Tamil Nadu and Rajasthan, as well as what was promised in the 2002 NHP.

Legislation on right to health

The reference to a "National Right to Health (RTH) Act" in the draft NHP has generally been welcomed by policy advocates and activists alike. The NHP says: "The Centre shall enact, after due discussion and on the request of three or more states (..), a National Health Rights Act, which will ensure health as a fundamental right, whose denial will be justiciable. States would voluntarily opt to adopt this by a resolution of their legislative assembly..."

In the absence of an actual draft, it is not possible to concretely comment on the extent to which such an Act would advance public health goals. However, a perusal of the NHP draft itself provides some indicators. The proposal to enact an RTH legislation is prefaced by several questions. These include: (i) whether the level of economic development and that of the development of the health systems allows us to make denial an offence; (ii) whether a central law is feasible, given that health is a state subject; and (iii) whether such a law should focus mainly on the enforcement of public health standards on water, sanitation, food safety, air pollution, etc., or on access to healthcare and the quality of healthcare. Clearly, the attempt is to circumscribe the discussions on the Act by questioning its feasibility, given the economic constraints and those of the health system, and by proposing that such an Act might pertain merely to adherence to certain (yet unstated) standards in certain areas (water, sanitation, food safety, etc). It is important to note that the latter course of action would pertain only to standards and not to entitlement to services. The ambition of the proposed Act is weak to begin with. It may be contrasted with the bold vision of the Universal Declaration of Human Rights, which affirms: "Everyone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, housing and medical care and necessary social services" (http://www.un.org/en/documents/udhr   ), or with the International Covenant on Economic, Social and Cultural Rights, which recognises "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health". (http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx )

Further, the mere enactment of a piece of legislation does not translate into real benefits in the absence of a system that can help to enforce the rights enshrined in the legislation. For example, the Brazilian Constitution recognised health as a human right in 1988 and made its provision the duty of the state. Yet, not much progress was made in the actual realisation of the benefits in the ensuing decades as the conservative government in power at the time was reluctant to frame the polices and pledge the resources that were necessary. It was only when a more progressive government was elected to office that concerted attempts were made to match the language of the constitutional guarantee with real action. Closer home, the Right to Education Act has been widely perceived of as a failure. This failure is due to the contradiction between a relatively progressive legislation and a neoliberal government that actively promotes cuts on social sector spending. The NHP provides indications that the government is reluctant to commit itself to significantly enhancing the allocation to healthcare. The model of healthcare it proposes is based on the premise of "strategic purchasing", which signals a retreat of the state from the provision of healthcare services. In such a milieu, even a progressive Right to Health Act might turn out to be mere empty rhetoric.

However, the actual mention of intent regarding a Right to Health Act in the NHP is a welcome step and can pave the way for larger debates on the progressive realisation of this right.

Challenges before JSA

The NHP needs to be read along with a range of measures initiated by the government in the social sector. The recent budget has seen wide-ranging cuts in social sector spending, including a cut of almost 20% in the health budget. The various pronouncements on a new model of "'Health Assurance" indicate the same overall vision that emerges from a close reading of the NHP – a very basic package of services for primary care and outsourcing of hospital services to the private sector.

The prescriptions of the NHP need to be seen in the overall policy framework of the aggressive promotion of neoliberalism, evidence of which may also be found in the government's pursuance of policies that curb the rights of labour and of farmers through the legislation on land acquisition. Clearly, the health movement and other popular movements have their work cut out if they are to turn the tide towards a vision of development that promotes equity and justice.

Note : The author expresses his gratitude to the following people , journal and websites for the data and information cited in this article.

  1. Website of Ministry of Health & Family Welfare-Government of India.
  2. Website of the Commission of Human Rights in India
  3. “ Shifting Care” :Kundan Pandey, Down to Earth 28th Feb,2015.
  4. Draft National Health Policy 2015: getting behind the rhetoric :Amit Sengupta: Indian Journal Of Medical Ethics :  Vol 2 No 2
  5. Website of Peoples’ Health Movement (www.phmovement.org)
  6. Website of Jan Swastha Abhiyan ( www.phmovement.org/india)
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