World Report
Seeing health care as a human right in India
The conviction of doctor and human-rights activist, Binayak Sen, could have implications for
India’s attempts to achieve universal health-care coverage. Patralekha Chatterjee reports.
At a time when India is working
towards making access to health-
care universal, a 61-year-old medical
doctor, nationally and internationally
acclaimed for running health clinics
for poor tribal communities in remote
parts of central India, is fighting a grim
battle to prove he is not a threat to the
country’s security.
Doctor and civil-rights activist
Binayak Sen, the first Indian recipient
of the Jonathan Mann Award for
Global Health and Human Rights, is
in jail. On Dec 24, 2010, a trial court
in Raipur, capital of Chhattisgarh state
in central India, sentenced Sen to life
imprisonment for sedition on the
charge that he carried a letter between
two members of a banned left-wing
extremist outfit.
The doctor vehemently denies any
wrongdoing and has appealed to the
High Court, which will take up the
matter on Jan 24. His family and legion
of supporters inside and outside India
point to the many glaring loopholes in
the prosecution’s evidence.
His supporters say that Sen is
paying the price for his strident
criticism of counter-terrorism forces
in Chhattisgarh, one among several
states afflicted by left-wing extremism,
and because of his sustained emphasis
on the nexus between health, human
rights, and equity. Sen’s mission is to
make people aware that health care is
a right, not a favour. At a time when
India’s Planning Commission has
appointed a high-level expert group
to develop a blueprint for meeting
the human resource needs to achieve
“health for all” by 2020, the Sen case
has implications far beyond his plight.
“Many people ask me why a good
doctor like Binayak Sen was not
content with just treating patients.
But ever since he was a student,
Sen had a questioning mind”,
www.thelancet.com Vol 377 January 15, 2011
Parapeedikail Zachariah, Sen’s teacher
at the Christian Medical College (CMC)
at Vellore in southern India, tells The
Lancet. “While studying for his MD, he
focused on child health. He was not
content with just classroom learning.
He moved around in the community
to see the effects of malnutrition on
“Sen’s mission is to make people
aware that health care is a
right, not a favour.”
children. Malnutrition served as an
entry point to Sen’s activism. Later,
when he worked in tribal areas, he
visited homes of people he treated and
saw first-hand gross starvation and
their lack of access to the many things,
which the government promises but
which do not exist on the ground.
His engagement with community
public health in tribal areas led to
involvement with civil rights issues.
Binayak Sen became an activist-
physician not only concerned with the
clinical side of health-care delivery but
all the other factors like ownership of
natural resources, malnutrition, and
so on that affect health.”
80-year-old Zachariah, a former
physiology professor at CMC, is
currently the managing trustee of the
Binayak Sen Support Fund, which is
helping Sen’s family to fight the legal
battle.
Sen’s view of health care as a right
is in sharp contrast to that of most
medical professionals in India, says
Zachariah. Until the Chhattisgarh
lower court verdict, the activist-
doctor was working on a project
that could have a far-reaching
effect on health-care education in
India. Because of the findings of the
report by the WHO Commission on
the Social Determinants of Health
(2008), Sen was appointed by CMC
as a consultant to draft a curriculum See Editorial Lancet 2011;
model that would incorporate human 377: 98
rights within the ambit of health-care See Comment page 181
education. “The medical profession See Series page 252
in the country is highly conservative.
Most doctors would like to play safe.
Doctors typically protest when their
own interests are at stake. But in a
developing country like India where
inequities are deeply entrenched or in
a conflict zone, thinking deeply about
health care inevitably raises the sort
of questions that Binayak Sen asked”,
Zachariah added.
Indian political analyst Mahesh
Rangarajan tells The Lancet, “If
universal health coverage is not a
political issue across the country, it is
because historically speaking, the idea
of political rights is more established
in India than social rights. However,
the latter has had greater currency in
southern and western India, due to
reformists who took up health and
education as key priorities. The social
movements in these parts shaped the
politics in the region. In north India,
a significant exception to the norm
of according less importance to social
rights is Himachal Pradesh. Generally
speaking, because of acute poverty,
and the sheer struggle for survival
AP
Binayak Sen is brought to a trial court in Raipur for sentencing on Dec 24, 2010
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Reuters
faced by millions of people, something
like access to food gets greater political
attention than access to health care in
this country.”
In the states where improving access
to health care is an important electoral
issue, parties are keen to lay claim to
health schemes to win votes.
In the southern Indian state of
Andhra Pradesh, for example, the
Rajiv Arogya Sri, a health insurance
programme for the poor named after
former prime minister Rajiv Gandhi, is
perceived to have contributed to the
Congress victory in the last elections.
The government in the state of Tamil
Nadu, also in south India, has launched
the Kalaignar Insurance Scheme for
Life Saving Treatments, after the
nickname of the state’s chief minister
Muthuvel Karunanidhi.
”The social sector has been an
important factor in Tamil Nadu
politics since Independence in 1947”,
Sankaran Vijaykumar, Special Secretary
for Health and Family Welfare, Tamil
Nadu, tells The Lancet.
Another example of politicians
promoting a health scheme to
mobilise support is the Yeshasvini Co-
operative Farmers Health Care Scheme
in another southern state, Karnataka.
Any farmer who is a member of a co-
operative society in Karnataka can
access expensive medical procedures
by becoming a member of this scheme.
Conceptualised by Devi Shetty,
chair of Narayana Hrudayalaya
Hospitals Group, and the man who
196
revolutionised cardiac care in India,
it was launched by former Karnataka
chief minister Somanahalli Mallaiah
Krishna. Krishna is Foreign Minister in
the federal government today.
Himachal Pradesh is one state in
northern India that is also seeking
political mileage out of health
interventions. Last year, on Dec 25, the
birthday of former prime minister Atal
Bihari Vajpayee, the state government
that is run by his Bharatiya Janata
Party, started the Atal Swasthya Seva
to provide free ambulance services
across the mountainous state nestled
in the Himalayas.
The state’s health minister Rajeev
Bindal tells The Lancet: “Health has
always been a political priority of the
state government and that is proved by
the fact that most people prefer to go
to government hospitals than private
ones, as is the case in much of India.”
The minister was referring to the
fact that health care has two faces in
India. Although an expanding middle
class has triggered a surge in the
number of private hospitals, some
with state of the art facilities, poorer
people, especially those living in less
developed parts of the country, have
little or no access to minimum health
facilities free of cost. Public spending
on health care is less than 1% of the
gross domestic product.
“Public investment in health,
particularly in primary health care,
needs to be much higher to achieve
health targets, to reduce poverty and
to raise the rate of economic growth”,
noted the 2010 evaluation of India’s
National Rural Health Mission by
Nirupam Bajpai, Jeffrey Sachs, and
Ravindra Dholakia. The report also
pointed out that “the average figures
for India hide a great deal of variation
in the performance of different states,
which are on different points along the
health transition path...While Kerala,
Maharashtra, and Tamil Nadu are much
further along the health transition
trajectory, the densely populated
states of Orissa, West Bengal, Bihar,
Rajasthan, Madhya Pradesh, and Uttar
Pradesh are still in the early part, with
the other states falling in between.”
Less than 20% of the population
have any sort of health insurance
and out-of-pocket health-care costs
drive tens of thousands of families
into debt. So the idea of using
health care as a vote catcher is not
far-fetched. The high-level expert
group appointed by the Planning
Commission, under the stewardship
of K Srinath Reddy, president of the
Public Health Foundation of India, is
working on a comprehensive strategy
to ensure quality, universal reach,
and access to health-care services,
particularly in underserved areas.
It is expected to submit its report
this year.
The group has good models from
other developing countries. In 2001,
Thailand extended government-
financed health coverage to all
uninsured people with little or no
cost sharing. The reforms were a big
hit with poor Thais, especially in rural
areas, and survived the change of
government in 2006.
At the First Global Symposium
on Health Systems Research
in Montreux, Switzerland, last
November, Viroj Tangcharoensathien,
director of International Health Policy
Programme in Thailand’s ministry
of public health, proclaimed that the
operative principle behind the Thai
health reforms was “good for the
most“ instead of “best for the few”.
He tells The Lancet, “It was national
politics that set the universal health
coverage agenda in Thailand”.
India has taken many positive steps
to improve the health of its people in
recent years. Now, as it contemplates
universal health coverage, it is worth
re-emphasisising what public health
advocates like Binayak Sen make
clear: health interventions cannot
be seen in isolation. They work best
when communities are conscious of
their rights and fully aware of their
entitlements.
Patralekha Chatterjee
www.thelancet.com Vol 377 January 15, 2011