Human Right Approach; A paradigm shift in understanding health

Chandrima B Chatterjee gives a historical overview and the various perspectives in understanding health from the 1950s

The use of Human-Rights approach heralds a paradigm shift in the understanding of health dynamics. The journey of understanding health from illness and medicine to health as human rights have been long and quite an interesting one building upon experiences from the past and vision for the future.

The new approach is claimed to be more holistic. After years of debate, it is now amply clear that health cannot be explained in isolation. Health outcomes of population in any geographical space depends on certain causes which can range from immediate to underlying and basic causes and is also influenced by the larger socio-cultural and economic realities.

1950s and 1960s

Health has had an organic link with the paths and patterns of development globally. Understanding of health has been curiously linked to the development debate. In the 1950s and 1960s, the economic development strategies were based upon the belief that less developed countries would repeat the economic development experience of the industrialised countries. Health policies adopted the healthcare model of the West, that is medical services being mostly curative, urban-based and highly technological.

1960s and 1970s

In the late 1960s and 1970s, reality dawned and it was realised that economic growth was not trickling down to the poorest sections of the ‘Third World Societies’, and there was a natural question raised about defining development in terms of national income ignoring the idea of redistribution of wealth.

In the 1970s this view was endorsed by a number of international agencies working in the social sector and the health focus enlarged its frame to incorporate the scope of identifying the vulnerable and their health concern. The late 1960s also experienced emergence of a radical theory of development, the dependency approach which viewed underdevelopment as a historical condition of Western capitalism.

Health status of the third world communities suffered due to their peripheral status at the core of the development i.e. the western society. To counter such a tide of underdevelopment, countries like China and Cuba and many other countries adopted a broadly socialist path of development. The dependency paradigm and the associated self-reliance or rather non-reliance on western societies for self-improvement was exemplary in many ways.

It lead the WHO and UNICEF to openly express admiration for the Chinese strategy of development and their health model. They used many elements from the Chinese health model into their statement on Primary Health Care (PHC).

Interesting enough, this was the same time that there was almost a universal acknowledgement that the health problems of the Third World was a result of an absolute lack of distributive justice and not from the lack of resources. It was realised much later that the zones of disparities were focused upon. While the architects of health for all were calling for a fundamental redistribution of power and resources, most developing countries began to implement market-oriented policies prescribed by international financial institutions. These policies collectively termed as the economic adjustment jinxed the scope of equitable healthcare dreams. The indebted third world countries lost its power and control to decide upon its policy and programmes under the binding contours of conditionality that followed the Structural Adjustment Programmes (SAPs).

Impact of globalisation

Globalisation, privatisation, unregulated expansion of the health industry, multitude of care providers, enormous growth of the pharma industry, induced imperfections in the health sector. The realities of globalisation progressively subverted the care element of health and allowed discrimination of all kinds to flourish.

Expenditure on health saw a drastic reduction of the state-based entitlements and their replacement by market-based, individualised entitlements and impacted health outcomes and breeding inequalities of access to quality care. The change in the nature of health financing by the state initiated the process of systematic discrimination in every aspect of care from access to health services to the quality of care. There have been studies that captured the relationship between the SAP and the health sector in the Third World communities in great detail.

Health as a Right

The rights-based approach has had its seeds in the notions of welfare state. But its presence in the health movements and research is an aftermath of the experiences of globalisation, the SAPs and the privatisation of the health sector. The emergence of an alternative paradigm to understand health was a response to the growing irregularities that plagued the health sector. It was claimed that questions of equal access across class, caste, gender, region, advocated within this framework would not only end discrimination but put an end to differentiation.

Advocates of this approach felt that there was a need for accountability and the state has a responsibility towards maintaining the health of its citizens. Health as a human right promised to codify the needs of people, reformulate them into ethical and legal norms and direct the efforts in a way that optimises the satisfaction of the vulnerable population’s basic needs in a sustainable manner.

The new approach acknowledged the fact those health outcomes are necessarily dependent on the structural and cultural dynamics in every community but there is a role of the state, which cannot be compromised upon. More importantly, health as an issue must have democratic participation of the civil society and encapsulate the needs and sentiments of people. It proposes to understand health as an enforceable right by the law of land across the globe. Internationally, the attempt to institutionalise health as a human right, found its way to the international conventions, pact and directives.

The history of the adoption of rights-based approach in India was linked intrinsically to the global developments and the changing role of the state in the backdrop of globalisation and the structural adjustment programmes. The health system underwent changes from the pre-colonial to colonial period. The modern medicine i.e., the allopathic system, is a colonial legacy, which like many other relics from the colonial past completely overshadowed the indigenous curative methods and juxtaposed them as ‘alternative systems’ to the modern allopathic system.

The homogenising process of the health systems was much a part of the larger process of modernisation in India. Modern India wished to believe that it was moving towards a progressive direction from the traditional to the advanced society and that the change in its various elements of social existence was a part of the larger goal and in consonance with the modernisation agenda.

The change in the structure of the health system started with colonisation and altered the entire structure of the health system in its bid to integrate the Indian health system with the so-called modern world. Systems and patterns of both curative and preventive care got altered under modernisation. But what started, as modernisation for a country with colonial past later turned out to be dependence on the developed world for its direction of change.

Now, 58 years post-independence, it may be preposterous to suggest that Indian population did not identify with the modern system of medicine, hence the movement towards a right-based approach. Infact, the over dependence on the modern system of medicine and its unprecedented growth on Indian soil reflects just the contrary. It is the growth of the modern system of medicine in the backdrop of globalisation and its polarising tendencies that initiated the dialectical relationship of health systems with the civil society.

The existence of the Indian health system, like many ‘Third World Communities’ became dependant on the West. But the west, failed to integrate it within the modern capitalistic societies and further pulled it into the vortex of underdevelopment. This pattern is now even more aggressive with the financial aid from International Financial Institutions (IFIs) with their implicit conditions.

The health reforms in India, with the introduction of the structural adjustment programmes experienced withdrawal of the state involvement and dependence on foreign aids to meet the health needs of the population. The WHO standard for expenditure on public health is five per cent of the GDP. The average spending today by less developed countries (LCDs) is 2.8 per cent of GDP while India spends less than one percent of GDP on health.

The health policies and programmes started to be guided more by technological determinism rather than epidemiological priorities or geographical realities. These had serious implications on the ground subverting the internal health priorities and allocations, nursing inequalities of all possible forms, stratifying the Indians society in terms of health outcomes along caste, class, religion, gender, age, etc. It has impacted the principals of free access, health status of the population, variation in health status across states, rural-urban residence, caste-class and gender and other differences, variation in access, PHC structure and health manpower.

The worst consequence of globalisation and the SAP is perhaps the unaccounted growth of private health sector. Private players in health system created highly unregulated health markets, induced provider pluralism, unequal access to healthcare services and health related knowledge and limited the scope of health planning.

The available macro data recognises the differential utilisation pattern of health services, the differential health outcomes that can actually hint at unequal distribution of health services both preventive and curative. The health system is perceived to be functioning in complete isolation by insulating itself from the needs and concerns of the health-seekers.

Will health as a Right make a difference?

The euphoria surrounding the human-rights approach refuses to die especially when it holds so many promises in an atmosphere of despair. But a question that visits every concerned mind is that, Can the human- rights approach in health make a difference by making healthcare accessible?

It can indeed be safely commented that the new approach holds more promise since it acknowledges health-seekers as citizens and not mere consumers or individuals. It suggests health to be a state responsibility and encourages the participation of the civil society in the whole process of monitoring the right.

Health as a human right conceptualises health as an element of obligation and not an option of the state. This definition of health instantly expands the scope of the state duties towards its citizens. It demystifies health from the opulence of technical jargons that surrounds it and makes it available to people in the form of right to information related to health. But having said so, it is important to also mention that with each right comes certain duty as well.

To enjoy the right to health, what duties should citizens discharge is yet to be clearly charted out. How do you realise the right to health in a society mired by structural and cultural complexities is another question, which the advocates of the new approach have to answer. Realisation of the right to health would require collective bargaining by the civil society, a co-operation and transparency among stakeholders. Is the Indian state and society ready to universalise the right to health or the politics of health would continue to undermine the movement towards health for all, only time will say.

The writer is a Senior Research Officer with CEHAT (Centre for Enquiry into Health and Allied Themes). Email - chandrima@cehat.org