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The Government of India has reiterated that the goal for India’s healthcare system is to progressively achieve Universal Health Coverage (UHC). This is the prominent focus of the National Health Policy (2017). Spending, however, has remained below the target 2.5% of GDP. As per the HRMI rights tracker, which measure how well a country is using its income to ensure people’s Right to Health is fulfilled, India ranks 68th out of 144 countries. This means India can achieve a lot more, given its income. India’s ambition to achieve UHC, therefore, needs more impetus. 

A crucial pathway to UHC is establishing health as a right. This could help in mandating a shift in government priorities, locking in multiple governments and political parties to the same objective, setting clear benchmarks and norms which can be used to hold service providers accountable, and guaranteeing access, especially to the most-vulnerable and marginalised. Recently, Rajasthan has passed a Right to Healthcare Act 2022. But it received a lukewarm response as experts and activists argued that it lacked clear implementation timeframes, guidelines, and guarantees for people, with which they can hold the government accountable. 

This experience is informative. Against this backdrop, visioning and framing pathways to UHC require thinking through some big questions on what it takes to actually conceptualise and then implement health as a right. 

What’s in a name? Definitions and implications

Firstly, there is a sharp distinction between health and healthcare. Healthcare covers the provision of medical and health services, which directly deal with the prevention and cure of illness, injury, and disease. On the other hand, health is a broad and varied term, and covers many other things. It covers not just healthcare, but also the underlying determinants of health, such as access to safe drinking water, sanitation, healthy occupational and environmental conditions, and access to health-related information. 

Therefore, the first big question to think about is what should a Right to Health cover? A related question is if the Right to Health should have comprehensive provisions to cover wellness or the act of practicing healthy habits on a daily basis to attain better physical and mental health outcomes. Wellness can also be described as thriving, instead of simply surviving a disease.  

The answer to this, of course, will have to account for the government’s ability to deliver. Should the government choose to focus on health, commitments will be bigger, and therefore more-costly and tougher to deliver on. And if it chooses to focus on healthcare, as the Rajasthan Health Care Act 2022 does, should it cover gender affirming surgeries, elective surgeries, rare diseases, etc. Currently Brazil, in their right to healthcare, publicly covers gender affirming surgeries. Any conceptualisation of a Right to Health or healthcare needs to start with clearly defining the scope, especially in a resource-constrained country like India. 

Health being a state subject remains a federal hot potato

The judiciary has defended the Right to Health as a part of the Right to Life (Article 21 of the Indian Constitution) on several occasions. This does set precedence to create a separate and distinct Act, with clear provisions of what people are entitled to. However, health is a state subject, and therefore it is difficult for the Union government to make a sweeping Right to Health framework for the country. Previous experiences are revealing. 

Despite clear federal boundaries, the Union government has persistently increased its own investments in health (more than a 1.5 times increase between 2014-15 and 2022-23). However, when the Supreme Court of India questioned both Union and state governments on their response to the COVID-19 pandemic, the Union government clearly stated that health is the responsibility of state governments, in contrast to their repeated (and arguably necessary) interventions in the delivery of health services. 

The in-practice muddled status of health in India’s federal landscape can be resolved by moving health from the State List to the Concurrent List of the Constitution. There is precedence for moving subjects from the State to the Concurrent List, such as education. 

An expert group had submitted to the 15th Finance Commission that, given family planning is part of the Concurrent List, health should be made a Concurrent List subject as well. However, it is important to note that many states have managed well without the Union’s support, and such a move will raise questions of State government autonomy. This could be a step away from a more decentralised form of governance. 

Till then, with health being a state subject, state governments will have to pass their own legislations, as Rajasthan has done. At the moment, Tamil Nadu is also working on creating a Right to Health. 

Biting off more than can be chewed? 

Another question to consider is that a Right to Health with teeth will be complicated in India’s current health landscape.

One criticism of the Rajasthan Right to Healthcare Act is the lack of clear rules and provisions on the exact services that will be provided, in what manner and quality, and timeframe. The current form of the Act falls short of providing guarantees, leading experts and activists to argue that it lacks teeth. But what would it take to provide ‘teeth’? 

An example of ‘teeth’ can be found in the rules for the Right to Education Act (2009). They provide for clear norms such as primary schools being made available within 1 km of any student. A similar rule to establish healthcare centres within a km radius of the seeker may be incredibly costly to execute, given several competing priorities for both Union and state governments. 

At present, the private sector is preferred by almost 50% households. Some of the reasons for not using government facilities include the lack of nearby facilities, absent personnel, inconvenient timings, long waiting times, and poor quality. While the situation has gradually improved over time, most states fall short of WHO norms for the provision of doctors and facilities. Even if funding was not an issue, doctors and healthcare professionals don’t always want to serve in remote areas, leaving several communities underserved. Massive financial incentives may help, but again, will increase costs. The same is true for ambulances for remote areas. 

This begs the question: should the private sector be leveraged and mandated to provide services under any potential right to healthcare? 

Gravy trains or penny pinching? Misaligned incentives for the private and public sector

Given that the private sector forms a large part of the Indian health system, any guarantees given to people may have to bring the private sector in. However, the private sector seeks profit, and will seek the same to deliver in remote areas. So, a guaranteed right to healthcare for citizens which involves the private sector may also require guaranteed profits for the private sector. If prices are unregulated, access becomes the challenge. If prices are regulated, setting prices and deciding who pays the cost (government or citizen) becomes a political quagmire, and will inevitably lead to backlash. 

Related questions are: what are the regulatory mechanisms that can be used to ensure access, quality, and timeliness of healthcare? Given the sheer information asymmetry with medical services at large and the government’s limited monitoring capacity, regulation could be a big question to think about in order to guarantee rights. 

Lastly, one of the biggest hurdles to a potential Right to Health is the sticky wicket of financing. However, having a right itself can spur investments, but implementing a right requires serious deliberation over a vast number of questions, which move beyond just the domain of healthcare provision, to re-imagining what kind of society we want to create. Answering these questions requires multiple stakeholders, and is critical to creating a pathway to UHC. 

Ritwik Shukla is a Senior Research Associate at Accountability Initiative. 

Also Read: India’s Major Challenges in Realising Menstrual Health

The previous blog in this series looked at how India’s existing menstrual health public service delivery prioritises the distribution of sanitary napkins (or pads). While the usage of sanitary pads – a hygienic menstrual method – by women and girls has improved, dependence on cloth remains high. Usage of other hygienic menstrual methods have not been given a policy push, especially at the Union level. This lack of comprehensive menstrual health contributes to period poverty, which is a situation of limited individual – and societal – level awareness of safe menstruation practices, and an inability to afford menstrual products. 

The awareness and availability of different services – products or methods, and facilities –  contribute to practising safe menstrual hygiene. It allows menstruators to make informed and empowered decisions. The lack of awareness, on the other hand, sustains the social and cultural taboos associated with menstruation. Thus, even though a lot of existing menstrual health public services are meant for adolescent girls, over 80 per cent of girls still  believe menstrual blood to be harmful. 

Further, as per the National Family Health Survey (NFHS 5) 2019-21, only 23 per cent never-married women discuss menstrual hygiene with health workers. Discussion on the topic further reduces significantly for ever-married women, who also do not use contraception, at 4 per cent. It is, thus, important to unpack how conversations on menstruation manifest at the grassroots. Who all is involved and who initiates such conversations? 

This blog takes the example of a few frontline health workers’ (FLWs) experiences from two districts in Bihar [1].

In Bihar, FLWs initiate discussions on menstruation and women seldom bring it up themselves. These discussions are prompted in group settings, such as the Village Health, Sanitation, and Nutrition Committees (VHSNC) and Mata Samitis [2]. Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs) explain how to properly use and dispose of sanitary pads. According to the health workers, women do not resist such information but do not seek any clarifications either. While there is also a general sense of awareness among the community because of television advertisements, women and girls without education are usually not comfortable discussing menstruation [3]. School-going adolescents, on the other hand, are open to discussing menstruation and also talk among themselves. However, conversations continue to be hushed around men.

Moreover, adolescent girls who go to school are entitled to ₹300 every year for buying sanitary napkins from the state government. While this amount is barely enough, health workers also express concern over the lack of medical facilities – including the purchase of napkins from regular shops – at the village level. 

Lastly, in these two districts of Bihar, health workers had not received any kind of training on effective dissemination (posters, rallies, etc.) of menstrual hygiene at the community level. 

In the above case, health workers prompted conversations in the community on menstruation. However, research also suggests that health workers may not be discussing it at all. 

A recent study in Delhi’s government schools found that health workers and teachers do not complement the distribution of sanitary napkins with discussions on menstruation-related misconceptions. Another study found that a low supply of napkins, lack of an incentive, and inadequate training demotivated ASHA workers to aid scheme delivery, which includes conversations on the topic.

Lack of communication on behalf of health workers and limited awareness among menstruators is a critical barrier to optimal menstrual health. 

But, there are other challenges too.

Unfunded mandates can under-prioritise menstrual health. Researchers at the Accountability Initiative (AI) found that sanitary napkins remained undistributed in the Sitapur district of Uttar Pradesh under the Rashtriya Kishor Swasthya Karyakram (RKSK) scheme. This was because the district did not spend on procurement of sanitary napkins over a period of four years and also failed to earmark any funds for their transportation to the last mile. While procurement and transportation are assigned functions under the scheme, the lack of earmarked funds makes it impossible to carry out the functions.

Moreover, poor financial planning for the procurement of sanitary products appears to be a widespread phenomenon in the country. Over the years, several states and Union Territories (UTs) have not reported any planned financing for the procurement of sanitary napkins under Menstrual Hygiene Scheme (MHS).

While transportation can be seen as an enabling aspect integrated with existing scheme delivery, several services remain outside of the purview of scheme design. Different enabling services are required to achieve comprehensive menstrual health. A ground report from Maharashtra’s Beed district found that women earning a livelihood through sugarcane cutting were not able to access safe sanitation and water facilities. Sanitation and water facilities are key enabling services for realising menstrual health. In the absence of such services, not only do these women wear unsanitary rags or cloth for long time periods, several of them have also been pushed to undertake the arduous procedure of hysterectomy to avoid missing work during menstruation.

Lastly, certain groups are also excluded at the policy level. The understanding of gender in binaries (male and female) is a barrier for transgender persons to access menstrual health services. There is no district, state, or Union level initiative that makes menstrual services accessible to transgender persons.

Conclusively, menstrual health service delivery in India remains constrained. It is not realised as a public health challenge and lacks key complementarities for women’s dignity and safety. On the one hand a predominant focus on the distribution of sanitary napkins faces shortcomings of poor quality and low supply under schemes such as the MHS, which the Ministry of Health and Family Welfare’s (MoHFW) own report admits. On the other hand, period poverty manifests, despite several initiatives to improve the availability of sanitary napkins.   

All of this has serious consequences. 

A recent study shows that households reduced their spending on period products during the pandemic, with rural areas bearing the major brunt of lockdown-induced shortages and accessibility challenges. Thus, even the shift towards using hygienic menstrual products, typically sanitary pads, may have been challenged since the pandemic incidence. At the same time, pads are not the only hygienic menstrual method; a holistic approach to service delivery is needed, the barriers to which have been identified in this blog. Further, not every menstruator has realised their right to avail menstrual health services from the government. 

Recently, Scotland became the first country in the world to make all period products free for menstruators. Codifying this into law, the country instils a best practice scenario for every other country in the world to follow suit and acknowledge menstrual health as a fundamental right.

The author is grateful to Seema Muskan, Senior PAISA Associate, Accountability Initiative, for her insights from Bihar.

Tanya Rana is a Research Associate at Accountability Initiative.

Also Read: Under-prioritisation of Women’s Safety in the Union Budget?

Notes: 

[1] FLWs include ASHAs, ANMs, and Anganwadi workers. We spoke to  3 ASHAs, 4 ANMs, and 3 Anganwadi workers from Nalanda and Patna districts. The role of Anganwadi workers is minimal.

[2] The Samiti comprises 7-12 members, including ASHA, Anganwadi workers, one person from Care India, and mothers. Mata Samitis are held once a month, majorly for health-related discussions.

[3] Women without school education are more likely to use unhygienic menstrual methods too. This was discussed in the previous blog.