Abstract
This chapter seeks to critically address the interface of ethics and public health rights. The dialectics of the interface of public health rights, interchangeably used as social right to healthcare (SRHC) and ethics, are marked by dilemmas, conflicts and contestations. The constitutional ambiguities in the articulation of SRHC on the one hand and the crisis of public healthcare on the other have further confounded such ambiguities that have resulted in gross systemic and individual violations of citizens’ dignity and wellbeing. This paper aims to (1) introduce the concept of rights in relation to ethics in public health discourse; (2) familiarise with the debates, dilemmas and contestations in the interface of rights and ethics; and (3) broaden the horizons of ethical framework in practice. The efforts of the civil society in India in foregrounding such ethical-moral argument are used to exemplify and argue for the dimension of social citizenship and rights as an inviolable constituent of the emerging public health ethics. Such terrain, however, is beset with challenges with contestations, dilemmas and conflicts, even as it is dynamic and ever expanding.
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- 1.
Institute of medicine defined public health as “what we as a society do collectively to assure the conditions in which people can be healthy” (IOM 1988); Turnock (2001) described public health as the “collective effort to identify and address the unacceptable realities that result in preventable and avoidable health outcomes, and it is the composite of efforts and activities carried out by people committed to these ends” (Noland 2004).
- 2.
Subsequently, discussion on universal insurance and an adequate legal framework began in the early 1990s, to be realised as Affordable Care Act (known as Obama Care), only after 15 years (Jaffe 2012). The republicans again have started the process of whittling down this Act by tabling amendments in 2017, indicating the political nature of SRHC of the marginalised.
- 3.
39 (e) ‘health and strength of workers (...) are not abused ...’; 39(f): ‘that children are given opportunities and facilities to develop in a healthy manner..’; Article 41: ‘... securing the right to work, to education and to public assistance in cases of unemployment, old age, sickness and disablement...’; Article 42: ‘humane conditions of work and for maternity relief’; Article 43: ‘conditions of work ensuring a decent standard of life...’
- 4.
In South Africa’s constitution, for example, Sect. 27 on healthcare, food, water and social security states (1) everyone has the right to have access to (a) healthcare services, including reproductive healthcare (Constitution of South Africa 1996).
- 5.
Article 37 states: ‘The provisions contained in this Part shall not be enforceable by any court, but the principles therein laid down are nevertheless fundamental in the governance of the country and it shall be the duty of the State to apply these principles in making laws’.
- 6.
The eight states with the poorest health indicators, namely, EAG states (Uttar Pradesh and Uttarakhand, Madhya Pradesh and Chhattisgarh, Bihar and Jharkhand, Orissa, Rajasthan) and Assam (DLHS-4-IIPS 2014). The sub-health centres (SHCs), primary health centres (PHCs) and community health centres (CHCs) are the backbone of citizens’ access to public healthcare in India. However, even in 2016, crucial infrastructure remains incomplete despite the additional support of the NRHM: there is a shortfall of 35,110 SCs (20%), 6572 PHCs (22%) and 2220 CHCs (30%) across the country as per the rural health statistics (RHS) 2016 (http://nhm.gov.in/nrhm-components/health-systems-strengthening/infrastructure.html, seen on April 28, 2017). The shocking lack of specialists in CHCs has been marked in the rural health statistics (RHS) 2016 as a ‘huge shortfall’ of 83% physicians, 84% surgeons, 80% peadiatricians and 77% ob/gyn doctors. A functioning OT is available for around half the CHCs in UP, MP and CG and even less in Rajasthan and Orissa, while for Assam only 13% CHCs have a functioning OT. Assam has blood storage in 23% of its CHCs, and Rajasthan comes a distance second at 13%. In all other states with high rates of MMR, the percentage of CHCs with blood storage ranges from 2% (UP) to 8% (Orissa).
- 7.
In fact out of 192 countries ranked in terms of out-of-pocket expenditure as a percentage of total health expenditure in 2014, India is placed at 183 just above neighbouring countries of Bangladesh (187 rank) and Afghanistan (184 rank).
- 8.
According to the National Health Accounts 2013–2014 (NHA), the government share of the total health expenditure has gone up only from 23% to 29% in this decade. The union government spends Rs 358 per capita for healthcare, while the State governments and union territories/local bodies spend Rs 684 per capita (NHSRC 2016), public health spending in China (2.9% of the GDP) and Brazil (4.1%). These insufficient changes over 10 years indicate that despite the NRHM, the impoverishment faced by the people as a result of catastrophic health costs is very likely continuing. The inadequate budgetary allocations described above are distributed very unevenly among different population categories, as the NHA 2013–2014 (NHSRC 2016 , page 16) indicates.
- 9.
Around 2.5 million people are estimated to be living with TB within India, about one-quarter of the global burden of TB (GOI 2017a). TB is one of the leading causes of death in India today with close to 5 lakh people dying in 1 year and 28 lakh cases detected in 2015 alone. India also has the highest burden of malaria among the Southeast Asian countries: data from 2014 indicates there were 1.1 million cases and 562 deaths due to malaria; however, in the last 10 years, total malaria cases have declined by 42% (GOI 2016).
- 10.
Approximately 12.5 lakh children under 5 years die every year whom an unfortunate 10 lakh die even before their first birthday. Estimates of maternal mortality ratio (MMR) are now at 167 deaths per 100,000 live births which translates to around 45,000 maternal deaths each year (Parliament of India 2016, para 2.40) (NFHS-4, IIPS 2017). The deaths of women and children are not evenly distributed across all states or all social groups, as studies have indicated. A child born to a scheduled tribe family has a 45% greater risk of dying in infancy compared to other social groups, especially if the ST family is in a rural area. Such differentials are seen within and between states. Maternal deaths among poorest women are reducing far more slowly than richer women who have better access to emergency obstetric care. The data from NFHS-3 (IIPS 2007) indicated that there are significant differences among women from the lowest and highest wealth quintiles in access to basic maternal services such as comprehensive ante-natal care or skilled attendance at childbirth.
One-fourth of rural women are underweight (with a BMI of less than 18.5 kg/m) although the national average has reduced from 36% to 23%, the proportion of women with anaemia has remained static, going from 55% to 53% in 10 years, and even now, half the pregnant women in the country are still anaemic. Comprehensive pregnancy care remains abysmal at 21% (NFHS-4 India Factsheet, IIPS 2017). This poor nutritional status of women in the reproductive age, coupled with their early marriages and lack of contraception, creates a significant probability of high-risk pregnancies in India.
- 11.
In this paper, social rights is used for the sake of brevity to include and a mean by the expression of the broader rights under social, economic and cultural rights.
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Premdas Pinto, E. (2018). Public Health Rights and Ethics: Conflicts, Contestations and Expanding Horizons. In: Mishra, A., Subbiah, K. (eds) Ethics in Public Health Practice in India. Springer, Singapore. https://doi.org/10.1007/978-981-13-2450-5_2
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