PM IAS MARCH 20 EDITORIAL

Editorial 1: Moving forward with a newer concept of UHC

Introduction:

• Universal Health Care/coverage (UHC) was implied as early as 1977. India, through its National Health Policy 1983, committed itself to the ‘Health for All’ goal by 2000.

A focus on primary care

• The International Conference on Primary Health Care, through Alma-Ata Declaration, 1978, listed eight components of minimum care for all citizens.

• It mandated all health promotion activities, and the prevention of diseases including vaccinations and treatment of minor illnesses and accidents to be free for all using government resources, especially for the poor.
• Any non-communicable disease, chronic disease including mental illnesses, and its investigations and treatment were almost excluded from primary health care. When it came to secondary and tertiary care, it was left to the individual to either seek it from a limited number of public hospitals or from the private sector by paying from their own pockets. There were not enough government-run institutions for the poor (who cannot afford exploitative and expensive private care).
• This abdication of responsibility, i.e., to provide secondary or tertiary care by the state, ensured the dominant, unregulated, profit-making private sector and also health insurance sector were kept happy and thriving. This created a dichotomy between peripheral primary and institutional-referred specialist care at the secondary and tertiary levels.

Looking ahead

• Realising that even the poor do contract chronic illnesses and non-communicable diseases such as cardiac, neural, mental and metabolic disorders, and also require investigations and management at peripheral primary health institutions, a Primary Health Care (PHC) Version 2 or Comprehensive PHC was defined.
• A sensible move, it was operationalised through the National Rural Health Mission (NRHM) in India from 2013. The second half of the last decade saw the operationalisation of the Health and Wellness Centre as a model of implementation of Comprehensive Primary Health Care.
• Every individual has a right to be healed and not have complications, disability and death. That right is guaranteed only by individualism in public health, the new global approach to UHC, where “nobody is left uncounted and uncared for”.

A newer concept of UHC:

• The Alma Ata declaration of primary health care can be left behind as a beautiful edifice of past concepts. Let us move forward with a newer concept of Universal Health Coverage (UHC) which encompasses primary, secondary and tertiary care for all who need it at affordable cost without discrimination.
• The UHC slogan must be avoided as it is deceptive. This is because it is neither universal in its implementation nor comprehensive in its coverage of services and never assures accessibility or affordability as its financing is conditional to insurance premiums paid either by the individual or state.
• However, the consolation is that the World Health Assembly resolution of 2011, urges countries for timely finance of the health sector to reduce out-of-pocket expenses and a catastrophic expenditure in health resulting in the impoverishment of families.

Astana declaration of 2018

• It calls for “partnership” with the private sector, though alcohol, tobacco, ultra-processed foods, and industrial and automobile pollution contributed by the commercial private sector are well established.
• Also, poorer countries miserably fail or are unwilling for “private sector regulation”. It never addressed poverty, unemployment and poor livelihood, but eulogises quality PHC only as the cornerstone for Universal Health Coverage and ignores broader UHC.
• A globally accepted health systems concept since the Beijing Health Systems Research Conference 2012 is that of a multi-nodal system of varied sectors, professional streams and specialities with a variety of staff to deliver Comprehensive UHC.

Conclusion:

• The National Health Mission with concurrent intersectoral thrusts on Poshan Abhiyan, National Food Security, the Mahatma Gandhi National Rural Employment Guarantee Act, water sanitation, Sarva Shiksha Abhiyan, etc. is a better model of fully tax-funded Universal Health Care, but the Ayushman Bharat Jan Arogya Bima Yojana damages that approach.

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Editoral 2: What is India’s stand on same-sex marriage?

Context:

• A Supreme Court (SC) Bench led by Chief Justice of India (CJI) D.Y. Chandrachud recently referred petitions to legally recognise same-sex marriages to a Constitution Bench of five judges of the SC.

Background of the case:

• The Court has been hearing multiple petitioners’ requests for legal recognition of same-sex marriages under a special law. Initially, it took up the case of two partners who said the non-recognition of same-sex marriage amounted to discrimination that strikes at the root of “dignity and self-fulfilment” of LGBTQIA+ couples.
• The petitioners cited the Special Marriage Act, 1954, which provides a civil marriage for couples who cannot marry under their personal law, and appealed to the Court to extend the right to the LGBTQIA+ community, by making the “marriage between any two persons” gender neutral.

Special Marriage Act: SMA, 1954 is an Indian law that provides a legal framework for the marriage of people belonging to different religions or castes. It governs a civil marriage where the state sanctions the marriage rather than the religion. The Act provides for the registration of marriages, which gives legal recognition to the marriage and provides a number of legal benefits and protections to the couple, such as inheritance rights, succession rights, and social security benefits.It forbids polygamy and declares a marriage null and void if either party had a spouse living at the time of the marriage or if either of them is incapable of giving a valid consent to the marriage due to unsoundness of mind. Section 5 of the Act specifies that the parties must give written notice to the Marriage Officer of the District and that at least one of the parties must have lived in the district for at least 30 days immediately before the date of such notification. Section 7 of the Act allows any person to object to the marriage before the expiration of 30 days from the date of the notice’s publication. Personal laws, such as the Muslim Marriage Act, 1954, and the Hindu Marriage Act, 1955, require either spouse to convert to the religion of the other before marriage. However, the SMA enables marriage between inter-faith or inter-caste couples without them giving up their religious identity or resorting to conversion. But, once married as per the SMA, an individual is deemed severed from the family in terms of rights like the right to inheritance.

• Even if LGBTQIA+ couples may live together, legally, they do not enjoy the rights married couples do:

1. LGBTQIA+ couples cannot adopt children or have a child by surrogacy
2. They do not have automatic rights to inheritance, maintenance and tax benefits
3. After a partner passes away, they cannot avail of benefits like pension or compensation.

The court’s stand:

• The Courts, leaning on Article 21 that guarantees the right to life and liberty, have time and again ruled in favour of inter-faith and inter-caste marriages, directing the police and other rights organisations to give them protection when they were threatened by parents or society, pointing out that “all adults have the right to marry a person of their choice.”
• In Navtej Singh Johar case (2018), when homosexuality was decriminalised, the Court said, “Members of the LGBT[QIA+] community are entitled to the benefit of an equal citizenship, without discrimination, and to the equal protection of law”.
• After the K.S. Puttaswamy verdict/ Aadhar case (2017) which upheld the right to privacy and Navtej Singh Johar (2018) that decriminalised homosexuality, there was hope that same-sex marriages would be legalised, but that has not been the case, prompting many couples to move court.

The central government’s stand:

• At depositions in courts and outside, the Centre has opposed same-sex marriage, and said judicial interference will cause “complete havoc with the delicate balance of personal laws”.
• In its affidavit filed in the Supreme Court, the government said that the “notion of marriage itself necessarily and inevitably presupposes a union between two persons of the opposite sex. This definition is socially, culturally and legally ingrained into the very idea and concept of marriage and ought not to be disturbed or diluted by judicial interpretation.”
• It submitted that despite the decriminalisation of Section 377 of the Indian Penal Code, the petitioners cannot seek same-sex marriage to be treated as a fundamental right and be recognised under the laws of the country.
• The government said that even if such a right (allowing same-sex marriage) is claimed under Article 21, the “right can be curtailed by competent legislature on permissible constitutional grounds including legitimate state interest.”

Way forward:

• Government and the apex court will have to come to a mutual understanding that will protect individual liberty while not also disturbing the ‘traditional societal values’ or ‘sanskar’ of Indian society.
• In this, the court might also have to rely on the doctrine of Constitutional morality, which adheres to the core principles of constitutional democracy. Constitutional morality is not limited only to following the constitutional provisions literally but is based on values like individual autonomy and liberty; equality without discrimination; recognition of identity with dignity; the right to privacy.

Conclusion:

• Enforcing something like same-sex marriage in a diverse country with well-entrenched traditions will not be easy. Rights activists are calling for awareness on sex, gender and constitutional rights from the school level to change things on the ground.