First request;

1. Towards Improving and Strengthening of the National Health System: The need for a Charter of Patients’ Rights By Dr K Balasubramaniam Peoples’ Movement for Rights of Patients Presented at the Annual Health Forum, 9-10th February 2007 at the BMICH

2. What is the Annual Health Forum and what will it deliver to change the present system for the better?

3. A Charter of Patients’ Rights is one of the means to improve and strengthen the health system which is the end. We cannot, therefore, discuss a Charter of Patients’ Rights in isolation but in the context of the present health system. This paper will present a critical examination of our health system.

4. First request; “Due to lack of concerns for patients’ rights, site instances (real cases or numbers) where harm/risk was caused by health professionals”.

5. The answer to the request is quite simple and every one knows the answer. There is no way at present in Sri Lanka, that one can site instances where harm/risk was caused by health professionals, simply because there is no Charter of Patients’ Rights mutually agreed upon by healthcare providers, the users and the state.

6. Why then was the request made? In our opinion this request was made to bring the issue of the need for a Charter of Patients Rights before the Forum.

7. A draft charter of patients rights was published in the Daily Mirror in July 2005 as a discussion document. Comments were requested from readers to finalise the draft. • Representatives of the Law and Society Trust (LST) and PMRP met on 30th September 2005 to review the draft and the comments received. Based on the discussion the draft was finalised. • The Charter of Patients Rights and Responsibilities; was published in LST review Vol16, issue 219, January 2006, pp 10-13.

8. The Charter of Patients Rights was presented by PMRP at the Workshop on Patients’ Rights, 9th July 2006 organized by the Organization of Professional Associations Sri Lanka. The participants recommended that the various stake holders should collectively initiate activities to take the Charter forward with a view to adopting and implementing it.

9. Question 2 “Given the Sri Lankan socio-political background what factors could impede the development of a health system that enshrines patients’ rights”?.

10. Human rights violations are not mere accidents, neither are they random in distribution. They are highly predictable and therefore preventable. They are linked to social, economic and political conditions that determine who will suffer abuse and who will be spared. Thus, in the Sri Lankan context it is the social economic and political forces at work that determine the risk of most forms of human rights violation. Denying the right to health is the foremost human rights violation.

11. When we consider right to health, a national health policy will determine who will be denied access to health and who will have access; who will live and who will die. Those who will be most affected are the vulnerable groups including the elderly, children, women and the poor.

12. A National Health Policy (NHP) is an important and essential pre-requisite which gives clear guidelines to politicians, health administrators and planners, the health profession and all others concerned with health and health care related issues within and outside the government. The NHP will also give clear directions for all investment in health.

13. The National Health Policy Sri Lanka, Abridged version, 1992 • Major Directions and Strategies • 2. National Health Policy, 1996 • 3. The Programme to be implemented in the year 2001 by the Ministry & Department of Health to improve the quality of life of the people – the 18 point scheme.

14. According to the document, “Macroeconomics and Health Initiatives, Sri Lanka”, published by WHO, Colombo 2002, Sri Lanka is suffering from the lack of a national health policy. It goes on to state, “Given today’s complexity it is difficult to precisely define what the Sri Lankan Health System is, what it consists of, where it begins and where it ends”.

15. “It is well known that the Government of Sri Lanka spends less on health as a proportion of the GDP. This is a result of political prioritizations taking place with regard to government spending”. (Concept paper prepared by the Ministry of Health for the AHF).

16. Sri Lanka and some other developing countries have regarded health spending by the public sector as pure consumption expenditure and have wanted to minimize it. This is often the perspective of the Ministries of Finance (and of the Central Banks, WB, and IMF). Public health spending is very low and less than two percent of the GDP. This means that most inexpensive and effective health measures cannot be made available to the whole population”

17. Public Health Expenditure as a percentage of GNP 1996-2002 Source: Annual Health Bulletin, Department of Health Services, Sri Lanka, 2002 & 2004.

18. The Sri Lankan Health System was once recommended by WHO as a model to all developing countries. Now WHO refers to Sri Lanka as a country where even the most inexpensive and effective health measures cannot be provided to the whole population.

19. The present macro-economic polices promoted by the World Bank and IMF and followed by Sri Lanka are based on the widespread view that rapid economic growth takes predominance and should occur at any cost, disregarding adverse impacts on the lower income groups. These policies also demand reductions in budgetary allocations for social sectors such as health and education. There is now a wealth of experience globally on the adverse impacts of macroeconomic polices focused primarily on rapid economic growth.

20. In seven out of the 17 districts poverty has increased in a period of about 10 years 1990-91 to 2002. • In seven out of 17 districts almost a third of the population lives below the district poverty line.

21. The depth and severity of poverty have increased in four out of seven provinces (North and East were not surveyed).

22. According to the WHO Poverty is the deadliest disease.

23. Poverty reduction is a priority in Sri Lanka. Health system should play an important role in reducing poverty. Formulating and implementing a National Health Policy based on the concepts of Primary Health Care outlined in Alma Ata in 1978 will be a very good entry point to break the vicious cycle of poverty.

24. There is a wide disparity in the income distribution on Sri Lanka Source: Household Income and Expenditure Survey (HIES) 2002, Department of Census and Statistics, 2002, Sri Lanka.

25. It has been documented that large and increasing income inequalities have a negative effect on health conditions not just for the poorest but for the whole population as the economic divide promotes social segregations, threatens community values and thus creates a culture that generates, rather than prevents, violence.

26. 71 per cent of the Sri Lankan youth are of the opinion that the Sri Lankan society is – “not just”. This percentage increases with increasing education level of the youth. Moreover, as many as 75 per cent of the youth believe that the benefits of development will be confined to “the well to do” and 51 per cent believe that the benefits will be limited to “those with political connection.

27. “Describe the disadvantages of paternalism and its relationship to patient’s rights as seen in the Sri Lankan context”.

28. Kofi Annan, the former Secretary General of the United Nations had stated that paternalism has no relevance to provision of healthcare. He said “It is my aspiration that health will not be seen as a blessing to be wished for but as a human right to be fought for”.

29. The Universal Declaration of Human Rights and the International Covenant an Economic Social and Cultural Right (ICESRs), both of which Sri Lanka has ratified and signed, contain explicit provisions on Right to Health that have influenced International Human Rights Law since the end of the second world war in 1945.

30. By recognizing the Right to Health as a Fundamental Human Right, International Human Rights Law removes Health from the status of a marketable commodity. (WHO)

31. This does not imply that the private health sector should be abolished in Sri Lanka. Private sector should continue to provide services but regulated as in all OECD countries where health is not a marketable commodity. The US is the only exception.

32. We find ourselves at a cross-road. Health can be considered as a commercial product; alternatively it can be considered as a human right. But we cannot take a comfortable middle path and say that health is both a commodity in the market and a human right as well.

33. This is the choice before the Government, the Ministry of Health and the People. What is chosen will decide whether Sri Lanka is a country where the citizens have a right to health and patients have their rights or a country which has consumers with or without purchasing power.

34. “Describe the characteristics of health systems that do not take into consideration patient’s rights”.

35. Health plans are worked out mainly for the purpose of preparing annual budgets. • Financing takes place independent of the impact of programes or efficiency of the system. • Budgeting is undertaken by increasing a certain percentage of the previous year’s budget • Health planners take into account implicit polices when explicitly stated polices are not available. • Such policy guidance is operational at all levels of health planning • Actions are taken based on implicit polices which are not officially stated positions. • Not much research has gone into finding empirical evidence in support of the consequences of such action based on implicit policies.

36. Good data is a pre-requisite for evidence based health policy formulation and planning of health programme. The health system has structures and processes to generate a vast amount of epidemiological information and channeled to the head quarters where it is documented. However, the question that remains to be answered is how useful would all that information be. • Will they say anything about the relevance of the programmes? • Do they say anything about the accessibility of the services? • Do they show how efficient the services are? • Will they indicate how effective the work has been and what real impacts or improvements of health have been achieved in the selected client groups? • If the data gathered routinely do not answer the above questions, may be health planners should find out why such information is collected and for what purpose. • Have the planners caught the wrong end of the stick?

37. Industrial action seems to influence the development and financing of health plans. The aspirations of various sectors of employees and of the end users are two major concerns for health planners. There is a tilt of balance in favour of the employees and very little is offered to the end users – the patient. This is demonstrated by the fact that there is very little capital development and most of the allocations are consumed as recurrent expenditure, a good percentage of which goes to paying salaries and overtime to employees.

38. The previous three slides do not describe a hypothetical scenario. They describe how the Sri Lankan health system functioned until recently as presented in the concept paper prepared for this forum by the Ministry of Health.

39. DRAFT CONSTITUTIONAL PROVISION ON THE RIGHT TO HEALTH • 1. Everyone has the right of access to: • Healthcare facilities; • Essential goods and services of adequate scientific and medical quality including emergency medical treatment irrespective of the citizen’s ability to pay for the same; • Sufficient food and water; • Appropriate social assistance • The proper organization and administration of healthcare and adequate control and treatment of diseases shall be made available by the State through adequate budgetary provision which shall not be reduced for whatever reason; • Provided that, nothing in this article shall prevent an increase in the health share of the budget as and when such a need or demand may arise.

40. Thank you.