“A Four Week Online Certificate Training Course on Healthcare & Gender Equity: Emerging Dimensions, Policies, Impact & Way Forward was organised by the Gender Impact Studies Center (GISC), at the IMPRI Impact and Policy Research Institute, New Delhi and Center for Ethics (CFE), Yenepoya (Deemed to be University), Mangalore from August 28th, 2023 to August 31st, 2023. Inaugurating the session Fiza Mahajan, a visiting researcher at IMPRI, welcomed the speakers and participants to the program with an introduction to the eminent panellists.
Our first speaker for Day 4, Dr. Amar Jesani, Independent Researcher and Teacher (Bioethics and Public Health); Editor, Indian Journal of Medical Ethics delivered an instructive session on the intersection of Gender, Health, and Human Rights. In his comprehensive presentation, he began by providing an extensive overview of the topics to be covered, which encompassed discussions on healthcare inequalities and their associated debates, extending to various other significant subjects.
Inequalities in Healthcare
The focal point of the conversation on healthcare and human rights was the “inverse care law,” which asserts that the supply of medical care is inversely related to the level of need. Paradoxically, those who require medical care the most often receive the least attention and support. A predominant reason for this is the substantial influence of market forces in determining healthcare provision. Furthermore, healthcare is sometimes perceived as a tool to perpetuate meritocracy, a concept defined as a pretence constructed to justify an unjust distribution of societal advantages.
Critics of this perspective advocate for alternative philosophies, including Egalitarianism, Sufficientism, and Prioritarianism. Egalitarianism seeks to diminish existing disparities and inequities in healthcare access. Sufficientism argues for a baseline of essential facilities that everyone should have access to, beyond which they are subject to the vagaries of market forces. However, the complex question of what constitutes this minimum and who should decide it arises.
Prioritarianism urges a focus on those in the most dire circumstances. These various philosophies collectively contribute to the notion of Universalism, which champions the goal of providing universal access to healthcare services to all, regardless of their financial capacity, thereby eliminating economic disparities from healthcare access.
Human Rights and Healthcare Systems
Dr. Amar stressed the significance of the Universal Declaration of Human Rights, adopted in 1948, as the foundational document for all discussions concerning human rights. The declaration underscores the universality, indivisibility, and non-negotiability of human rights. Social and Political Rights assert that individuals should not be deprived of services on social and political grounds, although it does not guarantee their actual accessibility. Since 1948, there has been substantial development in these rights, with widespread recognition of the significance of these human rights.
It is imperative to understand that, when advocating for basic civil and political rights, addressing the socio-economic dimension is equally vital. Access to conditions conducive to good health and overall well-being is pivotal. The United Nations’ general comment on Article 14 of the International Covenant on Economic, Social, and Cultural Rights underscores the right to the highest attainable standard of health, emphasising several key aspects including service availability, accessibility, acceptability, quality, and the prevention of discrimination in healthcare service delivery. Importantly, it is the state’s responsibility to respect, protect, and fulfil these rights.
Historical Development of Healthcare Systems
The evolution of universal healthcare service systems is rooted in the recognition that most primary determinants of health and well-being are influenced by social and economic factors. Dr. Jesani referenced Rudolf Virchow’s assertion that “Medicine is a social science, and politics is medicine on a grand scale.” This profound observation was particularly embraced by developed nations that had colonised many third-world countries. Utilising their resources, they significantly improved living standards by investing in nutritional food, sanitation, safe drinking water, and early disease eradication, thereby outpacing other countries in healthcare progress.
The latter part of the 19th century saw the development of scientific medicine, the establishment of hospitals as dedicated treatment facilities, and the emergence of nursing as a recognized profession. The development of universal healthcare systems was catalysed by various factors, including the recognition of the market’s inadequacy in addressing access to medical care, where patients had little influence in medical transactions.
Additionally, the realisation of the interconnectedness of poverty, ill health, and private costs revealed that medical care, initially considered a private and merit-based good, had significant societal implications. By keeping citizens healthy, a state not only benefited from a more productive labour force but also curtailed the cycle of poverty.
The post-World War II era ushered in a sense of solidarity among people, as the poor had made significant sacrifices during the war, and the affluent felt indebted to them. This sentiment gave rise to the principle of solidarity, where the wealthy contribute more than the less fortunate, creating a cross-subsidy system that bolsters universal access to healthcare services.
Critiques of Developed Healthcare Systems
A few decades after World War II, it became apparent that achieving formal equality was insufficient in ensuring healthcare access for all. Reports indicated that, despite the availability of healthcare services, social determinants played a pivotal role in perpetuating the marginalisation of the poor and underprivileged. Additionally, it was revealed that healthcare systems themselves harboured biases, including those based on gender, caste, class, and race.
In the 1960s and 70s, when the women’s rights movement gained considerable momentum, it illuminated the inadequacies of the Universal Healthcare System. There was a growing understanding that building a universally accessible healthcare system could not be accomplished without addressing existing inequities and the social determinants that perpetuated them.
The prevailing strategy of establishing a universal healthcare system should not only emphasise inclusivity but also prioritise those who face discrimination and exhibit sensitivity to the most marginalised segments of society. While Universal Health Coverage advocates for equity, it is important to recognize that certain groups in society have higher health needs and lower financial capabilities than others, underscoring the need for a concept known as “progressive universalism.” This approach places the needs of vulnerable groups, particularly women and children, at the forefront.
Achieving this goal involves a stronger emphasis on public financing, the utilisation of progressive taxation systems, regulation of the private healthcare sector, including both control and price regulation, and efforts to provide social protection to individuals living below the poverty line. It is essential to pay attention to the political and social determinants that impact healthcare access, such as education, access to clean water, nutrition, and more, which affect the ability of vulnerable and marginalised groups to access healthcare facilities and services.
Gender-affirmative healthcare is tailored to the needs of transgender individuals and those who do not identify with the gender assigned to them at birth. There is an ongoing debate regarding the necessity of providing medical and financial support for gender-affirming surgeries. It is crucial to understand that this is not an ailment that can be “cured” in the traditional sense, as it is neither a physical illness nor a mental health issue.
The rationale for the healthcare system’s involvement in providing financial and other forms of support for gender-affirmation procedures is rooted in the recognition of individuals’ right to live authentically and in alignment with their self-identified gender. This right should be considered a duty of the healthcare system. Moreover, individuals have the right to be genuine and true to themselves. These philosophical and ethical justifications underpin the need for the healthcare system to intervene and fulfil the rights of transgender individuals, advocating for their authenticity and well-being.
In conclusion, Dr. Amar Jesani’s session on Gender, Health, and Human Rights offered a profound exploration of the intricate interplay between healthcare, human rights, and societal inequalities. It shed light on the challenges posed by the inverse care law and the importance of philosophical frameworks like Egalitarianism, Sufficientism, and Prioritarianism in striving for equitable healthcare access. Moreover, the discussion emphasised the universal nature of human rights and the need to bridge the gap between civil and political rights and socio-economic aspects to ensure comprehensive well-being.
The historical evolution of healthcare systems and the critique of developed healthcare models highlighted the importance of addressing social determinants and biases. Dr. Jesani’s call for required changes underscored the significance of progressive universalism, public financing, and an inclusive approach that prioritises the most marginalised segments of society. The session also underscored the necessity of recognizing and supporting gender-affirmative healthcare as a fundamental aspect of human rights, rooted in individuals’ rights to authenticity and self-identification. Overall, this session serves as a vital catalyst for reimagining and reforming healthcare systems to achieve greater equity and inclusivity in the realm of human rights and health.
Acknowledgement: Aasthaba Jadeja is a research intern at IMPRI.
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