Abhay Shukla
Part I
It is said that good decisions come from experience, although experience often comes from bad decisions. While we debate official decisions taken during the novel coronavirus epidemic in India, we need to use the experience generated in this process as a source of learning, both for the present and the future.
In a two-part series, I focus on the health system aspects of this epidemic, which has produced the most devastating public health emergency in the last century of human history. I distill ten key lessons which might make us somewhat wiser, at least in hindsight. Here are the first five.
1. Public health services, the lifeline of societies, need an upgrade.
Public health services, politically neglected for decades in most Indian states, have proven their irreplaceable value during this crisis. Although despised by the rich and middle classes, they are shouldering the lion’s share of not just preventive and outreach services but also clinical care. Nearly 80%-90% of critical Covid-19 cases are currently being treated by public health services.
States with robust public health systems like Kerala have been far more successful in containing Covid-19, compared to richer states like Maharashtra and Gujarat, which have under-staffed public health systems.
Given this background, now is the time to reinvent and rejuvenate public health services across the country, for which health budgets must be substantially upgraded. India’s measly public health expenditure – at 1.15% of its gross domestic product – must take a quantum leap and be more than doubled to reach the goal of 2.5% set by the National Health Policy 2017, while being further increased to 3%-4% of the GDP in medium term.
For large states like Uttar Pradesh, Bihar, Maharashtra and Gujarat, per capita spending on health is well below national average of Rs 1,765 annually – under Rs 5 per day. All states should upscale their health budgets to reach Rs 3,800 per capita, at 2019 prices – the level attained by Himachal Pradesh and surpassed by smaller states like Goa, Mizoram and Sikkim. This is possible if state governments spend at least 8% of their total budget on health and the Union government share is hiked, bringing this to 50% of total public health spending.
Further, we need to critically re-examine Niti Aayog’s recent proposal to privatise large district hospitals. Imagine if hundreds of district hospitals across the country had been managed by a large number of disconnected, profit-oriented private medical colleges during the epidemic. Rapid response and district-level coordination would have ended in chaos. While planning for public health systems expansion and rejuvenation, proposals for handing over public health assets to private players should now be permanently shelved.
2. Primary healthcare must be given primary importance within health services.
Wherever the Covid-19 epidemic has been well contained, as in Kerala, it has been primarily due to action at the primary health care level. All public health activities required for epidemic control – including testing, early detection of cases and various preventive measures – are being carried out by PHC-level staff, despite often being overburdened due to inadequate staffing in many states.
In this context, we see that the proportion of the Union health budget allocated for the National Health Mission, which is focussed on supporting primary and secondary health care, was reduced to 49% in 2020-21 from 56% in 2018-19, while the share for health insurance schemes, focussed on higher level hospitalisation care, has more than doubled to 9% from 4% in the same period. The declining trend for support to PHC must be reversed and at least 70% of all health budgets must be earmarked for this less glamorous but vitally important frontline level of care.
3. Outreach-based strategies are core to epidemic control, while generalised lockdowns come at high costs.
Most known models of effective control of Covid-19 – South Korea, Kerala, Bhilwara, Sangli and others – are based on rigorous implementation of intensive outreach-based public health measures. These are centred on extensive testing and case identification, isolation and treatment of cases, meticulous contact tracing, home quarantine of contacts, and localised restrictions on movement in some cases.
Although implementing these measures requires certain health system preparedness, there is no substitute for such outreach strategies.
On the other hand, various modelling exercises and expert public health analyses have argued that generalised lockdown-type restrictions imposed on the entire population are of relatively less value for containing transmission, and definitely cannot supplant the set of outreach measures mentioned above. Now, despite huge social and economic costs being exacted by widespread lockdown, the level of political and administrative emphasis given to this generalised restrictive measure is much higher than the attention given to implementing outreach measures.
Looking at the South Korean experience, where the epidemic was largely contained through intensive testing and outreach measures without resorting to general lockdown, it is worth speculating whether the Covid-19 outcome in India might have been qualitatively different if the level of political priority for lockdown versus outreach-based public measures had been reversed.
4. Frontline health workers are critical to protect and care for us.
Daily news tells us that the real heroines and heroes during Covid-19 response have been the frontline health workers – including nurses and doctor, auxiliary nurse midwifes, accredited social health activists, field and hospital health staff. Working at considerable personal risk, often without adequate personal protection, toiling long hours daily, sometimes even subjected to violence, these lakhs of unnamed stars are protecting all of us.
At least in keeping with enlightened self-interest, what we need to ensure is that health workers are provided with the minimum basic requirements to fulfil their duties effectively, now as well as after the epidemic. This requires large-scale regular appointments to ensure that huge understaffing is eliminated and workload of existing staff is rationalised.
In Maharashtra alone, there are estimated over 17,000 vacancies in public health and 11,000 vacancies in medical education, where long-overdue recruitments are expected now. Linked with this, large numbers of contractual health staff working without job security need to be urgently regularised.
An estimated 275,000 contractual staff work and around nine lakh ASHAs work at various levels as part of the National Health Mission alone, often receiving less than one-third the salary of permanent health staff performing similar tasks. Major shortages of personal protective equipment for frontline health staff during the epidemic highlight the need to ensure proper working conditions for all health workers, including living quarters and transport in rural areas. Much more than occasional clapping and thali beating, it is imperative to ensure that those who protect our health and lives can themselves live and work with dignity.
5. Wealthy cities may not be healthy cities, unless urban health systems are created.
The coronavirus epidemic is highly urban focussed – half of the confirmed Covid-19 cases have been reported from 15 predominantly urban districts of India, including Delhi and Mumbai. This epidemic has exposed the vulnerable underbelly of India’s glittering metropolises, where major gaps exist in urban health services and urban planning. Many large urban conglomerations lack comprehensive public health services, especially in suburbs and newly-developed areas.
The National Urban Health Mission launched in 2013 seems stuck in a policy traffic jam – even in the current year, its allocated budget was just Rs 950 crores, barely 1.4% of the Union health budget, amounting to just Rs 2 per urban person per month.
Municipal corporation funds for health are often focussed on existing hospitals, leaving little scope for expansion of services to newer areas or strengthening primary health care. The status of basic urban services – housing, water supply, sanitation and environmental management – is even worse, especially in slums which house at least 30% of urban India.
Hence, the urgent need to launch a massive programme for revamping of urban health services focussed on primary healthcare, along with major upgradation of urban living conditions, especially in “non-notified” slums which must be recognised as integral to the city. Our cities cannot be considered “developed” without developing their health-related systems.
Part II
The novel coronavirus pandemic is the most devastating public health emergency in the last century of human history. It is making countries around the world take a hard look at their health systems.
In India, instead of just planning a “return to normal” once we are past the immediate crisis, it is time to begin a society-wide debate about the need for a paradigm shift in our health system.
In a two-part series, I have attempted to distill ten key lessons for India’s health system. The first part focussed on why it is imperative to recognise the importance of public health services and the need to upgrade them. This part looks at what lessons can be drawn from the epidemic for better engagement of the public and private sectors.
1. Tertiary healthcare schemes must not be given primary importance.
The much-projected Pradhan Mantri Jan Arogya Yojana under Ayushman Bharat was supposed to be a game changer: it allows patients to access private hospitals using a government insurance scheme.
However, one month after National Health Authority offered free Covid-19 testing and treatment in private hospitals under this scheme, only 300-odd patients had used this insurance scheme for Covid-19 treatment. This is a miniscule number, considering that around 10%-15% of Covid-19 cases – around 9,000 to 13,000 patients – might have required hospitalisation until now.
While accepting that private hospitals have a role to play in caring for severely ill Covid-19 patients, the health insurance scheme mode of engaging private providers appears inadequate. No wonder several state governments have decided to requisition private hospitals to supplement public health facilities, as a more dependable arrangement.
It is also notable how certain “medical superstars” from prominent corporate hospitals, who regularly speak on TV programmes championing such schemes, have nothing substantial to offer during this unprecedented health emergency. If we compare the responses of public health services and health insurance schemes in the current epidemic, we might agree that actions speak louder than words, especially during a crisis.
2. The market never regulates healthcare in public interest. States must ensure this.
While the public health system has gone into overdrive to tackle Covid-19, the response from private healthcare providers – responsible for 70% of healthcare provisioning in India – has been muted. There have been reports of massive overcharging of Covid-19 patients, with rates charged in Mumbai by certain private hospitals being up to Rs one lakh per day.
Many private hospitals and clinics have shut down or have been refusing suspected Covid-19 patients. This has highlighted once again that unregulated markets invariably fail in case of healthcare, being unable to allocate this essential service rationally or equitably.
In light of frequent overcharging, it is notable that the Maharashtra government issued an order requiring all private hospitals in the state to cap rates for over 170 medical procedures, based on the charges agreed upon with insurance companies.
Regulation of private hospitals, on the backburner in the state for six years, is now back on the agenda. As we move past the epidemic, it is important that comprehensive regulatory measures, resisted by influential private sector lobbies until now, be systematised and legally institutionalised through implementation of appropriate Clinical Establishments Acts.
Concerns over overcharging, problematic quality of care, and unnecessary procedures by unregulated private hospitals require long term solutions. The Covid-19 crisis can open opportunities for change.
3. Private healthcare providers must fulfill public health obligations, now and in future.
For decades, governments encouraged private healthcare to run as a lucrative “industry” led by profit-maximising corporate hospitals. During the epidemic, it became obvious that commercial private players cannot be left to their whims as they need to fulfil important public health obligations. However, there is hardly any legal framework to ensure that these obligations are routinely ensured.
For example, the Maharashtra government has invoked the archaic Epidemic Diseases Act 1897, among other laws, to ensure that private doctors mandatorily treat Covid-19 patients. State governments in Rajasthan, Madhya Pradesh and Chhattisgarh have taken over private hospitals for Covid-19 care. While requisitioning private hospital beds for Covid-19 care in Maharashtra, officials emphasised that “charitable” private hospitals running on government-subsidised land have public obligations.
Emergency measures, like requisitioning private hospitals highlight the fact that private healthcare providers have public health obligations that should override commercial considerations if required. These include notifying cases of communicable diseases, cooperating for implementing public health measures, observing patients’ rights, and treating poor patients free of charge in case of “charitable” private hospitals. Now is an opportune time to discuss robust frameworks to ensure that these obligations will be observed by private hospitals even in “peacetime”.
4. Public health demands active public involvement. States and people must work in synergy.
Kerala’s Covid-19 control experience demonstrates that outreach-based public health strategies became effective due to proactive social engagement. Panchayat representatives, community volunteers and women’s groups worked with public health staff to implement public health activities. Pending any vaccine or definitive treatment for Covid-19, the main plank of epidemic control currently is various forms of modification in social behaviour that can be ensured only with high-level social awareness and people’s informed participation.
Hence, public health services need to develop platforms for health system-community interface, including active community members, panchayat representatives and civil society groups, from village and primary health centres to district and state levels.
These participatory bodies, relevant during and beyond public health emergencies, must foster “broad spectrum involvement” – not just implementing official programmes, but also promoting awareness campaigns, facilitating entitlements for vulnerable and excluded groups, monitoring delivery of services towards addressing service gaps, and providing inputs for local health planning. Frameworks such as community-based monitoring and planning in Maharashtra, and social audit-based models in several states need to be generalised as core components of public health initiatives, since health programmes initiated from above are most effective when working in tandem with social mobilisation from below.
5. Illness can attack anyone. We need Right to Healthcare to protect everyone.
The Covid-19 epidemic is concentrated in cities and has affected the middle class. Therefore, “public opinion” – often another name for middle class opinion – is currently focussed on health concerns. With the critical role of public health services highlighted and “ailments” of commercialised private healthcare further exposed, this epidemic might change the way society views healthcare. Since Covid-19 affects everyone, it holds potential for building social solidarity around health concerns, traditionally weak in most of India.
This setting is appropriate for taking forward Right to Healthcare, which by definition must be universal. Legal provisions for ensuring this would primarily involve revolve around state governments, while national frameworks must be supportive. Health system transformations required to support the Right to Healthcare would involve developing Universal Health Care systems in various states – based on expanded public health services, massive increase in public health spending, and regulated involvement of private providers – organised to provide free, quality healthcare for everyone.
Assuming action upon the lessons outlined in this two-part series, there is no reason why the Right to Healthcare and Universal Health Care cannot be achieved in most states across India in the next five years. This can become reality, provided political will is generated within governments from above, and is mobilised among wide sections of people from below.
It may soon be an opportune time to launch a massive and sustained social movement, demanding sweeping health system reforms and health rights for all. This should involve diverse sections of society, which together constitute the silent majority – working people in rural and urban areas, socially oppressed sections of the population, groups among the middle class, health workers and professionals – who all have a stake in transforming the health sector.
These 10 lessons could be signposts while developing the movement for a new kind of health system in India, which ensures universal health care based on health rights for all. We owe it to ourselves, and to coming generations of Indians, to draw lessons from this once-in-a-century pandemic, and do our best to act upon hard earned lessons. We may not experience such a turning point again in our lifetimes.
