Pandemic: Time to Finally Accept Public Health Needs Investment

WHILE the continuously mutating Novel Coronavirus wreaks havoc on lives, India's commitment to spend on healthcare—health research in particular—remains weak. The imbalanced expenditure on different healthcare schemes further weakened India's response to the second wave. Investment in health must rise at least to what government committees and policies recommend, and soon, write ARIF JWADDER and SHASANOWAR H FAKIR. 

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INDIA is among the countries worst hit by the Covid-19 pandemic. The numbers of the infected are staggeringly high, and fatalities escalated exponentially over April and May during the second wave. Disturbing visuals of mass funerals and shallow graves on the banks of the rivers Ganga and Yamuna, news of hospitals overwhelmed and people issuing desperate appeals on social media for medical oxygen and life-saving medicines for the sick drew widespread attention.

Now, new forms of post-Covid-19 complications are emerging, making the treatment process even more fraught. Although generous help poured in from many countries, still it is not proving sufficient to care for all those infected.

A combination of India's slack response to the second wave, the poor condition of the healthcare sector, the deadly new variants of the virus and the slow vaccination process led to the current situation. All India can do is ensure it does not pay such a heavy price in a future wave of Covid-19 or another crisis.

Since independence, Indian governments have set up both world-class medical institutes such as AIIMS and a network of district hospitals, Primary Health Centres and sub-centres. However, these have not sufficed to serve the needs of its nearly 1.4 billion people. As a welfare state, elected governments and the executive must provide medical services to every citizen.

The Directive Principles of State Policy say the state must promote the welfare of people as its primary duty and assist the public during sickness, disability or undeserved want. Just and humane conditions of work and improved nutrition levels with a better standard of living are the route to get there.

The Constitution does not expressly say the right to health is a fundamental right. However, judicial pronouncements have melded it inseparably with other fundamental rights such as the right to life and personal liberty (Article 21).

The Indian public healthcare sector has grown 22% since 2016 (Compounded Annual Growth Rate (CAGR), NITI Aayog), but it strikes cruel contrasts. Well-equipped private healthcare facilities are affordable to only a fraction, while public healthcare facilities for the poor are reeling under neglect. This gap has been widening ever since independence and is in keeping with the disproportionate economic development of Indian society.

The Covid-19 pandemic, especially the second wave, is unique for even the relatively better-off were unable to access healthcare; folks usually accused of ignoring the flawed public health structure. This time, this section was not immune to the devastating consequences of the neglect of public healthcare, since even private health facilities let them down like never before. 

Deaths due to lack of oxygen or medication, to the order of several thousand a day, prove this. From inadequate ventilators to ill-equipped hospitals and under-trained medical staff, especially in rural areas, Indians have been through the worst of public and private healthcare in rural and urban areas.

The underlying reason for this situation is the low expenditure on healthcare. The world's sixth-largest economy has a public health expenditure much lower than the countries dubbed the poorest, at 1.1% of GDP (2020-21).

Also read: Explained: Despite Govt Claims, India's Health Budget Only Around 0.34% of GDP

India ranks 179 among 189 countries in how government budgets prioritise healthcare, the Economic Survey 2020-21 notes. For 2021-22, the Union Ministry of Health and Family Welfare got allocated Rs. 73,932 crore, a 7% growth over 2019-20, of which the Department of Health and Family Welfare accounts for 96% or Rs. 71,269 crore, whereas the Department of Health Research accounts for 4% or Rs. 2,663 crore of the total.

The National Health Policy, 2017, aims to increase expenditure on public health to 2.5% of the GDP by 2025. It is immediately required as India is seriously inadequate in physical infrastructure and human resources in the public health sector. For instance, there is one bed per 1,000 people (High-Level Group on Health Sector, 2019), which is significantly less than the global average of 2.9 beds. The National Health Policy aims to increase the number of beds to two per 1,000 people.

According to the World Health Organization, there should be at least one doctor per 1,000 people and one nurse per 300 people. But in India, as of 2019, there was one doctor per 1,511 people and one nurse per 670 people. A hike in allocations to public healthcare is the only solution.

The government has adopted many policies and schemes to improve healthcare, such as the September 2018 launch of what is considered the world's biggest healthcare program, Ayushman Bharat, an offshoot of the Pradhan Mantri Jan Arogya Yojana (PMJAY). This scheme provides a health cover of Rs. 5 lakhs per family per year in secondary and tertiary hospitals to over 10.74 crore poor and vulnerable families (approximately 50 crore beneficiaries).

This scheme caters to the bottom 40% of the Indian population. The households are included based on deprivation and occupational criteria of the Socio-Economic Caste Census (SECC) 2011. Another objective is to achieve the vision of Universal Health Coverage (UHC). A beneficiary can visit any empanelled public or private hospital in India to avail of cashless treatment.

Due to insurance-based schemes, government hospitals do not get investments in infrastructure and equipment. The High-Level Group on Health Sector (2019) and the Fifteenth Finance Commission observed on Ayushman Bharat that the government's priority should be primary healthcare. Early management and prevention will reduce the need for secondary and tertiary healthcare, a model that succeeded in many countries. 

The PMJAY and other such schemes enable the government to outsource its liability to provide treatment at government hospitals. The cases are shifted to private hospitals—to their benefit, leaving people at their mercy. In a way, such schemes transfer resources from the state exchequer to private players.

Instead of investing in government hospitals, people end up paying substantially out-of-pocket to treat themselves or members of their families.

Also read: Economic Survey | 'High out-of-pocket expenses for health can lead to poverty'

The failure to improve public hospitals has contributed to the loss of faith in them. Their lack of facilities pushes people to move to private hospitals in the hope of getting better treatment.

What is worse, insurance-based schemes and similar policies also benefit the better-off more than the socio-economically deprived.

To be fair, some health insurance is better than none at all. Further, the recent reduction in the infant mortality rate got attributed to the PMJAY. However, there is no balance maintained in fund allocation with other schemes such as the National Health Mission or Pradhan Mantri Swasthya Suraksha Yojana (PMSSY), which involve capital expenditure. 

Such expenditure goes into creating infrastructure—the only permanent solution to the perilous state of the health system. For instance, in 2021-22, PMSSY allocation decreased by 7% (over the previous year), getting only Rs 7,000 crore. Under this scheme, AIIMS-like institutes and select state government hospitals are to be built or upgraded.

On the other hand, a 2019 report of the Fifteenth Finance Commission estimated that the total cost incurred by the Centre and states on the Ayushman Bharat scheme could reach Rs 28,000 crore. Out-of-proportion allocations are of grave concern in an economy such as India's, where only a few can access reliable paid healthcare.

Poor accountability and delays in completion of projects is another factor holding back the healthcare sector. The Comptroller and Auditor General noted that all the new AIIMs overshot their deadline by around five years. Even upgrades of numerous state government hospitals were behind schedule.

India's poor performance in the health sector is also due to the lack of expenditure on health research. In 2021-22, India allocated a meagre Rs. 2,663 crore, or about 4% of the total Ministry of Health and Family Welfare allocation, to the Department of Health Research.

Since Independence, India's health research has not seen any substantial expenditure, and people pay the price for it year after year.

In March 2020, the Standing Committee on Health and Family Welfare noted low allocations to the Department of Health Research and recommended 10% of the budget go into research. The committee recommended raising investment in health research to the world average of 1.72% of GDP within two years.

Between 2015 and 2016, the Indian Council of Medical Research (ICMR) published only 1,685 research papers and was granted three patents against the 45 it filed. Therefore, India needs new research facilities across the country. Without these, the health sector cannot improve, and there is no better time than now to understand this.

(Arif Jwadder is an advocate at the Delhi High Court. He works on RTI and transparency. Shasanowar H Fakir is an assistant professor at the Department of Petroleum Studies, Aligarh Muslim University. The views are personal.)