The government’s economic response to the COVID-19 pandemic was announced two weeks ago by the finance minister Nirmala Sitharaman in instalments over the course of five days.
A lot was expected from the fifth and the final press conference, since there were expectations that it would finally unveil the much-needed succour for the health sector – crucial to battle a health crisis of global proportions.
In the prologue to the fifth day’s announcements of the health sector stimulus, the finance minister proclaimed, “After all, as I said, if there was this crisis if there was this challenge we also should see the opportunity and be ready to face any future emergency situation that may arise (sic).”
That the minister spent nearly two minutes of her two-hour-long media interaction on healthcare, underscores the gravity this government accords to the public health crisis. A perusal of the announcements she made, however, suggests that the government has clearly missed the opportunity that this crisis offered to strengthen public health systems. Schemes and programmes already in existence or approved earlier were not even properly repackaged and hurriedly presented as new initiatives.
A total of six announcements under two major categories were made – ‘Increase investments in public health’ and ‘Preparing India for any future pandemic’. However, there was nothing novel in the ‘Health Reform and Initiatives’ announced by the minister and her deputy.
Increase investments in public health
The announcement that public expenditure on health will be increased is an expression of intent that has been repeated ad nauseam by successive governments, committees and health policy documents. It has failed to be translated into increased spending and therefore seems merely rhetorical and fails to evoke any confidence.
‘Increase by how much and by when’ is the moot question. Even if the government increases expenditure now, one should remember that the 12th five-year plan (2012-17) proposed to increase the outlay on healthcare to 2.5% of GDP, which was to be achieved by the end of 2017. This did not happen and the government pushed the deadline to 2025! Therefore, unless the increase is above 2.5% of GDP, there is nothing new in the announcement.
Similarly, the proposed ‘ramping of health and wellness centres in rural and urban areas’ is a mere reiteration of a commitment made two years ago. The government announced a plan to convert 1.5 lakh sub-centres (SC), primary health centres (PHC) and urban primary health centres (UPHC) into health and wellness centres (HWC) as a part of the Ayushman Bharat Scheme (ABS) by the end of 2022.
HWCs are envisaged to provide a range of specialised clinical services, more than what a typical SC or a PHC does and as of now 39,922 HWCs are functional. Allocation towards ABS doubled in the 2020-21 Budget while the allocation towards the National Health Mission (NHM) was reduced. So, the ‘ramping up’ of HWCs was already in progress perhaps at the cost of NHM.
But what happens to the remaining SCs, PHCs and CHCs? There are about 1.9 lakh SCs and PHCs in the country, will these wither away while the government ramps up a minuscule fraction of them into HWCs? The Rural Health Statistics (RHS) data reports that as of March 2019, 96% of functioning SCs, 92% of PHCs and 79% CHCs in rural areas did not meet the revised Indian Public Health Standard (IPHS) norms. A few HWCs can be enclaves of good healthcare at best, but these would not alleviate the huge lack of access to comprehensive primary healthcare in India.
And then there remains the question of the specialised workforce that the HWCs would require. There is an 80% shortage of specialist doctors in community health centres (CHCs) in rural areas; where will the specialists for HWCs come from? India has one government allopathic doctor for 11,000 people, which is more than 10 times the World Health Organisation’s recommended ratio. Is the government planning to recruit more clinicians to run these centres or will they simply divert them from the already stretched healthcare system?
Preparing India for any future pandemic
Three out of the four next set of announcements have been borrowed from the World Bank’s ‘COVID-19 Emergency Response and Health Systems Preparedness Project’ document in toto. An agreement for the project was signed between the bank and Centre on April 3, 2020. The agreement delineates how the $1 billion loan provided by the bank is to be utilised in the next four years. It comprises of six components that broadly includes Emergency COVID-19 Response, Strengthening Health Systems to Support Prevention and Preparedness, Strengthening Pandemic Research and the One Health platform, Community Engagement, Monitoring and Evaluation and Contingent Emergency Response.
The plan to open ‘Infectious Disease Hospitals Blocks’ in all districts, as announced in the stimulus package, is also an essential part of the emergency response to the pandemic in the World Bank loan agreement. The agreement talks about designating hospital beds and creating isolation wards “in public health facilities including district hospitals, medical colleges, other civil/general hospitals, and designated infectious disease hospitals.”
The logic behind this verticalisation of services is questionable and runs counter to the philosophy behind the HWCs. The epidemiology of the new coronavirus infection asks for a stronger health system that is able to handle co-morbidities. It is well acknowledged that the risk of mortality due to COVID-19 is considerably higher for patients with cardiovascular, kidney and lung diseases.
In order to handle the double burden of communicable and non-communicable diseases, India needs to adopt a comprehensive strengthening of public health systems. Opening specialised hospitals/blocks could provide temporary respite but it can never be an alternative to a robust health system. Neither the World Bank document nor the government has explained how the additional and specialised health workforce needed to run the proposed hospitals/blocks will be organised.
Forty percent positions of lab technicians are vacant at PHCs and CHCs in the country; how will an infectious disease hospital run without well-trained lab technicians remains yet another unanswered question. The massive shortage of lab technicians is likely to scuttle the finance minister’s next announcement of ‘Strengthening of lab networks and surveillance’. Although the World Bank plans to ‘develop human resources with core competencies in integrated disease surveillance across different states’, it’s unclear if the intent is to recruit new technicians or train some of the existing ones.
The ‘One Health’ initiative announced by Sitharaman is a strategy to fight zoonotic diseases involving the Department of Animal Husbandry and Dairying and NCDC’s Centre for Arboreal and Zoonotic Disease, states and the ICMR. The initiative would need collaborations between people working in human and animal health for the first time in India. However, according to the latest livestock census, India has one veterinarian for 7,900 livestock, twice the recommended ratio. In light of the extreme shortage of both doctors and veterinarians, such a collaboration would most likely be a failure, until large-scale recruitments are done.
The last announcement concerning the National Digital Mission is again not a new initiative. Proposed in the National Health Policy 2017 and endorsed by NITI Aayog’s National Digital Health Blueprint in 2019, it plans to create an integrated health information system for patients. Primarily the goal is to digitise health records and link it to their UID numbers. It proposes to save significant cost and time for a patient. Apart from the data safety concerns, in a country where more than 25% of rural PHCs have no computers and internet coverage is around 40%, digital health seems nothing but a dream.
Whether the components of the stimulus package will lead to improved health conditions during the current pandemic and afterwards could still be a matter of debate. However, what is unambiguous is that there is zero novelty in the stimulus for healthcare; there have been no new initiatives and no fresh infusion of funds as of now.
The whole world is witness to the critical role that the public healthcare system is playing in fighting the COVID-19 pandemic, yet the reality has failed to evoke a concerted response from the Indian government to strengthen its enervated public health system. Repackaging and representation of schemes already in place and not addressing the systemic weaknesses of the public health system is a lost opportunity for universal healthcare.
Pratyush Singh is a doctoral student at the Centre for Social Medicine and Community Health, JNU.