In December 2019, the news of the spread of COVID-19 in China came into the public domain. In India, there was no perceived severity of the disease nor were there preventive measures taken by the state till March. Since then, we have jumped from a one-day Janata Curfew to four lockdowns, all with no forewarning.
The consequences of the historical neglect of the right to health are most visible in the time of a pandemic, and the worst affected are the poor and marginalised. In this context, post lockdown, a top-down vertical health programme will just be a populist, medicalised measure that will fail to ensure rights of people as patients, workers and citizens.
Vertical health programmes
Vertical programmes of health are standalone disease-specific approaches, with centralised management and means such as staff, funds and transportation specifically earmarked for the diseases.
Vertical programmes have been preferred by donor-driven programmes because of the centralised authority, time-bound intervention in project mode with quantitative deliverables. Newell (1988) has argued that the distinction between vertical and horizontal is a contradiction of power, whereas the horizontal responds to patients’ needs and demand, the vertical suits the requirements of the centralised state or international donor.
Sunil Amrith has argued that in India, the state’s depth of ambition for public health failed to match the provision of infrastructure and resources and the state continued to rely on ‘narrowly targeted, techno-centric programmes assisted by foreign aid’.
India, over the decades, has invested in many vertical programmes like malaria, tuberculosis, vaccine preventable diseases, population control and HIV. These programmes have often received fund allocation at the cost of general health services of the country. They had limited success because of the limited integration with general health services, fragmentation of the health system and decision making being concentrated with a few, and they are formulated based on evidence that are not context specific.
Over the years, health activism has challenged the attempts to turn public health into a techno-centric approach concentrated in the hands of the ‘experts’ and demanded a focus on social determinant of health and right to health. A cursory glance at the five-year plans shows that while the language of social determinants has been in use in government documents, the focus is on insurance models which have adversely affected the poor and impoverished.
Short term measures: Lockdown and other strategies
We are currently following one of the harshest lockdowns which has followed punitive action and policing measures to ensure compliance.
Smith (2004) has argued that when fear of infectious diseases becomes a principal force in public health decision making, serious ethical violations of health rights and distribution of resources are bound to happen. This is clearly visible in the lockdown, which has been marred in controversy because it was unplanned, with limited preparation of the authorities and the people.
Poor health care systems have hampered the health of many including the doctors and hospital staff at the forefront of the fight against the pandemic. The lockdown also exposed the interplay of privilege. In the lockdown a large section of the population remained at home and maintained ‘social’ distancing because of the promise of essential services being delivered at their doorstep. The privilege of ‘social’ distancing was made possible at the cost of poor who could not afford the luxury of it.
The lockdown extension announced on April 30 came with a new set of rules. There was the opening of business and small-scale industries and a renewed set of rules for specific set of establishments that can be open in particular colour coded zones. They also relaxed the rules of travel and transport of goods and interstate travel of people who have/had been stuck in a different state other than their native state.
With the new set of rules in place, there have been special trains that have transported people (mostly migrant labour) stuck in different parts of the country. The states have been given the right to open industrial activity strictly based in green zones based on classification rules of the central government. The Ministry of Health and Family Welfare would share with the states the list of red zones and the states must put in place measures to control the situation. While the states can decide about activities that can be done in green zones, the states cannot however lower the categorisation of hot spots or red zones as set by the central authority. A cursory glance of the directive makes it clear that they are only disciplinarian in nature with relief and recovery limited to provisions of essential items.
The colour-coded geographical approach is thought of as most effective to flatten the curve and curb the spread of the disease. The containment is enforced on the idea of larger public good. The ethical corruption of the containment strategy raises questions on the ethical standing of the state. Measures such as geographical containment plans have been made with the assumption that all the people in a said geographical area have the privileges of livelihoods, social security, housing and water and sanitation facilities which is far from the truth.
Medicalised measures seem to be the only focus in these containment zones with policing the people seen as the most effective way to control them. In many areas there have been news reports that COVID-19 patients have not been dealt with sensitively. Quarantine centres have not communicated properly to people, increasing anxiety and mental health issues. There are hardly any measures to combat the stigma that the people will face because they are either exposed to the diseases or are in containment zones. In unplanned cities these zones coincide with the distal causes of the diseases i.e poverty, hunger and neglect.
Even after 40 days of disciplinarian measures, there is no transparency about what the future holds. Other than appeals for cooperation there has been limited information about action taken, updates and efforts to address public concerns. The directives are not planned and followed up with adjuncts. A prime example is the directive that was issued in hindsight saying migrant workers cannot be doused in disinfectant following a few unfortunate incidents. A planned effort would not have resulted in a direct violation of Article 21 of the right to live with dignity and freedom from exploitation.
The latest of the examples is the directive to allow migrant workers to be sent to their hometowns in special trains. Migrants with no source of income for the last 40 days have been asked to pay to reach their hometowns, where only joblessness and poverty awaits them. The moral and ethical compass of a state that does not respect the dignity and worth of its citizens is hollow and needs to be questioned.
Lack of transparency has opened avenues for rumour mongering that only widens the already existing divides in society about who is responsible for the spread of the diseases. This was seen when the communalisation of the diseases narrative was at its peak, with no efforts to curb it. It is also the reason for the increased social divide among people.
WHO in their statement had mentioned that they no longer will be referring to ‘social distancing’ as it denotes a break from social connections, now the usage will be physical distancing with a focus on social connections. In India, which is already divided on the lines of caste and religion, lack of transparency will only intensify ‘social distancing ‘and create social divide. This is already visible in stigmatisation of patients, health care providers, racial abuses to people from north east and abuse of the Muslim community. In this context, it is needed to reiterate that spread of virus can be stopped by physical distancing but in order to fight this pandemic, social solidarity, transparency and community participation should be the core of these efforts.
Another important point is politicisation of the pandemic, which is visible through the Centre-state divide. There have been attempts to centralise the authority and dictate terms with states. This is visible in the allocation of relief funds to states, there was no transparency over why there was inequitable distribution of the funds.
Another example is the current demarcations of the zones as per colours has to be approved by the centre, while the state can only enforce stricter rules and there is no decentralised method to ensure that context-specific measures are being taken by the states. This will add to the already existing chaos surrounding the diseases, resulting in more harm than good.
Long-term measures: Need for a horizontal approach
The long-terms measures planned can be gaged from the India COVlD-19 Emergency Response and Health system preparedness package. This is a four-year programme with $1 billion from the World Bank’s COVID19 Fast-Track Facility. While the measures to be taken by the state are not there in the public domain, we examine the ‘Preliminary Stakeholder Engagement Plan (Sep) India Covid-19 Emergency Response And Health Systems Preparedness Project (P173836) March 27, 2020’ and the ‘World Bank Document-project Appraisal Document On A Proposed Loan In The Amount Of US$ 1 Billion To India For A India Covid-19 Emergency Response And Health Systems Preparedness Project’. These documents give us a broad understanding of the steps that India will take in the long term to combat infectious diseases especially COVID-19.
The directive issued by the Ministry of Health and Family Welfare in the public domain mentions that the emergency response and preparedness package is a 100% Centrally-funded plan which will be implemented in three phases during the period of January 2020 to March 2024. The package is to ‘support the acceleration and scale up of the GOI response to COVID-19 while serving the purpose of building systems to respond to future disease outbreaks’.
The project has six major components: Emergency COVID-19 Response; Strengthening National and State health Systems to support Prevention and Preparedness; Strengthening Pandemic Research and Multi-sector, National Institutions and Platforms for One Health; Community Engagement and Risk Communication; Implementation Management, Capacity Building, Monitoring and Evaluation and Contingent Emergency Response Component.
The emergency COVID-19 response has funds earmarked for procuring essentials and improving the existing diagnostic facilities by engaging private facilities and increasing capacities of hospitals for isolation wards and providing safety gear to the health care workers. The procuring of essentials and improving diagnostic services is a welcome and much needed step.
We are apprehensive of the private sector appeasement that continues to be the bane of the Indian healthcare system. Amid the pandemic, the engagement of private laboratories for testing has created a lot of controversies. On April 8, the Supreme Court had passed a judgement making tests free in both government and private facilities. This plea was immediately modified to state that only Ayushman Bharat card holders can avail free tests while others will have to pay for the tests. The modification came on the heels of the argument that free testing would lead to people coming out in huge numbers for unwanted testing.
If we recall, the same argument was used to impose user fee during the structural adjustment policy that free service will make people entitled and they will come for unnecessary services. User fees proved to be a barrier for many in getting essential services. That coupled with the deteriorating state of the public health services pushed many to get services in the private sector. Baru and Bisht (2020) have argued that although the state has the power to hold the private sector accountable to play a major role in the provision of health services during an emergency, it has only provided prescriptive measures.
Instead of playing a role in the national effort to curb the crisis the private sector is only seeking support for itself for the decreased footfall of patients. The appeasement of the private sector and inability to trust its citizens as participants in health has been the hallmark of the neoliberal policies.
Another crucial area of engagement in the document is strengthening of the national and state health system, which will be a welcome move. The focus will be on building a network of biosafety level, improving molecular testing for viral diseases in district and sub district laboratories and sample transport mechanism, improving diseases surveillance and strengthening Integrated Disease Surveillance Programme (IDSP) and integration of all health information, improving the community based surveillance through the increased use of Information Communication and Technology (ICT) systems and developing workforce with core competencies to monitor out breaks and improving district level mechanisms for disaster management and last strengthening referral system linkages.
A key component of this is public health workforce development. While it is important to focus on strengthening health systems, the pandemic has made it noticeably clear that the primary health care of the country, both in rural and urban areas is abysmal and requires special focus. A range of writings over the decades has proved the importance of focusing on prevention and quality of care for everybody. We need to trace our steps back to the Bhore committee which spoke about the importance of health care ‘at the doorstep of the individual irrespective of their ability to pay’. We have not been able to achieve this nor will we be able to if combating COVID-19 becomes yet another vertical programme, focused on disease outbreaks without investments in social determinants, especially when intersections of caste, class, religion and gender remain visibly invisible when it comes to planning for health.
Community engagement in the documents remains confined to behavioural changes and the methods to ensure the changes, especially in relation to physical distancing and hygiene practices. The other engagement is participation in research. Behavioural change without the presence of essential physical, environmental, and social resources is bound to be limited in its success. This was clear even in terms of Swachh Bharath Abhiyan, a populist behaviour change programme that was critiqued for its caste-blind approach without ensuring adequate resources or community participation.
Provision of basic services, food security, housing facilities and measures to improve quality of human life are precursors to behaviour change and improvements in health. Kerala’s success in combating COVID-19 is a strong example of the importance of investment in the social determinants of health coupled with an alert public health system and strong political will. This is also a chance to communicate about health in a way which reduces ignorance, discrimination and otherness in the practices observed by the people.
Widening the lens of response
On one hand, the pandemic is about the numbers of infected, deaths and recovered patients, on the other hand it is also about numbers of livelihoods lost, poor urban planning, religious scrutiny and market-driven investments and neglect of the social sector that have resulted in these cases.
In the Indian context, the problem should also be acknowledged in the background of social inequities. Already caste and religion-based discriminations have been noticed in the treatment of COVID-19. The future challenge is to ensure that our health care practices are not discriminatory in nature. Similarly, at the time when transgender people have been among the worst-affected group with loss of livelihood, it came to light in Hyderabad that posters linking them to COVID-19 transmission had appeared in public places. Strict and firm notifications to stop any form of discrimination is the need of the hour.
The rural-urban divide in the condition of healthcare systems in India is visible. At the time when migrants are returning back to their villages, preparedness for quarantine facilities and social integrities in the villages is of prime importance.
If the interventions against COVID-19 are going to be the same as other vertical health programmes, we will miss the chance to redefine our understanding of health beyond the absence of diseases. India continues to have a high dual burden of communicable and non-communicable diseases. We are also one of the countries with the highest number of hunger deaths. The pandemic will only intensify these issues in the long run because of the loss of livelihood and collapse of the economy.
We realise that we are not suggesting a new way of looking at the crisis. Rather we argue that it is time that the state takes the debates around rights seriously so that they are not limited to classroom settings or model community health programmes. The current crisis is a consequence of the neglect of the state as well as the apathy of the people. We strongly assert the need for innovative steps not limited by technological interventions. What we require is political will beyond populist measures, strong steps towards improving the healthcare systems and the most important a responsive community.
At this point the right to health in itself will be a radical step towards consistent and persistent change. The lockdown will end and we will find a way around COVID-19, but this crisis has shown that it is not virus that is the enemy but the idea ‘that some are more equal than others’.
Smitha Sasidharan Nair is Assistant Professor, Centre for Health and Mental Health, School of Social Work, Tata Institute of Social Sciences. Rani Rohini Raman is at the Anveshi Research Centre for Women’s Studies, Hyderabad. Jisha C.J. is a PhD scholar at the Centre for Social Medicine and Community Health, Jawaharlal Nehru University.