COVID-19 Is the Fine Line Between Public Health and Healthcare

Testing and healthcare for symptomatic patients are inaccurately not being considered under the domain of public health.

In the absence of treatment, testing has become one of the pivotal elements of the COVID-19 containment strategy.

In India, the Indian Council of Medical Research (ICMR) has been given the role of designing and managing the lab testing strategy for COVID-19. While a network of public labs is conducting tests free of cost for individuals, the government’s capacity to test is inadequate for the current situation. Therefore, the ICMR has allowed selected private labs to test for COVID-19 at a price cap of Rs 4,500.

The role of private labs and the costs of testing has been a contentious issue since the inception of the outbreak. The Supreme Court recently considered the problem of payment for COVID-19 testing in a Public Interest Litigation before it. On April 8, the court ordered that:

“The tests relating to COVID-19 whether in approved Government Laboratories or approved private Laboratories shall be free of cost. ”

This raised concerns about the viability of the order, including questions about whether private labs would be willing to absorb the costs for performing COVID-19 tests or if the government would pay for these tests.

Curiously, by 13 April, the court passed another order with a clarification that free testing for COVID-19 shall only be available to persons eligible under the Ayushman Bharat scheme and any other category of economically weaker sections as notified by the government. Private labs have now been allowed to charge the payment of Rs 4500 for testing for COVID-19.

The fallacy behind the ‘those who can afford’ argument

While clarifying its order on testing, the court observed that it had meant free tests for economically weaker sections of the society and not those who could afford its treatment.

This is not the correct approach in the face of a public health emergency. To understand this argument, we need to discern what constitutes health policy and the role of the government in it.

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There are two facets of ‘health’ in public policy. These are public health and healthcare. Sometimes, these terms are used interchangeably in health policy. However, there is a fundamental difference in their meaning from an economic perspective. Kelkar and Shah (2019) describe public health as population scale initiatives that address externalities and provide public goods. These are usually preventive interventions, like vaccination and sanitation.

Healthcare consists of transactional services provided through doctors to individuals. There is a case for government intervention in both these components of health policy. However, the government is solely responsible for public health function as there is no market to provide it.

Public health interventions do not have immediate political gains. For example, cleaning the air is a complex problem requiring considerable effort. However, the gains of clean air are taken as granted by the electorate. Public health interventions, therefore, get priority at an advanced stage of neglect when society can observe the ill-effects of the problem.

On the other hand, healthcare is alluring in the context of political gains. For instance, the announcement of a publicly funded health insurance scheme provides better political gains even when most public hospitals provide subsidised services anyway.

What kind of problem is COVID-19?

The coronavirus outbreak in India has unearthed gaping holes in our lack of thinking about health policy. The pandemic is a public health concern, even when it contains elements of healthcare. It is not a problem which can be solved by individuals going to their preferred healthcare providers and seeking treatment. There are various peculiar elements of the pandemic:

  1. It is highly contagious;
  2. It has no known treatment;
  3. It is idiosyncratic in the presentation of symptoms amongst people

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Prevention, contact tracing, quarantine and lockdown are traditional public health measures being undertaken by the government to control the pandemic. However, testing and healthcare for symptomatic patients are inaccurately not being considered to be falling in the domain of public health, as seen by the government policies and the clarification order of the Supreme Court.

The risk of considering COVID-19 as a healthcare problem

Historically, the Indian government has not been able to provide reasonable quality of healthcare services to its masses by itself. We adopted a healthcare system designed by the Bhore committee consisting of a three-tier system of public hospitals at the time of independence. This healthcare system is paid for and run by the government from the preventive level to the super-speciality level.

However, government healthcare is not the preferred service by a majority of the population. As a result, the poorest among the Indian population have been given a limited form of a safety net through health financing where the patients get to choose between certain public and private hospitals while being under government-funded health insurance schemes (RSBY, Ayushman Bharat and state schemes, starting 1997).

For the rest of the population, healthcare services available in an unregulated private market have been the only viable alternative. Persons are expected to navigate this non-transparent market with information asymmetry all by themselves. This is acceptable because the person seeking healthcare does not usually harm his or her neighbours and communities while making bad decisions for themselves regarding healthcare.

It is not so for COVID-19. These bad decisions could include, drinking cow urine to treat COVID-19, using diets to prevent COVID-19 or visiting quacks instead of getting testing and treated.

The current government policy of pay-for-tests and the Supreme Court’s endorsement of it has taken COVID-19 related health functions out of public health problems and put it squarely into the realm of healthcare problems. This is an undesirable step in the management of COVID-19.

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This is because while a public health differentiation allows the government, to a limited extent, to suspend the consent of an individual, it would be not possible to do so under a healthcare approach towards the COVID-19 pandemic. This puts the containment strategy at risk as many people who traditionally do not fall under the economically weaker sections of society would be forced to make the decision on whether they can afford to test for COVID-19.

Given that containment of the disease can only be strategised through vigorous testing, this policy needs to be urgently revisited. Government reimbursement to private labs for testing is a viable solution to the problem.

Harleen Kaur is a research fellow in health policy at the National Institute of Public Finance and Policy.