Watch: Strengthening India's Public Health System Is the Need of the Hour

The response to the COVID-10 emergency was and continues to be steered by India’s public healthcare system, a system that has been sidelined and plagued with chronic underfunding.

Presented in partnership with Oxfam India and A Little Anarky Films.

We are in the midst of a pandemic and playing peekaboo with lockdowns across the country. India has over 3.7 million confirmed COVID-19 cases; it is third behind USA with nearly 6 million and Brazil with 3.9 million cases (as on 2 Sept, 2020).

Earlier this year, the Global Health Security Index, 2019 (which measures a country’s pandemic preparedness) ranked India at 57 out of 195 countries; much lower than the world’s global COVID-19 hotspots China (at 51) and Italy (at 31). The response to this emergency was and continues to be steered by India’s public healthcare system, a system that has been side lined and plagued with long chronic under-funding.

Chronic neglect of the public health system: India’s public investment in healthcare is one of the lowest in the world. India allotted 1.28% of GDP as health budget in Financial Year 2018, as compared to the national target of 2.5%. As a result, there is only one government doctor for every 1445 Indians, much lower than the WHO’s prescribed norm of one doctor for 1000 people. The availability of government beds is abysmally low with only 0.7 beds per 1000 population.

This lack of resources have also put hurdles in India’s COVID response. The Integrated Disease Surveillance Programme (ISDP) which was once considered to be India’s first line of defence against epidemics continues to struggle for manpower and resources. Similar reasons were responsible for poor quality data of Health Management Information System (HMIS), as outlined by Comptroller and Auditor General (CAG) report in 2017.

The legacy of favouring the private sector: While the public sector languished, the private sector grew exponentially over the last few decades. The government has offered exorbitant discounts for land for building private hospitals, along with other subsidies and tax rebates. Immediately before the start of the epidemic, Niti Aayog had proposed that private health should take over government-run district hospitals. Instead of investing in the public healthcare system, the government had entered into partnerships with the private health players.

A substantial private health infrastructure has been created using taxpayers money, yet the private hospitals were reluctant to comply. And the taxpayers themselves have had to pay unreasonably high prices for receiving care. Overcharging and unethical practices by private players to maximise profits has often hit the headlines.

Consider this, the average medical expenditure in private hospitals in rural areas is almost four times that in government hospitals. As per the survey, patients spend Rs 5,606 per hospitalisation in government hospitals as against Rs 23,821 in private units. The difference in cost rises to over seven times in urban centres where the average spend in government hospitals is Rs 7,189 as against Rs 42,540 in private hospitals.

Rising healthcare costs pushes nearly 5.5 crore Indians below the poverty line every year. The poor and vulnerable are often denied treatment by private players. This points towards the urgent need to regulate the private health sector to protect the health and rights of patients in the country.

The need for an umbrella right to health: As India’s health system struggles to respond to the potential scale of the disaster that COVID-19 unleashed, it might be an opportune moment to reflect whether it is time for India to legislate a core minimum responsibility of the state in the form of a right to health. This would be critical to ensure effective systems to avoid similar situations in the future and make communities more resilient during public health emergencies going forward.

The public sector to the rescue: Despite its drawbacks, a crippled public health system equipped with a weak arsenal continues to shoulder the responsibility of blunting the COVID-19 outbreak. On the other hand, the privileged private sector which constitutes nearly 70% of healthcare system has latent role during this crisis. While privatisation of government district hospitals was on the cards a few months back, several state governments have instead moved to temporarily ‘nationalise’ the private health sector to address the COVID-19 crisis. Andhra Pradesh, Rajasthan, Chhattisgarh, Madhya Pradesh and Uttarakhand have ordered the taking over of private hospitals.

Building back better: In March, Prime Minister Narendra Modi announced Rs 15,000 crore for improving the healthcare system. However, most of this money was to be spent on importing safety and PPE equipment, testing kits, ventilators and other such items which were urgently required to combat COVID-19 outbreak. It was not enough or even designed to address the historic gaps in the public healthcare sector. India needs a greater push to build back a better health system as part of its emergency preparedness.

There is no alternative to infusing significant new resources into the public health system. This includes a substantial increase in the public health budget; ramping up human resources and other infrastructure; improvement in governance to ensure quality health care. No amount of strategic purchasing or outsourcing to private actors can replace a robust public health system which is for everyone, but particularly for India’s poor and the lower middle class.

At the same time, the private sector that dominates healthcare in India needs to be regulated to play a greater public function like it is being forced to play at this time of crisis albeit reluctantly. Enhanced transparency, accountability and patients rights are essential in both healthcare sectors to achieve the goal of universal healthcare. It is time for everyone in India to truly enjoy the right to quality healthcare.

This piece was funded by Oxfam India.