The Covid Call: India cannot afford to neglect healthcare anymore

Rahul Nandan

We are living in extraordinary times. A virus has brought down the world to its knees this year. More than 119 million people worldwide have been infected and over 2.6 million have died (as on March 15, 2021) since the novel coronavirus outbreak started in China’s Wuhan last December and spread to every corner of the globe in no time.

Never in our lives have we spent days on end in home. Cities wore a deserted look as countries imposed nationwide lockdown. Schools and colleges remain shut, an unimaginable number of people are working from home, few are travelling anywhere, hotels are empty and flights and rail services have resumed after months.

We have seen how the Covid-19 pandemic has levelled the gap between the rich and poor nations, exposing gaping holes in their healthcare response to the crisis, leaving them helpless alike.

India has lost over 1,58,725 lives so far (as on March 15, 2021) and now has the second highest number of cases in the world. In a country with over 130 million people and a long ailing public healthcare system, the virus outbreak  has unveiled alarming inadequacies of our healthcare infrastructure – poor public health spending; severe scarcity of beds, ICUs, doctors, nurses and testing labs; shortage of critical medical equipment like ventilator and oxygen cylinder; heavy dependence on imports for medical equipment, testing kits and protective wear, low health insurance penetration; poor disease surveillance; lack of robust health data and rural inaccessibility to healthcare.

The alarming disparities in India’s rural-urban healthcare have been exposed during the pandemic, magnified manifold by the large scale movement of migrant workers back home during the lockdown.

The fact that there has never been a strong political will to take up healthcare on priority has been well established but there has not been a better time than now to rise up and realize how important it is and to start working on it on a mission mode.

India’s public health spend is just a little over 1% of GDP, one of the lowest in the world, according to the National Health Profile 2019. [1] There has been no significant increase in public health expenditure since the past 15 years. In 2004, the government committed to raise public health spending to 2%-3% of GDP over the next five years but did not. The National Health Policy 2017 once again committed to increase the public health expenditure to 2.5% of GDP by 2025 but there has been no such move so far. [2]

The recently released Commitment to Reducing Inequality Index 2020 report by global charity Oxfam revealed that India’s health budget is 4^th lowest in the world and the country spent less than 4% of its budget on health, one third of what the world’s second poorest country Burundi did. The survey ranks India 155^th on the health spending index and has found that just half of its population has access to even the most essential health services. [3]

The abysmally low public health expenditure for decades have adversely affected the quality, reach and provisioning of adequate healthcare services in the country.  India’s healthcare infrastructure remains grossly inadequate and falls short of the minimum WHO requirements. We have a total of 7,13,986 government hospital beds, which amounts to 0.55 beds per 1,000 people as per the National Health Profile 2019 data, out of which just 5%-8% are ICU beds. We have a single doctor for 1,445 people in the country. [4]

The past six months have seen heart breaking incidents of patients running from one hospital to another in search of beds and many eventually dying without it. Stories of hospital beds being denied to patients were reported from large as well as smaller cities.

If a 47-year-old Covid positive man died after being shuttled between five hospitals for two days for lack of a bed in Delhi, a 52-year-old garment trader died in Bengaluru after being turned away by not less than 18 hospitals citing shortage of beds and ICUs. [5] [6] A 61-year-old retired scientist died in Pune in July amid his family’s desperate attempts to find an ICU bed for him in various city hospitals. [7]

Shortage of ventilators and PPE kits had left the frontline health workers struggling amid sharp rise in cases in the months following the lockdown. India had just around 40,000 working ventilators in March, 80% of which were with private hospitals. [8] Doctors and nurses worked tirelessly amid scarcity of quality protective kits, risking their and their family’s lives. The Indian Medical Association on October 2 said that more than 500 doctors died treating Covid-19 patients across the country. [9]

India imports around 80% of its medical devices whether in terms of raw materials (components) or finished products. [10] We continue to import widely used diagnostic tools like MRI and CT scanner, apart from ventilators, other basic devices and tools like stethoscope and glucometer, mostly from China, Europe and the US. The Covid crisis has seen a phenomenal effort by India’s medical device industry in terms of innovation and ramping up production capacities in short time. It’s time to capitalize the government’s Make in India initiative to start making these devices and incentivize local manufacturers.  

Until the third week of March, the country had only 72 government laboratories that could test for Covid-19. [11] However, many more were gradually added in the following months.

Health data collection is an important part of any health system but is often not done systematically in low-income countries and poor data are inadequate for informing health policy. The Covid-19 crisis has been a major revelation about the lack of patient records and health data in India which could have been key to disease surveillance and more efficient response to the pandemic. Less than 5% of medical data from patients is being collected in the country with only 400 of 62,000 hospitals collecting relevant medical information of their patients.[12]

India also needs a major push in research and development in healthcare, particularly pharmaceuticals. It’s spending on overall R&D has been an abysmal 0.6%-0.7% of GDP in the past two decades, way below smaller countries like South Korea and Israel.  [13] Apart from government funding, large scale private investments in R&D are required in India, as it is in most countries. It must take the necessary steps to gradually build a robust R&D ecosystem and reduce dependence on the US and Europe.

The pandemic has aroused wide concern about the non-existent primary healthcare infrastructure in the rural areas where 70% of India’s population lives.

There is a shortfall of primary health centres (PHCs) and community health centres by 22% and 30% across India, with the highest shortfall in West Bengal, Uttar Pradesh, Bihar, Jharkhand, Rajasthan and Madhya Pradesh. [14] At least 60% of PHCs in India have only one doctor while about 5% have none, according to the Economic Survey 2018-19.[15] More than 10% PHCs in Jharkhand and 20% in Chhattisgarh don’t have any doctors. More than 90% PHCs in Gujarat have only one doctor as 80% of PHCs in Kerala and Karnataka, 70% of those in Rajasthan, UP and Bihar.

Our primary health centres lack bare minimum physical infrastructure – enough beds, labour rooms, medical equipment, a computer with internet connection and even regular electricity and water supply.

With an underfunded and overstretched public healthcare system and low insurance penetration, millions have to shell out of pocket money to meet steep healthcare expenses. The WHO’s health financing profile for 2017 shows that close to two-thirds of expenditure on health in India is out of pocket, while the world average is just 18.2%. [16] [17] Only 48 crore people (37.2% of the country’s population) were covered under any health insurance in the year 2017-18. [18] Over 63 million Indians are faced with poverty every year due to health costs alone, according to government estimates. [19] One in four Indians is at risk of dying from non-communicable diseases - cardiovascular conditions, cancer, diabetes and obesity - before they reach the age of 70. [20]

The pandemic has indeed been an eye opener to the harsh reality of India’s chronic state of public healthcare infrastructure and the immediate need to start making big reforms to ensure accessibility, affordability and quality care for all in the future.  Needless to say that India has immense potential in healthcare and we have seen its resilience to fight back to an announced enemy. More than 29.74 million vaccine shots (as on March 15, 2021) have already been administered in India since it rolled out the world’s largest vaccine programme on January 16.

So, what are the key steps India cannot afford not to take anymore for a robust and responsive healthcare system?

1. Considerable increase in health expenditure

First and foremost, considerable increase in allocation to national healthcare expenditure can help in solving key issues related to infrastructure building and strengthening the existing ones. The National Health Policy recommends raising the budgetary allocation – Union and state combined – to 2.5%. It also recommends that states increase health allocation to 8% of their total budgets. India needs a long term plan for the healthcare sector to gradually match the healthcare budgets of its BRICS counterpart nations. 

The increased spending should be used to finance national health mission, improve the quality of primary care, universal health insurance and a robust preventive care.

2. Strengthening primary healthcare

To ensure that a large section of the population in India are able to access quality healthcare at affordable costs it is necessary to strengthen primary healthcare centres with quality infrastructure; enough qualified doctors, nurses and midwives and availability of drugs. A robust and responsive primary care will also decrease burden on the secondary and tertiary level. India can learn from successful models in developing countries such as Thailand, Brazil and Mexico where primary care serves as the anchor of the healthcare delivery along with high levels of integration with other levels of care.

India’s 70% population lives in rural areas which have 25,743 PHCs, 1,58,417 sub centres and 5,624 community health centres
(as of March 31, 2018). [21] These primary care centres should be strengthened and equipped to provide OPD care for common health conditions and medical emergencies; conduct safe childbirth; manage communicable and non-communicable diseases; provide preventive care to women and children; run vaccination and awareness programmes. 

3. Hiring more doctors & nurses; training paramedics in primary care

Immediate steps must be taken to address shortage of doctors, nurses, paramedics and ANMs in the country, particularly in rural areas. There is only one government allopathic doctor for every 10,926 people in India against the WHO recommended doctor-population ratio of 1:1000. [22] There were 41,371 registered allopathic doctors possessing recognized medical qualifications (under MCI Act) and registered with state medical councils in 2018. A total of 8,60,927 auxiliary nurse midwives were serving across the country till 2017.

For a staggering 90 crore people living in India’s rural areas there are only 27,567 doctors at PHCs and 4,074 specialists at CHCs. [23] The distribution of medical personnel across rural and urban areas in highly distorted, with villages facing severe scarcity. Among the major reasons for this is low salaries of doctors and other medical staff apart from poor working and living conditions in rural areas.

Firstly, the government needs to immediately fill all the existing vacant medical posts and create many new ones, particularly in rural areas. The second important step would be to provide certification and training to new categories of paramedical staff focused on primary and preventive care for a shorter period than the typical MBBS, who should then be incentivized to serve in PHCs and CHCs. Chhattisgarh was the first state in the country to have rural medical assistants who underwent a three-year diploma course to cater to the villages and inaccessible tribal population.

4. Universal healthcare insurance

India needs to protect a staggering 60% of its population that is still not covered under any kind of health insurance. There is need to think beyond government health schemes and rope in private sector in a big way – both insurance companies and hospitals – for designing an affordable targeted health scheme for the large middle class and the poor. More than primary care and secondary care, it’s tertiary care that remains beyond reach for most, even middle class families. It’ important to create very thin tertiary care insurance model that covers high cost and low volume conditions (eg. heart diseases and cancer) and is not necessarily comprehensive. Such an insurance scheme is likely to cost little and could be affordable for most except lowest income families for whom the government can pay the premium.  [24]

We have seen how the host of existing government-sponsored health schemes have not been much success in increasing access to quality healthcare.  Low cost of services fixed under such schemes leads to poor quality of treatment and low outcomes. Low cost of healthcare does not assure high quality of care. The existing cost-based model incentivizes doctors to provide more treatments because payment is dependent on the quantity of care. What we need is value-based healthcare where a patient pays according to the quality of care offered not quantity, that focuses more on value for patients than just cost containment.

For private insurers it’s time they expanded themselves from tertiary care to low cost primary care, secondary care preventive care and OPD care.

5. Digital Healthcare Is Future

The health ecosystem across the world and particularly in India is witnessing a paradigm digital shift to ensure accessibility, affordability and quality care in times of Covid-19. We have seen the immense potential of digital technology in data-based epidemiological intelligence in accurate assessment of disease burden, tracking disease activity in real time, in identifying cases and clusters of infection, rapidly trace contacts, monitor travel patterns and enable large scale public messaging.

There is need for large scale digital integration in healthcare systems to boost access and affordability. Technologies like telemedicine, virtual OPDs are facilitating evaluation, diagnosis and treatment of patients. The convenient and user friendly system can also connect rural health centres to big hospitals in cities to facilitate quality patient care, providing a long term solution for India’s fragmented healthcare structure. The way AI has started transforming diagnostics and digital imaging is before us. Still, there is low affinity among medical professionals and centres to adopt digital systems like electronic health record and decision making tools.  A robust single patient health information platform will go a long way in considerably improving healthcare outcomes, disease surveillance and predictability.

ENDS