The Covid-19 pandemic is testing the Indian healthcare system like never before, as growing numbers of patients continue to flock to India’s hospitals. While the system struggles to cope with this unprecedented demand, people have been turned away from hospitals, some have died from sheer neglect, and overcrowded healthcare facilities are running perilously short of bed space, oxygen cylinders, essential drugs, intravenous sets, and ventilators. Almost inevitably, mortuaries, crematoria, and burial sites have filled up, and waste ground sites have been commandeered to provide resting places for the newly deceased.
Despite India’s status as a leading global vaccine producer, chronic under-investment in primary healthcare and public health have blunted the nation’s response to the pandemic. To identify the root causes of this problem, you have to look back a few decades. In the run up to independence, the colonial Government of India set up a Health Survey and Development Committee in 1943 to set the priorities for a new health care system in India. But the Bhore Committee’s ambitious recommendations in 1946 for a publicly-financed national health service with universal and comprehensive preventive and curative care have yet to come to fruition. Instead, the combined efforts of successive governments have yet to deliver universal healthcare and an effective public health system.
Indian health is based on free-market principles, as seen in its multiplicity of providers, a profusion of choices, and the dominant influence of the private healthcare sector. India’s mixed healthcare economy includes a resource-starved public sector, with crumbling hospitals and health centres staffed by a disillusioned and underpaid workforce, which coexists with a booming private sector, where every possible treatment is available and where health tourists come from abroad to facilities that at the top end resemble five-star hotels. Whenever financially possible, and sometimes even when not, people concerned about quality of healthcare far prefer the private sector over the public. As a result, out-of-pocket expenditure accounts for as much as 80 per cent of all healthcare spending. This heavy expenditure imposes a significant financial burden and may lead long-term debt, not to mention a depleted income in the shorter term from the loss of daily wages.
Indian healthcare suffers from a lack of regulatory oversight, as well as from a lack of standardisation of treatments. Apart from conventional Western-style “allopathic” health care, there are six competing officially sanctioned forms of healthcare, including Ayurveda, Homeopathy, Siddha and Unani, relying upon conflicting knowledge bases. The latter systems often prevail in rural areas, where it is hard to recruit graduates from mainstream medical colleges. To complicate matters, there are also faith and spiritual healers, purveyors of unproven herbal remedies, and other fringe operators to contend with. Professional standards vary, performance is rarely monitored, and sanctions against poor performers are infrequent and lack teeth. The pharmaceuticals market itself is also unregulated, allowing self-medication with antibiotics and steroids bought without prescription, with no questions asked.
India’s healthcare system requires a major overhaul, and the pandemic may justify much-needed reform. Indian government spending on healthcare has never exceeded 1.8 per cent, resulting in a grossly under-resourced public health infrastructure. Even before the pandemic, the need for a fairer system has been recognised at the highest levels of government. Most recently, in September 2018 the Government of India launched the Ayshuman Bharat programme to help the 500 million Indians at the lowest rungs of the socioeconomic ladder. Under this programme, Health and Welfare Centres will supposedly provide comprehensive primary healthcare to the poor and downtrodden, while the National Health Protection Scheme will improve their access to specialist secondary and tertiary healthcare.
Urban overcrowding, practical difficulties in maintaining lockdowns, religious beliefs that promote vaccine hesitancy, prevalent misinformation, and a mistrust of government policy have all compromised India’s pandemic response. The lull from January to March this year proved particularly deceptive. Official complacence and self-satisfaction, a belief among some doctors that India had achieved “herd immunity”, and a more widespread view that the pandemic had finally come to an end only facilitated a far deadlier second wave. The unrestricted spread of Covid-19 was enabled by officially-sanctioned superspreader events in the form of election rallies, religious festivals, wedding ceremonies, and cricket test matches, where large numbers of people mingled in close proximity, just as in better times. The Holi festival went ahead as planned at the end of March, while the Kumbh Mela, held once every twelve years, was even brought forward by a year, on the advice of astrologers in the know.
Covid-19 has once again exposed disparities in healthcare within India. The urban affluent are generally well catered for in their respective bubbles and have less to fear from the rampages of the virus. On the other hand, the sufferings of the poor have only worsened with the intrusion of Covid-19 into their already very marginal lifestyles. Many Indians are still denied basic healthcare, while a disjointed public health system has prompted uncoordinated action by individual states in a futile attempt to contain the spread of the virus. And if it isn’t bad enough, it appears that the B.1.671, or so-called “Indian” variant, first recognised in October 2020, may prove to be more contagious and more lethal when compared with other Covid-19 variants. While the pandemic has already taught us some lessons, it would seem unfortunate that the pupils are not always willing to learn.
Ashis Banerjee