If India had invested three per cent of GDP on health over the last 30 years, we would have been in a much better position to face the Covid-19 pandemic
After the Second World War, the war-torn but victorious Britain decided to build a system of Universal Health Coverage (UHC). The country had suffered heavily in the war and realized the value of medical care and public health to save lives and protect health during the war years. The war killed and maimed hundreds of thousands of people but the medical professionals had helped many more to survive and get back to work. Disease, disability, and sickness were rampant in post-war Britain and hence the nation decided to invest precious resources of post-war era in developing a national health system - the famed National Health Service (NHS) - to provide universal health coverage.
India has also been a combatant in the world war against Covid-19. As the second wave recedes, 400,000 people have died and more than three crore were affected by official count. A recent national sero-survey showed that 67 per cent of the population was infected and have antibodies. Those who suffered Covid disease may show delayed effects - the so-called long-Covid. The Indian economy too suffered a major setback. A large number of people in the formal and informal sectors lost their jobs and maybe in dire economics traits. While governments are providing relief, hardship continues for many families.
During the first, and more so in the second wave, Indian citizens and media recognized the importance of strengthening public health, expanding medical infrastructure, and ensuring efficient delivery of services. Several parts of the country ran out of beds, oxygen, vital medications, and medical and public health staff were grossly overworked. The lack of anticipation and preparation reflected the weakness of our public health system which did not pick up the early signals of virus mutation, high infectivity, and rapid spread. As India has invested only around one per cent of GDP in health for many years, public health infrastructure in India is very weak and inadequate even in normal non-pandemic times. With the pandemic, it was overwhelmed in no time -in spite of building temporary hospitals. Despite stopping almost all other health service delivery and dedicating available staff and beds to Covid, it was extremely difficult to get assured of a bed and early admission to a well-equipped hospital, during April-May, in many cities. If India had invested three per cent of GDP as government funding for health, over the last 30 years, we would have been in a much better position to face this pandemic. Many lives could have been saved if our public health capacity was thrice the current size. If our public health systems were stronger, transmission could have been contained more effectively, limiting the number of patients who needed hospitalization.
Now, as the second wave is ending what can the new young and dynamic health minister Mansukh Mandavia do to ensure that the people of India never have to face such a tragic situation in the future? He has to work with the Finance Minister and the Prime Minister to rapidly increase the budget for health department over next 2-5 years. He also has to work with State governments to prod them to increase their health budgets so that the total spend in India on health from the public sector goes to three per cent of GDP. The priority should be to expand primary care substantially and ensure secondary care to all, at little or no cost.
An unspoken dimension of the Covid-19 pandemic is the huge financial cost borne by citizens who had to go to private hospitals. Anecdotal stories are horrendous - in many cities, private sector ICUs charged ? 1 lakh per day and many Covid patients needed 10-15 days in ICU including the use of ventilators. Even without any sophisticated treatment, many hospitals billed? 20-40,000 per day by adding up a variety of charges and jacking up prices. A very small proportion of Indians can afford these kinds of charges, as they do not have any insurance. In many States, the PMJAY scheme did not provide coverage for Covid care. Many private insurance schemesalso did not provide cashless service. Hence many people suffered great financial hardship in the covid pandemic. Many families lost their life savings or are in deep debt due to Covid treatment costs. This would not have happened if we had universal health coverage. PMJAY is a good initiative to move us on the road to UHC, but it has still many limitations. It does not cover out-patient care and cost of medicine. It is disconnected from primary care. The lack of well-equippedhigh-quality hospitals in many tier-2 and tier-3 cities hampers accreditation by PMJAY.
Coming out of the shock of the second wave, India’s politicians and the public should be ready to invest in an efficient and well-resourced health system that will protect against such health shocks in the future. If as a nation we decide to give ourselves UHC, via our own tax money, it is quite possible given India’s rapid economic growth in recent years. The Central government can provide the framework by extending the reach, coverage, depth, quality, and cost protection offered by the two components of Ayushmann Bharat programme. Both Central and state governments should increase their funding for health and join efforts to create a single-payer system. Segments of the population that are not presently covered by government programmes, because of higher incomes, should be encouraged to join the pool through income-graded premiums till a truly universal programme emerges. Such premiums will work out to be much cheaper than the current private sector insurance premiums.
We need to ensure that a sick person never has to pay the medical bills when he is sick. Citizens pay direct and indirect taxes, which entitles them to essential health services. The government has to be the guarantor of health service delivery, even if it is not the sole provider. The additional two per cent of GDP, provided via UHC mandate, will need to go first to expand the government infrastructure at primary and secondary levels. As per need and availability, private providers may be contracted at a pre-determined bulk discounted price for medical care. A strong public sector will not only ensure greater equity at all levels of care but also, with good governance, set cost and quality standards for the private sector to match.
We also have to substantially strengthen the public health and preventive care system. This can be done via new national and state-level public health cadres. Strong public health will also reduce the need for curative care hence decreasing the cost of UHC. Such a UHC system will not only improve the health of the nation but increase the productivity of the people. It will also create jobs for women and young men in the expanded architecture of public health and health care. So UHC is not only a health measure it is an overall economic and welfare measure.The Indian people desire it and they deserve it. Post pandemic is the right time for such bold measures which Prime Minister Narendra Modi is known for.
(Dr. Dileep Mavalankaris Director, Indian Institute of Public Health, Gandhinagar and Dr.K. Srinath Reddy, President, Public Health Foundation of India. The views expressed are personal.)
