Decentralisation of delivery of services has not been achieved due to loss of initiative in planning, delivery.
When the virus invaded India, it found a country with serious underlying conditions. Chronic ailments—a flagging economy, rampant inequalities, poor implementation of social welfare schemes, neglect of health and educational infrastructure—had gone untreated for years. The scale and the indiscriminate nature of the pandemic have exposed the severity of these ills. As the virus rages, with thousands of cases being added daily across the country, this unprecedented health crisis has totally ravaged our already torn and tattered health infrastructure. Juxtaposing this pandemic with war, George Packer, in a recent article, rightly states that “[I]nvasion and occupation expose society’s fault lines, exaggerating what goes unnoticed or accepted in peacetime, clarifying essential truths, raising the stench of buried rot”.
Today, India is paying a very heavy price for decades of governmental neglect and equivocation of, and mass public disinterest in health infrastructure. Each year, when the Budget is announced, dismay is expressed at the dwindling budgetary allocation for public health. Thereafter, we retreat into our private lives, absorbed in personal and professional business, leaving public business and governance to others. According to a recent study by Centre for Disease Dynamics, Economics & Policy (India) and Princeton University, for a total population of 1.3 billion, public hospitals have only 713,986 beds, which include 35,699 in ICUs and 17,850 ventilators. Private hospitals offer 1,185,242 beds, 59,262 ICU beds and 29,631 ventilators. These figures are extremely worrying, because as on 18 June 2020, the country registered a total of 366,946 cases, 160,384 active cases and a total death count of 12,237, and we are given to believe that the worst is still to come, as India has yet to reach its peak rate of infection.
1.5 million children below the age of 5 die every year due to lack of healthcare. Crores of people have been dying from treatable infectious diseases such as tuberculosis and malaria. Yet, since Independence, our GDP expenditure on healthcare has remained abysmally low and stagnant. India’s stagnant allocation to the public healthcare budget is reflected in the following sorry figures—0.53 beds available per 1,000 people (as against 0.87 in Bangladesh, 2.11 in Chile, 1.38 in Mexico, 4.34 in China and 8.05 in Russia) and one doctor for every 1,456 people. Clearly, these figures belie the country’s claim to be a welfare state.
Way back in 1943, the Bhore Committee had recommended one bed for every 550 people; in October 1946, the Conference of Provincial Ministers diluted these norms. The pullback today is so great that from spending 4% expenditure of budget on health since 1946, it is now down to about less than 1%. WHO data places India at number 165 out of 186 countries in terms of government expenditure on healthcare.
As we hope for the best and prepare for the worst, hard questions need to be asked as to what went wrong with the lofty assurances of “Health to All by 2000” (Alma Ata Conference, 1978). Under the Constitution, health is a state subject, yet it is the Centre that sets the agenda even on areas within the domain of states, since it is the controller of funds. Different stakeholders, pulling in different directions, have not permitted a clear strategy or long term vision to be developed. Liberalisation of the 1980s and 1990s shifted the focus from government funded healthcare to the private sector and by late 1990, private players accounted for 58% of hospitals, 29% of beds. Today the dominant provider of healthcare is the private sector, having the majority of out-patient/in-patient care, specialists and modern technology. The pullback of the state from public health has been coupled with the emphasis on increasing public private partnerships and the privatisation of health education. The deplorable condition of public health facilities, where they exist, government pullback from primary health centres, the disconnect between primary, secondary health facilities (which falls to the share of the government) and tertiary care (which is primarily with the private sector) has led to a mismatch and incoherence in the integration of different levels of healthcare delivery system.
Attempts to resurrect health reform through schemes such as the National Rural Health Mission, though met with initial success, yet the decentralisation of delivery of services has not been achieved due to a subsequent loss of initiative in planning and delivery. The shift from providing healthcare infrastructure to universal health insurance via the Pradhan Mantri Jan Arogya Yojana (earlier known as the National Health Protection Scheme and which subsumed the Rashtriya Swasthya Bima Yojana) has led to further withdrawal of the state from providing public healthcare.
In the midst of this pandemic we find ourselves in a health crisis of unimaginable proportions. In ignoring health, the basic building block of human development, governments after governments have succumbed to the lure of privatisation. It does not help matters that inadequacies of regulating healthcare education by the Medical Council of India and Dental Council of India have led to a proliferation of private medical colleges without adequate infrastructure and offering medical education for a steep price. Estimates placed the size of the medical education industry to be in thousands of crores annually. This drive has mainly supported private healthcare and makes it well nigh impossible for the public health sector to have access to doctors who perforce have to start at higher salaries than offered by the public hospitals to recover the high cost of their education.
There is no excuse for a hospital to turn away the sick and the diseased, whether from Covid-19 or other ailments. Just as the migrant and economic crisis has had a catastrophic fallout on human lives, inadequate public health infrastructure and poor governance of public hospitals has created an environment where we daily hear horror stories of patients being refused access to hospital beds and dying, literally at the doorstep of hospitals. The poor condition of public facilities utilised by the poor and vulnerable are a reflection of the economic disparities that characterise India and its healthcare. We cannot excuse this situation citing lack of resources, as it is a consistent failure of leadership and vision which has brought the state of our public health and hospitals to what it is.
From 2002 onwards, we knew of the increasing vulnerability to cross border infections such as SARS, MERS, Ebola, Zika, H1N1 and of the need for higher levels of vigilance and preparedness. In July 2008, the “National Disaster Management Guidelines—Management of Biological Disasters, 2008” were drawn up under the Disaster Management Act. As per information in the public domain, these guidelines have not since been updated or reviewed. The present scenario shows that its recommendations have in fact not been implemented, in as much as the shortcomings highlighted in the guidelines still exist. Way back in 2008, these guidelines acknowledged that at the national level, there is no policy on biological disasters, that all components related to public health, namely apex institutions, field epidemiology, surveillance, teaching, training, research, etc., need to be strengthened; that preventive and social medicine departments of medical colleges need to be oriented for public health management; that core capacity needs to be developed for surveillance, border control at ports and airports and quarantine facilities; that each state needs to have a public health institution to collect epidemiological intelligence, provide for outbreak investigations and be capable of managing outbreaks; that there is an urgent need to establish an incident command system in every district, and that is a shortage of medical and paramedical staff and public health specialists, epidemiologists, clinical microbiologists at the district and sub-district levels; that for effective management of biological disasters and prompt diagnosis, virologists and bio-safety laboratories are required; that there are major issues regarding indigenous capability of preparing diagnostic reagents and quality assurance; that there is need for using sophisticated real time PCR methods for rapid diagnosis of biological agents; that there is no stockpile of drugs, important vaccines, PPE or diagnostics for surge capacity; that protection, detection, decontamination equipment are not available with most first responders. The list is endless, and sadly remains just a paper list—with little to show in terms of achievements.
While provisions of the Disaster Management Act of 2005 are being invoked daily to tackle this crisis, questions have to be asked of the outcome and implementation of the annual National and State Disaster Management Plans mandated to be drawn under the Act. The 348-page long Annual National Disaster Management Plan 2019, no doubt like those of the preceding years, drew up an exhaustive framework to tackle “Biological and Public Health Emergencies” (Chapter 7.15). Yet, as the pandemic sweeps across the country, we see little or nothing of its stated objective of “a) Mitigation (prevention and risk reduction), b) Preparedness, c) Response and d) Recovery (immediate restoration and build-back better)”, nor its avowed endeavour of a “paradigm shift from the relief-centric approach of the past to a proactive, holistic and integrated approach for Disaster Risk Reduction (DRR) by way of strengthening disaster preparedness, mitigation, and emergency response”.
On the contrary, despite the exhaustive and detailed National and State Disaster Management Plans prepared each year since 2005 which list short, mid and long terms plans of preparedness in the event of a biological and public health emergency, both the Centre and the states have been caught totally un-prepared and have disintegrated under stress, unable to fulfil the administrative and organizational tasks required to muster resources to provide even the most minimal and basic health services.
With such an exhaustive Biological and Public Health Emergency Framework meant to be in place, there ought not to have been the need to be put the entire country into a two-month-long lockdown, imposed ostensibly to ramp up medical preparedness. As we enter the third week after the lifting of the two-month-long lockdown, the question is—did our administrations waste these two months? It certainly appears to be so. Worse still, and inexcusably so, what has been brought to the fore is that the past 15 years since the coming into force of the National Disaster Management Act, 2005, have been totally squandered.
The Indian State has to ensure health as a focal point of development. Starving the public health sector of funds needs immediate reversal. Healthcare must be defined through co-operative federalism and by enhanced public spending on health alongwith a decentralisation of healthcare to the village level and revamping the processes, procedures for releasing and utilising funds for healthcare in an environment of limited resources. The failure to utilise allocated budgets on account of the procedural wrangles is simply not going to be acceptable.
When presenting the Union Budget 2020-21, the Union Finance Minister, allocating a mere 1.15% of GDP to the health sector, highlighted the government’s vision to create a happy and healthy India. The jury is still out, and may perhaps remain out for a long long time, on when there will be a happy and healthy India.
Adv. Ketaki Goswami practises at the Supreme Court and Delhi High Court. Sr. Adv. Siddharth Luthra has served as Additional Solicitor General (ASG) of India and practises in the Supreme Court and Delhi High Court.