COVID-19 exposes India’s weak public healthcare

Asia Health World

Author: Ranjan Ray, Monash University

The number of COVID-19 cases in India is increasing dramatically — the country recently overtook Russia and is now behind only the United States and Brazil in the global rankings. While much of the discussion in India is dominated by the sudden lockdown and ensuing hardship for migrant workers, stories of patients being refused admission to hospitals are shifting attention to the nation’s inadequate public healthcare system.A doctor wearing a protective face shield uses an infrared thermometer to measure the temperature of a child at his mobile health clinic, after his clinic and its adjoining areas were declared a micro-containment zone, after authorities eased lockdown restrictions that were imposed to slow the spread of the coronavirus disease (COVID-19), in Ahmedabad, India, 15 June 15 2020 (Reuters/Amit Dave/File Photo).

A doctor wearing a protective face shield uses an infrared thermometer to measure the temperature of a child at his mobile health clinic, after his clinic and its adjoining areas were declared a micro-containment zone, after authorities eased lockdown restrictions that were imposed to slow the spread of the coronavirus disease (COVID-19), in Ahmedabad, India, 15 June 15 2020 (Reuters/Amit Dave/File Photo).

Most COVID-19 patients in India cannot afford private healthcare and are dependent on the public system. While India’s per capita expenditure on health increased from Rs 621 (US$8.31) in 2009–10 to Rs 1112 (US$14.88) today, this is still only 1.02 per cent of GDP — well below the global average. This is reflected in the country having just 0.53 hospital beds per 1000 people, far less than the United States (2.77), Russia (8.05) or Brazil (2.2). By this metric, India also lags well behind its Asia Pacific peers in China (4.3), Singapore (2.4), Indonesia (1.04), and Vietnam (2.6).

India’s preparedness to tackle COVID-19 is worse than these figures suggest, as proper treatment — at least in more serious cases — requires ICU beds and ventilators. Very few hospitals in India have ICU facilities, and fewer still have ventilators. This may explain why many patients are being refused hospital admission. To add to this dismal picture, the few places that have ICU facilities are concentrated in just seven states, namely Uttar Pradesh, Karnataka, Maharashtra, Tamil Nadu, West Bengal, Telangana and Kerala.

A lack of trained doctors in the public health sector is causing still more problems. India ostensibly achieved the World Health Organization’s recommendation of one doctor for every 1000 citizens in 2018. But this statistic is misleading as many practitioners lack formal qualifications — in rural India, as few as one in five ‘doctors’ are actually qualified to practice medicine.

Mental health is another serious challenge on the rise that India’s public healthcare is unprepared to tackle. The nationwide shutdown disrupted the lives of more than 1.3 billion people, resulting in mass unemployment and high levels of distress among significant sections of the population. Those who hadn’t experienced mental health obstacles prior to the pandemic are now finding it difficult to cope. Mental illness affects at least one in five in India and the number of mental illness cases has increased by 20 per cent since lockdown, according to the Indian Psychiatry Society. Even before COVID-19, India had one of the largest populations suffering from mental illness. The loss of livelihoods and increasing levels of economic hardship, isolation, as well as the rise in domestic abuse amid the pandemic is triggering a new crisis in mental health. Adding to the seriousness, modern psychiatric facilities are only available in the cities.

This dismal state reflects a lack of willingness right across the political spectrum to improve the state of public health in India. Over the past two decades, India recorded one of the highest rates of economic growth globally, yet this performance did not change the low priority given to health. From 2000–17, global healthcare spending grew faster than the global economy — this makes India an outlier with its growth in health spending lagging behind GDP growth. In India, there remains just one government doctor for every 10,189 people, one hospital bed for every 2046 people and one government-run hospital for every 90,343 people.

Unlike the United Kingdom or Australia, India lacks a universal health safety net. This denies protection to India’s economically vulnerable citizens. The over-reliance on the private health sector and lack of basic public health services leaves the country unprepared to deal with a medical emergency. When the pandemic hit, private hospitals lacked the required medical equipment to respond to the emergency and the public hospitals were swamped.

India made a start toward universal healthcare when it launched the PM-JAY scheme in September 2018. The scheme aims to provide free health coverage to the poor under ‘Ayushman Bharat’, the Modi government’s flagship health program. But funding for the scheme (Rs 64 billion or US$856 million) is grossly inadequate, and implementation problems include delayed payments and an unviable rate — especially given that more than half of the services offered under this scheme take place in private hospitals.

If there is anything positive that may still come out of India’s present crisis, it is to put the spotlight on the low priority given to health. In the Asia Pacific region, Singapore’s health care system may serve as a model for India to follow — a government-run system with universal coverage alongside a sizable private healthcare sector. But before that, there must be a major shift in India’s attitude to public health.

Ranjan Ray is Professor in the Department of Economics at Monash University.

This article is part of an EAF special feature series on the novel coronavirus crisis and its impact.