As the coronavirus pandemic rages on, all countries are learning that health is critical for economic prosperity. They have come to learn that if we don’t invest in universal health coverage and a robust public health system, we end up paying a heavy price—thousands of lives lost, and millions of dollars lost in economic productivity. Like the rest of the world, Indians are for the first time so singularly focused on healthcare and public health. And everyone suddenly wants to fix healthcare! But can this COVID-19-driven attention translate into longer-term gains for the health system in India?
For decades successive Indian governments have neglected public health and healthcare. Like a broken record, that no one really listens to, we once again cite India’s miserly 1.5 percent GDP expenditure on health. Even the bare minimum recommended health expenditure of 2.5 percent of GDP has not been realised.
We have come to accept countless small and big shortcomings as par for the course—lack of water in slums and villages, insufficient pre-hospital transport systems, two patients on one hospital bed, broken referral systems, vacant health worker positions, high out of pocket expenses for health, lack of personal protection equipment, and so much more. All these shortcomings were obvious before the pandemic. They seem monumental during this crisis.
Strong health systems matter
A big lesson for India, the US and many other countries is that no country can strengthen its health system during a lockdown. Being prepared means having a robust healthcare system with universal health coverage, including primary, secondary and tertiary care.
As part of the Sustainable Development Goals (SDGs), all countries have pledged to deliver universal health coverage (UHC) by 2030. This includes India. But, sadly, nearly 50 percent of the world’s population lacks essential health services.
Data show that India ranks poorly on progress towards health-related SDG goals. For example, the prevalence of underweight children in India is among the highest in the world. TB kills nearly half a million Indians each year, with India leading the world in TB burden. India has more people living in rural areas without access to clean water than any other country.
The above trends are explained by the fact that India has failed to invest in health for decades. This chronic under-investment has left the public health system weak and has allowed the private and informal health sectors to dominate. This means, access to healthcare is not equitable—the rich and the middle class will survive the COVID-19 or any other crisis, but what happens to the millions below the poverty line?
If any good comes out of this crisis, then it will be India waking up to the reality that investing in health is not a luxury. It is a basic need.
The need to think beyond single disease initiatives
Decades of global health experience have revealed the limitations of narrow “vertical” disease-based programs and there is increasing recognition to combine vertical programs with “horizontal” health system strengthening. In fact, UHC is exactly that.
With COVID-19 we risk once again falling into the trap of a narrow vertical disease-specific approach. While the attention on COVID-specific approaches, like the Delhi government's dashboard on COVID-19 bed availability, is a welcome move, the risk with this narrow approach is that there may be unintended harmful consequences. In the case of the COVID-19 bed dashboard, it does not mention how many of these beds are merely allocated to COVID-19 from other essential health services and how much of this is additional, augmented health capacity.
Many government hospitals have a mismatch in bed capacity and patient load. Multiple patients on one bed are a common sight in many Indian hospitals. Now they can no longer do this due to social distancing norms. For many maternity units in public hospitals, this may mean they can only accommodate perhaps half of the clients than before. But there has been little talk of ramping up the number of beds and facilities for maternity and other non-COVID conditions.
Similarly, several helplines have been launched, but only for COVID-19 guidance and care. Many people with non-COVID conditions are struggling because they do not know where to go for care—cancer patients, dialysis, tuberculosis, pregnancy care etc. Blood banks are running dry, and social media is flooded with urgent requests for blood donations.
With the lockdowns easing, there will be massive numbers of people seeking healthcare for not just COVID-19, but a range of non-COVID-19 conditions. A narrow COVID-centric approach will come and haunt us when India has to deal with this ‘big surge’ of pent-up demand for medical care.
COVID-19 as an impetus to improve the quality of health care
According to a 2018 report on the quality of health care services in low and middle-income countries, a majority (60 percent) of deaths are due to poor quality health care services. This implies that these people were able to access health care services but the care was either inadequate or led to harm.
A major healthcare quality issue, of critical relevance during this pandemic, is infection prevention and control. A 2015 study in 40 hospitals across 20 cities showed that there has been an increase in healthcare-associated infections (HAI’s) in India and rates of HAIs are higher than in the US. Infection control is even more important now, because of COVID-19.
Experience in some places has shown that simple methods, like quality improvement, exist to improve healthcare even within resource constraints. A hospital in New Delhi improved handwashing by family members of neonates by engaging staff and caregivers in understanding and redesigning their processes of care. Broader application of quality improvement methods in healthcare will help strengthen the system and ensure that paper guidelines and protocols actually translate into practice and save lives.
The need for a more compassionate and equitable system
History shows us that “blame” has been a standard human response during pandemics. In India, several sections of society have communalised the pandemic. Even medical professionals have not been immune to this and there have been cases of denial of care due to discrimination. This has exposed the need for better medical education and training of professionals to act with compassion and social justice. Healthcare workers should counter stigma and discrimination instead of becoming part of the problem themselves.
The COVID-19 crisis has elevated the importance of digital tools and e-health. There is a growing use of mobile apps, online consultations, e-pharmacies, and other tools. These are all welcome and must be leveraged, but given India’s digital divide, technology transitions can even worsen inequity. India cannot code its way out of the healthcare mess.
Digital technologies also simply cannot replace a functional, robust public healthcare system. How can the Aarogya Setu app magically test for COVID-19 and provide medical care to those who have a severe respiratory disease? How can the Nikshay platform for TB deliver anti-TB medicines to those who desperately need them right now?
The need of the hour is multidisciplinary conversations and initiatives that bring public health expertise and technologists together to create solutions grounded in reality and aspiring to further equity and quality of care. India must also use this crisis to better regulate and govern the large private health sector and make sure it works in the best interests of the people.
For too long, India has allowed the private health sector to grow, with little regulation. The lack of alignment between the public and private sectors has been clearly exposed with COVID-19 testing and treatment in India. The cost of COVID-19 testing in the private sector is unaffordable to many. Private hospitals have been reluctant or unable to deal with patients with COVID-19, resulting in a huge crisis in the management of COVID and non-Covid19 patients in the country.
India’s health system strengthening efforts can no longer afford to trudge along at its previous glacial pace. The country needs all hands on deck during and after this crisis—both public and private sectors must work together and deliver universal health coverage for all citizens. The onus of governance always rests with the government, which needs to set standards, invest resources, ensure quality, and strategically purchase services from the private sector, as needed.
We should channelise this unprecedented attention on healthcare and direct the energy towards developing a stronger, sustainable, reliable health system for India.
-Sonali Vaid is a physician and public health specialist with the Medical Support Group in India. Madhukar Pai is a physician & epidemiologist, and a professor at McGill University, Montreal, Canada. The views expressed are personal
First Published: Jun 13, 2020 10:39 AM IST
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