By Abhay Shukla
A case for a strong public health system: COVID-19 in India has been an unprecedented tragedy and a saga of major mistakes. I will not go into the different aspects of governance, especially related to the second wave. But I will mention one which was quite striking — the Kumbh Mela in Haridwar was advanced by one year. It takes place once every 12 years, and the last one was in 2010. It was advanced by a year in the middle of the pandemic, and at the beginning of the second wave. Around 70 lakh people participated this time at the active encouragement of the government. This led to the huge spread of Covid-19 in northern states, especially in Uttar Pradesh and Bihar.
The pandemic crisis in the North was severe. The kin of many of the victims did not even have means to cremate the dead bodies. I believe that the second wave of Covid-19 was triggered by the Kumbh Mela. It must provoke every thinking person to introspect. Funeral pyres were burning day and night in some of the cities in northern India, which is in stark contrast with places in South, especially Kerala. I think that we need to realise that something different could have been done. According to the official figures, more than 4 lakh people have died due to Covid-19 in India. The actual figures are probably much higher.
Let’s compare four major states of India that have seen the highest numbers of cases and find out why Covid death rate varies in these states with comparable human development scores. Gujarat, Karnataka, Kerala, and Maharashtra have seen large number of Covid-19 cases. The four states at a similar level of per capita income. Despite this, various health outcomes are totally different. It has been mentioned that even in Kerala, there have been some under-reporting of Covid-19 deaths.
Even if we apply the same factor of under-reporting to all the four states, it will not change the proportion. We can safely say that the Covid-19 case fatality rate in Maharashtra is more than four times that in Kerala. This means that if Maharashtra had a similar Covid-19 fatality rate as Kerala, three out of four people who died in Maharashtra would not have died.
Needed: A strong public health system
As I mentioned earlier, these four states have similar per capita GSDP. So, socio-economic differences are not a major factor. We are not comparing incomparables, like Delhi with Bihar, or Goa with Madhya Pradesh. We have four states that have similar per capita incomes. What are the factors responsible for different fatality rates in these states? Let’s look at how many government doctors are there for a lakh population. For Maharashtra has six, for Karnataka and Gujarat 8-9, while Kerala has 15. So, the public health system can be the differentiator.
Share of hospitalisation in public health system is 22% for Maharashtra, 27% for Karnataka, and 31% for Gujarat, while for Kerala it is 38%. Clearly, many more people are accessing public health services in Kerala compared with Maharastra. Per Capita expenditure for health is Rs 1266 in Maharashtra, Rs 1500 in Karnataka, and Rs 1600 in Gujarat. In Kerala, the per capita expenditure is almost 2000. And these are large states. I have not taken states like Delhi and the Goa. In smaller states, per capita expenditures tend to be higher because of other reasons.
The per capita public health expenditures as a proportion of GSDP is 0.6 for Maharashtra, 0.7 for Karnataka and Gujarat. In Kerala, it is around 0.9. So, all these four or five parameters — the level of functionality, the level of resources, and the level of utilization of public health services – determine Covid-19 outcomes. So, across multiple health system indicators, weaker public health systems and a higher degree of privatisation are associated with worse outcomes.
The number of the total hospital beds per thousand population is actually higher in Maharashtra and Karnataka, compared with Kerala. Total hospital beds, including the private sector beds, may be higher in some of these states. So, it’s obviously privatisation which is the problem. It’s not just the issue of availability of beds in general. A large number of beds available in the private sector does not translate into availability of adequate healthcare during an epidemic.
Healthcare is a public good, not a commodity
All this means healthcare must be a public good and not a commodity. We already know this in the health movement and public health circles that public health structures have a vital and irreplaceable role. Unregulated private healthcare leads not only to market failure, but also to market disaster. Therefore, it needs to be regulated. The much-touted health insurance schemes may not be of any benefit. As we saw in the Northern states where the PMJAY was in operation. It failed to benefit people in the time of crisis. In some Southern states, it performed somewhat better. But even in states like Maharashtra, the health insurance schemes failed to serve a large number of patients.
One positive, you know, is the lesson that state governments can act to regulate private healthcare. When it comes to this kind of a situation, the political will to regulate risks which was non-existent actually materialised overnight. The state governments, acted decisively. But many of these actions have been kind of piecemeal and ad hoc, because of the inadequacy of legal instruments. This means more effective legal and operational frameworks are needed for the regulation of private healthcare.
What are the things that could have been done now during the Covid-19 epidemic? Around 15 state governments invoked the National Disaster Management Act. In some cases, the Epidemic Diseases Act was invoked and the government stepped in to regulate rates for Covid treatment in private hospitals. This was reasonably remarkable, given the earlier history. The national human rights commission issued two sets of detailed health rights advisories especially focusing on the observance of the patient’s rights charter.
Rate capping was done by state governments, but the Union government did not take a single step during the entire period to ensure the implementation of the Clinical Establishment Act which applies to 11 states of the country. And not has there been any central initiative regarding the regulation of private hospitals. Whatever has been done was being done by the state governments. This is something we need to take note of.
There was an option of taking over private hospital beds which was done in Kerala where 50% of the beds were taken over. Some of the states did it on some scale, but this option could have been exercised on a larger scale. In the private sector, the whole Remdesivir scare panic was created artificial scarcity to jack up prices of this drug.
Overuse of medicines like steroids also happened in many cases. Diabetic Covid-19 patients were also given high doses of steroids. So, there was no uniform treatment protocol. ICMR adopted some protocols, but those were not actually regulated in the private sector. So, these are many of the things that could have been done and still can be done regarding the private healthcare sector.
PPP model, insurance schemes failed
We need to start looking at the two different ways in which public engagement can take place with the private health sector. But on the one hand, what we have is market-based engagement that is there in most PPPs and health insurance schemes that are kind of optional. Market remains dominant throughout the sector. Even when the patient enters the hospital, there’s no rationalisation of treatment practices.
Admissions control remains in the hands of the private hospital and there’s weak social accountability. This is the kind of engagement that we have seen till now in the case of PPPs and this method is obviously not functioning. During the peak of Covid-19 pandemic, we have seen arrangements like rate capping and temporary takeover of hospital beds, but that needs to move even further towards mandatory involvement. India needs to have the rates regulator, and there has to be free service environment.
There has to be rationalisation of treatment practices in the private sector and the control of admissions has to shift to a public system, rather than leaving it to the private management. And it has to be universal with inclusion and accountability. That needs universal healthcare where there is public regulation of private sector resources. This is the model that we need in Covid and post-Covid situations.
It’s very clear that market-based arrangements have failed. What we need is a public sector that works. I just like to draw your attention to another aspect, which has not been sufficiently highlighted in the Covid-19 situation. Some organisations have done research on the corporatisation and financialisation of healthcare, a huge phenomenon in India, especially in the last few decades.
Five large hospitals have grown by almost 80% in a five-year period in the last decade. In the case of Apollo, Fortis, Narayana, and Max, financialisation accompanied corporatisation with penetration of multinational finance on a large scale, pushing these hospitals to maximize their revenues, pushing doctors to pursue clinical targets, and inflating the prices of healthcare in a major way.
Therefore, many of the top corporate hospital chains in our country like the Fortis, Medanta, and Apollo are now primarily owned or taken over by foreign investors. Foreign investment in the hospital sector in India has increased 100 times between 2001 to 2013. There has been a huge influx of foreign capital in the Indian healthcare sector, which will demand maximisation of profits, which is not good for public health.
So, I’ll sum up by saying that there is a need to shed the profit logic that has dominated the sector in the pre-Covid period. The profit logic must be controlled and we don’t want to return to the old normal. We want the reconstruction of public sector system, not a return to the privatised and commercialised healthcare system. And that is why we must block all moves towards privatisation. The most important lesson from the pandemic is the need to strengthen public health systems.
(Dr Abhay Shukla is the national co-convenor, Jan Swasthya Abhiyan. This article is the edited transcript of his presentation at a webinar organised by Policy Circle.)