Trigger warning: Covid death
People are howling in emergency wards, asking for the doctor to examine their loved ones’ dropping SPO2. The person next to them has been declared dead and it’s been an hour since anyone came to attend them. Meanwhile, a queue of patients stand outside the emergency ward entrance, waiting for beds that are getting emptied by those passing away.
For a government hospital such as AIIMS in Delhi, this is not a sight in a healthcare crisis. Pandemic or not, this is how government hospitals in India treat the poor. The only thing that the pandemic has brought out are the faultlines to the rest of the world and the upper-class Indians who can be seen running around in private hospitals with a similar desperation.
For a Capital city of a 136-crore-peopled country, 33 Delhi’s state government hospitals had only 348 ICU beds in February 2019 – an abysmal number even on a healthy day. Amid the peak of a national healthcare crisis, Delhi has a total of 6,867 ICU beds (including government and private) for Covid patients – all of which were occupied even in November 2020.
These numbers go on to show what healthcare in this country has never been: accessible, available and affordable. Article 21 (right to life) and Directive Principles in our Constitution declare access to healthcare as a fundamental part of governance. But today, as we still bid goodbyes to our closed ones, make condolence calls to friends and turn into hypochondriacs ourselves, how do we navigate our country’s health in the future? Let’s open this can of (non-infectious) worms and see all that is wrong with our medical system.
India’s expenditure on primary health crossed 1% of its GDP only 2009 onward. In 2017, it was 1.28% of the GDP and after a year in the pandemic, in the Budget 2021, public expenditure on healthcare stood at 1.2%. For reference, the average healthcare expenditure of other BRICS countries is 3.6% of their GDP and the USA spends 18% of its GDP. The Centre plans to increase the 1.3% to 2.5% by 2025, “but it’ll be too late by then,” said Dr Ananya Awasthi, Assistant Director, Harvard School of Public Health, India Research Centre at a webinar on right to health in the context of the pandemic.
But where do we spend this money on, even if India’s budget increases to 2.5%? Currently, Dr Awasthi added, out of every Rs 100 spent on a patient in India, only Rs 35 are incurred by the government, the rest Rs 65 are spent out of the patient’s pocket. This high expenditure on healthcare is what has pushed many people below the poverty line in the pandemic year, while pharma firms and hospital chains were drowning in profits.
There was only one hospital bed for every 2,000 people as of December 2020, with states including Jharkhand, Assam, Haryana, Bihar, Gujarat, Odisha, Madhya Pradesh and Manipur having not even that. “There are a few good hospitals in 2-3 towns of Bihar,” said Professor Manoj Kumar Jha, MP (Rajya Sabha), RJD. The rest of the state depends on district hospitals and Primary Health Centres (PHCs), which only have basic OPD and natal care services, and work as centres to run sanitation and health-related programmes. Even if some district hospitals have high-end equipment, they don’t have an equipped medical staff to operate those machines.
Instead of investing on creative innovation and announcing construction of new facilities, the government should first spend on the existing infrastructure. For instance, establishment of 162 oxygen plants was approved in October 2020, out of which only 33 are up, and before the rest can become operational, a plan of new oxygen plants was announced during the peak of the second wave.
Furthermore, investment on public healthcare has to be proportionally allocated in rural as well as urban areas. Over 60% of hospitals and 80% doctors work in urban India, which only caters to 40% of the population. The rest of the 60% population that lives in rural areas depends on far-off district hospitals and inadequate PHCs and CHCs. To add to their plight during Covid, the Centre even took away their chance to get vaccinated, as only those with smartphones and high-speed internet can get jabs.
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But even if the Centre spends on rural hospitals and healthcare centres, most of the medical students in urban colleges aim to set up hi-fi clinics in cities or go abroad. Who wants to work in rural hospitals, asked Dr Awasthi and Dr Bhaswati Bhattacharya, a Master’s in Public Health. They suggest that a mandatory six-month rural internship for medical students can help increase our focus to rural health. The government will still have to spend on stipend, basic infrastructure and security in rural areas for the students.
Another area of healthcare the government needs to spend on is the country’s health talent. As per the Economic Survey of 2019-2020, India has one doctor per 1,456 population and 1.7 nurses per 1,000. There is a need to fill the vacancy of 20 lakh doctors and with the 30,000 medical graduates from 542 colleges who enter the field each year, this gap won’t be easy to fill for another 40 years. Even among these graduates, many leave for practice abroad. Out of those left behind, the majority are from private colleges whose parents paid under the table to get admission, putting a question on their merit.
“Medical education is only unaffordable due to the state and national medical authorities allowing price gouging in universities. If NITI Aayog announces salary caps and tuition caps on these private institutions, then how will the rich able to make money from education,” said Dr Bhattacharya.
What she is also pointing at is the dominance of upper-caste and upper-class doctors in healthcare. Thus, to make healthcare accessible, affordable and available to all, we must make medical education accessible, affordable and available to all. More government colleges with reservation for people from rural areas and marginalised castes should be opened in non-urban areas and private medical colleges should be regulated. As reported by The Week in 2019, as against the medical graduates from general category who leave for practice abroad, over 70% graduates from Dalit or tribal communities from AIIMS stay in India to practice medicine.
Another way to strengthen health talent from rural areas, Dr Bhattacharya suggested, PHCs in villages can organise health camps to train people in basic hygiene, primary healthcare skills to become primary health workers.
Talking about filling the demand-supply gap of doctors in India, Dr Bhattacharya raised another point – the lack of recognition of AYUSH doctors practicing in Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homeopathy. Considered ancient medical systems that treat the human body through natural ingredients, these practices are often seen with scepticism by modern medicine. While most of this negative perception has come after the preposterous claims made by Hindu-smitten leaders Pragya Thakur, Baba Ramdev and Swami Chakrapani, Dr Bhattacharya, an academic in modern medicine as well as alternative medicine, says that the two fields shouldn’t be seen as exclusionary. “There are many well-trained MBBS doctors who also hold a degree in alternative medicine such as Ayurveda and integrate that knowledge in their practice,” she said.
“India is a model country for health freedom in the world. There are many medical systems followed here including Allopathy, Homeopathy, Ayurveda, Naturopathy and so on, and patients should have the right to choose from them. Allowing these doctors to practice in urban and rural areas can also fill the demand gap in our healthcare system, but unfortunately, the Indian Medical Association (IMA) is apprehensive to get doctors from any other medicine system involved. No legal credibility or infrastructure is made available to these systems,” said Dr Bhattacharya.
She contended that the IMA vs AYUSH issue is a larger political issue as the allopathic medicine system is backed by the practice of big pharma companies, while alternative medicine systems recommend a more home-based treatment.
Responding to people’s apprehension over incompetent practitioners who misguide their followers, she said that there are incompetent AYUSH doctors as there are MBBS doctors in modern medicine. Both of them should be made to clear competency exams every 10 years or so (like in the US) before giving them the license to practice.
Wherever the government finds itself incompetent or too lazy to participate, it happily welcomes big corporates with their big bank accounts, turning essential services such as education and healthcare into money-gobbling monsters.
Medical students are inculcated the ethic of making money right at the beginning – where they have to pay lakhs and crores of rupees to get admission, and then get harassed, corrupted and disrespected by the medical system itself, found Dr Bhattacharya when she talked to many students and practitioners during her research. They then open hospitals where a patient has to make a huge deposit even to get admitted in a general ward.
But to deny private hospitals their rightful space in India’s healthcare, said Mr Sameer Wagle, Managing Director, Asian Healthcare Fund, a venture capitalist firm that invests in companies in healthcare, would be unfair as 62% of healthcare is handled by the private sector. He said that by bringing in innovative technology, efficacy and efficiency that a bureaucratic system can’t often afford, the private sector can take up a complementary role in public healthcare.
A successful example of this was brought up by Krishna Devrayalu Lavu, MP (Lok Sabha), YSRCP, from Andhra Pradesh (AP). In 2018, the AP state government partnered with Apollo and launched a programme called the e-Eye Kendram, under which ophthalmology screening, diagnosis and consultation was provided at Community Health Centres. Apollo has also partnered for similar projects with Himachal Pradesh, Uttar Pradesh and Jharkhand, there is more community-based participation that private healthcare firms should be taking up.
Of the many steps that the current government has taken back over its tenure when it comes to healthcare, it did take one step ahead in the form of Ayushman Bharat programme. To make healthcare affordable, the scheme provides health insurance of upto Rs 5 lakh to low-income groups. By December 2020, a total of 1.5 crore hospital admissions had been made under the scheme, involving an expenditure of Rs 17,000 crore (albeit with a few cases of corruption). However, the insurance scheme can only work well with better infrastructure and health talent.
Healthcare has been too longer ignored as a political issue to be mention in political parties’ manifestos or sloganeering during election; health infrastructure is a long-term impact, while parties are interested in focusing more on tempting short-term promises. Now that healthcare has entered the mass consciousness as an issue, the governments must be pressured to think in the direction of national healthcare coverage that is primary health-centred.