India should take this as a chance to overhaul its healthcare sector.
New Delhi: As the world battles coronavirus and with the death toll continuing to rise and threatening to touch 28,000, the spotlight has been on the health systems around the world. Italy—which has emerged as the epicentre of the crisis with the single highest death toll at over 9,000—has posed challenges even for an advanced health system. Northern Italy, where the outbreak has been most acute, has emerged as a warning about what can happen even in a region that is considered to have one of the most proficient public health care systems in the world.
Covid-19, a novel coronavirus, which emerged in China in November 2019 and has since spread around the world, is testing healthcare systems. In fact, health systems are now stretched to the limit. Till now, between 4% and 5% of infected patients are likely to require hospitalisation, of which 30% are most likely to need intensive care, including invasive mechanical ventilation.
And as country after country struggle to address the growing number of patients, it is clear that policymakers need to address the inherent anomalies in different, in fact opposite systems.
But examples of Italy, the United States and India seem to suggest that healthcare facilities and apparatus need overhaul and a complete fresh perspective.
INDIA VS ITALY & USA
Before we come to India, let us first understand why did the US and Italy, both developed countries, with much higher per capita income and per capita spends on healthcare, end up having such an acute crisis to deal with coronavirus patients. Of course dealing with a pandemic is no easy task as countries with superior health apparatuses have realised, after paying a very high price.
Most relevant in trying to understand a Government’s response to deal with Covid-19 is to clearly assess the health system surge capacity.
This is the ability of a healthcare system to treat patients at times of a large-scale surge in demand for services, and decide on the next course of treatment (triage in medical terms). Just like in Covid-19 patients, a decision is taken about which patient needs ICU facility and those who need ventilators.
ITALY: PUBLIC HEALTH MODEL
Italy has a public health system, where patients are treated almost at no charge (or very nominal). Of course, there is a waiting period and those patients who choose not to wait can always opt for the private sector. Italian private hospitals and doctors are also much cheaper than their European counterparts. Essentially, Italians pay much less for healthcare than any other European country. The public healthcare system is funded by higher tax spends—roughly 50%.
US: CAPITALIST MODEL
Now contrast this with the US—the pinnacle of capitalism—where hospitals are run like any other private enterprise, that is, they are expected to make a return on investment for promoters. And like any other loss-making business proposition, owners exit the healthcare facility if they don’t find their investment lucrative enough. Add to this the fact that all 50 US states will have to deal with health issues at their level, and very little is expected at the Federal level. (This is the difference between India and US where although health is a state subject, the Centre continues to have a significant/parallel strategy at the national level.) Even as the US continues to struggle for an adequate number of N95 masks, President Donald Trump’s advice to the states gives an insight into exactly how the system works. Trump told the states that they needed to manage on their own and should not expect the Federal government to help out right now.
As per the OECD Health Data 2017, in Canada, the per capita health expenditure is about US$4,753, while in the UK it is US$4,123. While the US is known for its best quality healthcare, it comes at an exorbitant price. According to the National Health Expenditures Account 2016, the total health expenditure per capita in the US is US$10,348. In fact, one may wonder why healthcare prices are so much higher in the US than anywhere else in the world. It has nothing to do with Americans being any more sick that their European counterparts! On the contrary, on an average Americans spend less time at the doctors than their Canadian or German counterparts. Per capita healthcare expenditure is higher in US largely because doctors overcharge, conduct excessive tests and are paid far better than other parts of the world. Most of these expenses are taken care of by insurance companies and hence the average American doesn’t care (or doesn’t know!) about the overcharging that’s the norm in the American healthcare system. Those not covered in the insurance net are of course very badly hit by this system and are unable to pay the high medical bills.
The reason for a deep dive into the healthcare systems of different countries is to be able to understand the impact and response to pandemics. Both Italy and the US, despite having diametrically opposite policies, are crumbling under the sheer scale of the pandemic. While on the one hand there is a crisis to find an adequate number of hospital beds, ICUs and ventilators for patients, there is an acute shortage of protective gear, masks and sanitizers for doctors and other healthcare professionals. So what are the lessons that can be learnt from this for India? We have a health policy that has taken on from both the models—a public model and a private model.
INDIA’S HEALTHCARE IN ICU
For India, it’s a well-accepted and well recognised fact that our healthcare capacity cannot prepare for any such eventuality that a Covid-19 outbreak poses. Decades of negligence and under-funding cannot be changed overnight and the population density compounds the challenge. Even now, a clear policy direction to address the serious lacuna in our healthcare strategy is needed.
Consider this, while 84% of the 23,582 government hospitals in India—as of 2017—are in the rural areas, these rural hospitals hold only 39% of the total government beds. So essentially, the overall apparatus in rural hospitals is sub-standard and weak. As such, India’s significantly larger rural population has less access to in-patient facilities and care. With 70% of India’s population in the rural areas, the demographic composition makes it more challenging for government to ensure people have access to care as compared to those who live in the urban areas. In fact, a report on healthcare in India found that the urban rich access healthcare at a rate that is almost double that of the rural poor and 50% higher than the national average. Providing greater access to care in rural areas is difficult due to a lack of both infrastructure and healthcare professionals.
India has a significant shortage of trained physicians nationwide as it falls much below the WHO recommendation for physician to population ratio. The WHO guideline is at least 1 physician per 1,000, but India’s ratio is 1 physician for every 1,674 patients. According to reports, India has 2.3 ICU beds per 100,000 people. Iran—where the medical system is overwhelmed with Covid-19 cases right now—has 4.6 beds ICU beds.
In order to improve the national healthcare system, future healthcare policy will have to address these large disparities that exist between our rural and urban populations.
As a per cent of GDP, India spends abysmally low on healthcare. Just a little over 1% of GDP goes into public health despite a significant increase in health expenditure since 2009, as per the latest National Health Profile data. For those who may want to see the bright side of these figures, public expenditure on health was 1.02% in FY2017 and has risen marginally to 1.28% in FY18. But to put this in perspective, US spends 18% of its GDP on healthcare. While some of it may be due to inflated costs, as I have highlighted earlier, these data points indicate where our priorities need to be.
In fact during a 15-year period (from 2000-2015), India’s healthcare expenditure remained the same—at 4% of GDP, of which 3% has been private investment. During this time, US increased its expenditure from 13.3% to 17.8%. The Narendra Modi government has aimed to raise expenditure on public health services to 2.5% of the country’s GDP by 2025.
The Ministry of Health and Family Welfare has estimated that the low government expenditure on healthcare leads to a much higher out-of-pocket (not covered by any health cover) expenses. So much so, that 7% of the Indian population is pushed into poverty each year because they are not able to afford the OOP costs. During a 15-year period, from 2000 to 2015, OOP payments in India have been nearly 69% of total healthcare expenditures. For the US, the figure, over the same period, stands at 10-20% of US national healthcare expenditures, indicating much better healthcare facilities and much higher insurance cover. This is also because in India, OPD (out-patient department) services are not covered by insurance cover, adding to costs significantly.
India is far from having a universal health cover and getting there will need policymakers to address the twin challenges of dilapidated (and in some areas non-existent) rural infrastructure and the very high costs of out of pocket expenses. Since health is a state subject, both Centre and States have parallel schemes, but under funding, lack of foresight and follow through in policy have resulted in the present state. In 2005, the National Rural Health Mission (NRHM) was announced to improve rural healthcare, while in 2008, the Government-funded Rashtriya Swasthya Bima Yojana (RSBY) was rolled out to provide better insurance cover to poor families. But the NRHM exacerbated the rural-urban divide by adding more beds in urban India, further neglecting and weakening the rural infrastructure. As for RSBY, the apathy of government agencies in ensuring higher enrolment has prevented impoverished families from receiving the coverage that RSBY sought to provide (30,000 per family in 8,000 hospitals). Furthermore, RSBY did not comprehensively cover medical costs for poor families by leaving out the OOP burden.
The Modi government has launched Aayushman Bharat—the boldest national health insurance plan in India’s history, providing more people with greater coverage than any previous program. The scheme, however, as a whole, underemphasizes primary care services that are provided by Health and Wellness Centers, especially in rural areas and tier 2 and tier 3 cities. Instead, Aayushman Bharat, which promotes the Pradhan Mantri Jan Arogya Yojana, only covers secondary and tertiary care, as the main aspect of the reform. This encourages people to opt for secondary and tertiary care, which may be unnecessary and far more expensive than primary care, which is a more cost-effective means to address the most pressing health concerns of developing countries. Future efforts at healthcare reform in India must place greater focus on access to primary care.
COVID-19 LESSONS FOR INDIA
The present state of health infra requires us to have a holistic approach towards healthcare, not quick fixes. As this author pointed out earlier, there is no way to reverse in a few weeks the generational neglect of public healthcare.
First and foremost, the State cannot relinquish its role in providing healthcare and leave everything to the private sector. In the last three decades, the private sector has completely taken control of healthcare, accounting for treatment of 2/3 of the diseases. As the present epidemic has taught countries around the world, over-reliance on the private sector has its costs, as it is the public health system that has to shoulder the responsibility of addressing the crisis. This is reason why Spain has taken the extremely radical decision to nationalise private hospitals and healthcare providers. India cannot look away.
Secondly, political interests that often dominate decision-making in states (in India health is a state subject) need to be addressed. The nexus between netas and medical colleges/hospitals needs to be broken and the time to do is now. The land that is given at throwaway prices is people’s land. It is deeply distressing that Indian taxpayers gave free funding to private hospitals where Indian taxpayers have to pay exorbitant costs for care.
Thirdly, ramp up investments in the sector by prioritising public funds. We have built enough toilets, it is time to start building hospitals and medical colleges. We have not just an acute shortage of doctors but also nurses. India has 1.5 nurses per 1,000 people, as against 2.7 in China, 7.8 in the US and 12.9 in Germany.
The coronavirus threatens to strip India’s health system bare, and, unfortunately, show it for what it is. There are several reasons why India could be severely impacted by coronavirus—population density, underlying morbidities (we are the diabetes capital of the world) and a neglected healthcare system.
The question to ask in this pandemic is not how many people will get infected, but how we, as a society, will respond. Maybe at the end of it, the Indian health system is treated for its own underlying conditions, and return strengthened to life.