New Delhi: With the COVID-19 contagion raging across the country, India’s public health sector has been pushed to firefight an unprecedented health crisis. But it is unrealistic to expect an already overburdened sector to do the heavy lifting without the required government support. The allocation for health in the Rs 20-lakh-crore ($260 billion) stimulus package announced by the central government on May 12, 2020, is grossly insufficient and amounts to 0.008% of the country’s gross domestic product (GDP), says Poonam Muttreja, executive director, Population Foundation of India, a Delhi-based NGO that works for gender-sensitive population, health and development strategies and policies.

While the Rs 20-lakh-crore package lends little support to the public health sector, it incentivises the private health sector whose contribution has been negligible during the pandemic, IndiaSpend reported in May. Private hospitals, which make for two-thirds of hospital beds in India, and almost 80% of available ventilators, are handling less than 10% of the critical load of COVID-19 patients, Muttreja said.

It is unfortunate that private healthcare facilities across the country are charging an exorbitant price for treating COVID-19 patients, Muttreja said, citing that the current price cap of Rs 4,500 for testing at private facilities is high even for middle-class Indians.

Muttreja was formerly the country director of MacArthur Foundation in India, a private foundation that supports non-profits. She has been working on issues of women’s rights, rural livelihoods, public advocacy, communications and behaviour change for over 35 years and serves on the board of several non-governmental organisations. She has co-founded SRUTI, Dastkar, WISH Foundation and Ashoka Foundation, and is an alumna of Harvard University’s John F. Kennedy School of Government.

In this interview with IndiaSpend, Muttreja talks about the current state of India’s public health system and government spending to strengthen it; India’s response to the COVID-19 pandemic; the role of the private sector; and the importance of universal health coverage (UHC).

How has the COVID-19 pandemic exposed the vulnerabilities of our public healthcare system? What are the gaps that need to be plugged to deal effectively with such health crises in future?

The COVID-19 outbreak has pushed India’s healthcare sector into ICU. Infrastructural inadequacies, shortage of human resources, lack of adequate funding and huge interstate and interregional variations in the availability of health services have been the major impediments in India’s COVID-19-containment strategy. India’s public expenditure on health as a percentage of GDP is a little over 1%, one of the lowest in the world, according to the National Health Accounts’ estimate.

An overstretched public healthcare system forces millions of people to seek health services from the unregulated private healthcare sector. WHO’s [World Health Organization] health financing profile for 2017 shows that close to two-thirds of expenditure on health in India is out of pocket, while the world average is just 18.2%. Over 63 million Indians are faced with poverty every year due to health costs alone, according to government estimates.

There is an urgent need for comprehensive strengthening of the health system--specifically health infrastructure and human resources--to make quality healthcare available, accessible and affordable to the vast majority of poor and underserved communities.

To what extent will the fiscal stimulus of Rs 20 lakh crore, announced by the government--equivalent to 10% of India’s GDP--encourage prominent investments in healthcare to strengthen India’s overworked public health system?

Public spending on health has been stuck at around 1% of GDP for close to 15 years. In 2004, the Government of India made a commitment to raise public spending on health to at least 2-3% of GDP over the next five years. That did not happen. A similar commitment was reiterated in the 2017 National Health Policy, which commits to increasing public spending on health to 2.5% of GDP by 2025. Till now, we have not seen signs of any significant increase in health spending by the government.

The amount included in the fiscal stimulus for health is grossly insufficient. The increase in allocation announced on May 12 by the Ministry of Finance amounts to 0.008% of the country’s GDP, according to analysts. It is not clear how this will be sufficient for opening infectious diseases hospital blocks in all districts, and public health laboratories at block levels. Financial contribution from the state governments may not be readily forthcoming given the serious fiscal constraints most of them face. Moreover, there is no clear way forward on how the additional specialised workforce, including lab technicians who already fall short in the existing facilities, will be recruited, trained and placed at these facilities.

Public spending on health is said to have been stuck at around 1.15% of GDP for well over a decade; do you think this has led to the poor quality, limited reach, and insufficient public provisioning of healthcare?

The stagnant public health spending in India reflects the lack of political support for health and the failure of policy makers to recognise that poor health is holding back the country’s progress. Limited funding for the health sector coupled with low efficiencies in public spending by the government for decades have adversely impacted the quality, reach and provisioning of adequate healthcare services. This has resulted in widespread inequities in distribution of health infrastructure and health personnel.

India’s healthcare infrastructure remains highly inadequate and falls short of WHO requirements. There are only 0.7 hospital beds per 1,000 people in India with variations across states, according to the World Bank. While there is better availability of beds in public health facilities in states such as Kerala (1.05) and Tamil Nadu (1.1), Delhi (1.05) and West Bengal (2.25), Bihar has only 0.11 beds per 1,000 people. Similar is the case with physicians, where India has only 0.857 doctors per 1,000 people. Further, one in four Indians is at risk of dying from non-communicable diseases--cardiovascular disease, cancer, diabetes and obesity--before they reach the age of 70.

Limited service availability and poor-quality services in the public health facilities have resulted in people seeking care at private facilities. This has led to increased spending by individuals at private health facilities with out-of-pocket payments, and households’ spending on private health insurance constituting 68% of the total health expenditure.

How has India’s public healthcare system responded to COVID-19 despite these figures?

The government sanctioned Rs 15,000 crore as emergency response to fund dedicated treatment facilities, ramp up the number of testing facilities, procure personal protective equipment (PPE), isolation beds, ICU beds, ventilators and other essential equipment for [treating] COVID-19. India realised the need for providing PPEs to its COVID-19 warriors and quickly leveraged its domestic manufacturing sector to produce from zero PPEs to 450,000 PPEs per day. With initial imports of testing kits from China facing quality issues, India decided to depend on test kits from domestic manufacturers. With only 19,398 ventilators available, the government encouraged domestic manufacturing of medical equipment and ordered for 60,000 ventilators from domestic vendors.

However, this is a very limited response. Selective investments in COVID-19 control will not meet the many other essential demands of the health system. The emergency response to COVID-19 has resulted in diversion of resources from other essential health services, including maternal and child-health services, which are bound to have repercussions in the long run. Adequate investments in strengthening the public health system are needed to deliver universal health coverage (UHC) and ensure system preparedness to withstand any kind of public health emergency.

What is the concept of universal health coverage (UHC)? How important is it in situations like the current pandemic, and how vital is it to invest in UHC by reversing the financial neglect of public healthcare?

UHC continues to drive the global health agenda today. The United Nations has included achievement of UHC by 2030 in its Sustainable Development Goals and proclaimed December 12 as International Universal Health Coverage Day.

The high-level expert group on UHC for India, instituted by the Planning Commission in 2010, envisioned UHC as a means to ensure that all people and communities could access promotive, preventive, curative, rehabilitative and palliative health services of assured quality.

Low health coverage and financial protection, inequality in access to healthcare, inadequate public healthcare financing and the lack of skilled human resources are considered to be the major barriers in achieving UHC in India. The institution of UHC would require dealing with inequities in health outcomes, regional and socio-cultural diversity, and the differential healthcare needs of populations in different locations.

Today, UHC is even more relevant. COVID-19 is a grim reminder that the government is primarily responsible to ensure people’s health as part of the social contract. UHC is critical to ensure that all, especially the most vulnerable and marginalised groups, such as women, daily labourers, homeless and migrants, are able to access free testing and treatment they need for COVID-19. Investing in the public health system and UHC will make a difference in the country’s response to COVID-19 [like health emergencies].

According to ‘Adding It Up’, a report by Guttmacher Institute, published in June 2020, there are advantages of simultaneous investments in sexual and reproductive health (SRH) services. It is critically important to include SRH and family planning services as part of UHC, and that adequate budgetary allocations are made [towards these services].

Which countries are successfully working with the models of UHC, and how have their experiences been?

Countries are at different stages of progress with regard to achieving UHC. A World Bank and Japan government study in 11 countries revealed that UHC goals are often adopted in conjunction with a major social, economic, or political change. For example, UHC became a national priority following a period of financial crisis in Indonesia, Thailand, and Turkey; at the time of re-democratisation in Brazil, and during post-World War II reconstruction efforts in France and Japan. All the 11 countries in this study used an incremental approach to the expansion of health and finance coverage. The study shows that movement towards UHC is a long-term policy engagement that needs both technical knowledge and political know-how.

Thailand has made progress in expanding healthcare coverage. Since 2001, Thailand’s universal coverage scheme (UCS) has targeted 45 million people who were not previously covered by existing insurance schemes. Thailand has designed innovative payment mechanisms to help contain its healthcare costs.

Mexico expanded UHC through legislated access to a comprehensive package of services in 2003 with the passing of the system of social protection in health (SPSS) legislation, and introduction of the Seguro Popular (health insurance), accessible to all Mexicans not covered by a social security scheme. By 2012, the programme had provided access to a package of comprehensive health services to more than 50 million Mexicans who were previously uninsured.

Ghana’s National Health Insurance Scheme (NHIS) is one of the more comprehensive schemes in sub-Saharan Africa, covering the basic health needs of a large proportion of its 24 million population. The system has decreased out-of-pocket payments, increased both health service utilisation and government expenditure on health.

Chile is a good example of how a rights-based approach can increase access to healthcare. In Chile, individuals who cannot afford insurance premiums receive free treatment in primary healthcare clinics or hospitals.

How has the public health system and private healthcare responded differently to the pandemic?

For the initial part of the epidemic, COVID-19 testing and treatment was focused in government hospitals, most of which are under-resourced and are often distrusted by patients. The increase in the number of cases and need for rapid testing brought in the private sector, but was followed by significant concern over exorbitant bills. Some states like Maharashtra, Tamil Nadu and Gujarat have set a cap on the tariff that can be charged by private hospitals. But with many government facilities being converted into dedicated COVID-19 hospitals, a large number of non-COVID-19 patients will need facilities and providers to take care of their healthcare needs. In such a situation, the private hospitals have a crucial role to play in managing the treatment of non-COVID-19 patients.

Despite a greater burden of the pandemic being borne by the public health sector, the stimulus package is said to be incentivising private hospitals. Your thoughts?

Resource constraints for healthcare, both at the Centre and states, along with a weak public health infrastructure necessitates a greater engagement of the private sector to equally join the fight against the pandemic. Private hospitals, which make up two-thirds of hospital beds in India, and almost 80% of available ventilators, are handling less than 10% of the critical load of COVID-19 patients.

With the number of infected cases increasing day by day, private facilities need to be roped in to take the load off the overburdened public health facilities. This is on account of the fact that private health facilities are better equipped to provide specialised care and have an advantage over public health facilities in terms of better infrastructure and staff. Andhra Pradesh, Chhattisgarh, Madhya Pradesh, Rajasthan have already involved private facilities to treat COVID-19 patients free of cost.

Private hospitals have continued to enjoy tax holidays and various subsidies from the government. During this hour of crisis, it is justified to make them accountable for treating COVID-19 patients through appropriate price control and regulations. The government should tap the potential of private health facilities and step up measures to maximise benefits for them as well as for the infected community at large.

With a daily increase of COVID-19 cases by the thousands, India is seeing a shortage of beds and other crucial healthcare services. What should India’s strategy be in terms of extending the capacity of the public health infrastructure?

The southern states of India are proof of the fact that a well-balanced and equitable health system is the only possible way to combat public-health emergencies of the magnitude of COVID-19. In contrast, weak health systems cannot suddenly step up to the challenge of a public health emergency. Also, a selective investment in some components of infectious disease control is not a long-term solution.

Strengthening of the health system and increased health budget allocation is the need of the hour. Efforts need to be made to ensure that the COVID-19 response doesn’t take away from other essential health services. Capacity building of India’s health workforce, particularly our 3.3 million female frontline workers (ASHAs, ANMs and Anganwadi workers), is needed to ensure continued access to essential health services to rural women. They [health workers] are, after all, the only point of contact for most of these women. It is also important to ensure women’s equal representation in all COVID-19 response-planning and decision-making.

There have been reports of private hospitals charging much higher prices for treatment of COVID-19 patients. This exploitation is likely to intensify as the number of cases are increasing rapidly. How can the government ensure a fair price or free treatment for all patients?

It is unfortunate and shocking to learn that private healthcare facilities across the country are charging exorbitantly, [bills] running into lakhs of rupees for treating COVID-19 patients. The current price cap of Rs 4,500 for testing at the private facilities is high even for the middle class, though there have been several reports of cheaper, locally manufactured testing kits being developed in the country. Affordability by the poor for testing at these facilities is completely ruled out. The government has to make efforts to provide testing free of cost for the poor. It is important for the government to keep a control on the prices of testing, drugs and admission of patients in these facilities to ensure availability of services at an affordable cost.

The government should structure a standardised treatment protocol and costs in agreement with the empaneled private facilities and ensure that these are adhered to. There should be strict monitoring and regulation of these facilities and stern action needs to be taken against those providers who violate the norms. The government could also act as a facilitator for the private facilities and ensure availability of adequate supplies and equipment to mitigate supply-chain risks. This would also reduce the costs of procurement of equipment and kits by private hospitals directly from the manufacturers to a large extent. The government should take stock of current operating mechanisms at the private facilities and ensure that the required supply of essentials stocks are provided based on need.

Do you think the pandemic has also exposed the lab-testing capacity of the country for a fast-spreading virus?

Currently, 737 government and 279 private laboratories have been enlisted for COVID-19 testing, resulting in rapid improvement in testing. Despite this, India falls short of testing when compared to other countries. India is able to test only 5.5 persons per 1,000 population when compared to Russia (124.1), Italy (85.4), USA (86.3), UK (66.8), South Korea (23.4), and Iran (17.9), according to data by Our World In Data, a live data portal. The low levels of testing manifest India’s inadequate health infrastructure and weak capacity of public health systems to track and scale-up rapid testing in the community. With stringent lockdown measures, India was able to contain the virus to some extent; however, the recent relaxations in these measures have resulted in an expected surge in cases.

The stringent nationwide lockdown, March 25 onwards, was expected to provide the time needed to build the public health infrastructure and capacity of Indian public health system. Countries such as South Korea, Singapore, Germany and Japan have been successful in controlling the spread of the virus and reducing mortality through early detection and quick containment. This has been possible only through widespread testing. India has opened up testing to private labs and payment for testing is covered under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojna (AB-PMJAY) as well. We need to substantially expand our testing capacity and at affordable prices, something not possible without the active participation of the private sector.

(Tiwari is a principal correspondent with IndiaSpend.)

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