India’s health care system was envisaged soon after its independence in 1947 as a three-tier system that could cover the entire country. It was to have a primary care system at the village level, a secondary care system to cover smaller urban centers, and tertiary care for specialized treatment. Over the years, though, the emphasis moved to for-profit tertiary care hospitals, mainly in big metro cities, with state-of-the-art that provided care mainly to the urban rich. Profits from these hospitals, which go into paying the high salaries of doctors and top executives, took precedence over attempts to regulate them or stop malpractice, such as overcharging patients or unnecessary surgeries.
Successive governments before Modi’s supported this unplanned growth, paying little heed to the health infrastructure that was underfunded, poorly staffed, and falling apart. The fact is that the poor in India have struggled to get health care for decades. Most health expenditures in India come under out of pocket expenditure and paying for health care is among the leading things that push people below the poverty line. A 2017 study by the Public Health Foundation of India found that health expenses were responsible for driving 55 million Indians into poverty between 2011 and 2012. As many as 90 per cent of the poor have no health insurance.
India’s health system inequality is a symptom of “Moral Malnutrition”
Indian doctors are among the best trained on the planet, and as is well known by now, the country is a pharmacy for the world, thanks to an industry built around making cost-effective medicines and vaccines. What is evident, however, is that the country suffer from moral malnutrition—none of us more so than the rich, the upper class, the upper caste of India. In addition, nowhere is this more evident than in the health-care sector.
India’s economic liberalization in the ’90s brought with it a rapid expansion of the private health-care industry, a shift that ultimately created a system of medical apartheid: World-class private hospitals catered to wealthy Indians and medical tourists from abroad; state-run facilities were for the poor. Those with money were able to purchase the best available care (or, in the case of the absolute richest, flee to safety in private jets), while elsewhere, the country’s health-care infrastructure was held together with duct tape. The Indians who bought their way to a healthier life did not or chose not to see the widening gulf. Today, they are clutching their pearls as their loved ones fail to get ambulances, doctors, medicine, and oxygen.
Fifteen months after the first case of Covid touched down, India is a tell tale case of missed opportunities despite getting many things right initially.
With just about 9,000 daily cases in February 2021, things seemed more on the brighter side. However, the splintering approach towards public safety, lackadaisical approach towards social responsibility, vaccine distribution that excluded super spreaders, and a public health system that was devoid of an upgrade envisaging a subsequent surge are some of the many reasons adding fuel to the mounting catastrophe. As cases ascend, deaths soar and a health system falls on its heels, indulging in blame-game or scoring political points will do the country no good.
Autonomy within states, given the enormous health system variances, is profoundly critical. Within states, lockdowns or smart restrictions will have to be implemented at the level of districts or municipalities. The rationale for decentralisation is to preserve districts or communities insulated from the current surge and to protect them from an influx of cases.
The explosion of the private healthcare market in India since the 1990s has done little to alleviate the growing demand for quality health services within the public health system. Due to the enormous variances between the states and urban and rural areas, a large proportion of the population from the six lakh-odd villages depends on the public health system.
Focus on building capacity within the public health system
Existing budgetary allocations for infrastructure, including, but not limited to, bridges, stadiums, transportation and other such services, should be redirected towards enhancing the capacity of the ailing public health system. India still spends a meagre 1.26 per cent of its total expenditure on public healthcare, which is an enormous dichotomy in a country where three-fourth of the people pay out of their pocket for health services within the growing private sector.
The devastation that is decimating India is unfortunate, given that two vaccines were available for public distribution around the same time the surge started to inflict the country. Mass congregations around religious practices or state elections may have played a significant role.
Given where we stand, our course correction hinges upon swiftly vaccinating not just high-risk groups but everyone above 16 years of age. Two-dose vaccines, in addition to having a six-week window, bring logistical challenges of deployment, travel, human resource as well as cost.
Mobile vaccination clinics will serve to penetrate communities that are cut off from accessing public health systems, depending on geography. The Oral Polio Vaccine deployment strategy may be a good model to follow.
Another important consideration has to be the notion of deploying them at no cost, given that the marginal cost can serve as a deterrent for the otherwise healthy population, who may feel a false sense of safety from the virus.
Strict protocols for mask mandates with stringent implementation protocols have to be in place. Social distancing is a privilege, and likely unrealistic in a country as dense as India. The mask remains one of the greatest preventive tools instituting source control. While the type of mask depends on the type of setting, any form of face covering has a non-zero degree of protection, with more formidable barriers coming from N95/ FFP2.
Studies on masks show up to 79 per cent effective protection from transmission within communities and a further increase when coupled with social distancing and sanitation measures.
The risk of Covid infection is real and often, cumulative and individual risks are distributed unevenly. This is partly what makes it challenging and difficult to contain. While it may be possible to practise all safety measures, including masks, social distancing and frequent sanitation, and be fully vaccinated, Covid infection remains a possibility.
However, there is growing evidence from around the world that such individuals are protected from severe disease, notably death. Risk also enhances with repeated exposure/ high viral titters, with growing evidence linking severity to repeated exposure.
Today, we know more about the disease, its progression, management and outcome than ever before. The virus adheres to an established set of rules of a biologically active entity. It spreads through respiratory droplets, mutates to survive, is extremely susceptible to frequent hand washing and use of alcohol-based sanitisers, and protects transmission through good quality face covering, including masks, and social distancing greater than six feet.
More importantly, any vaccine that is available for public use will prevent transmission as well as mortality, and prevent new mutant variants from forming.
(Dr Naresh Purohit is a Medical Expert and Advisor National Communicable Disease Control Programme. He is also Advisor to six other National Health Programmes and visiting Professor in five Medical Universities of Southern India including Thrissur based Kerala University of Health Sciences. (The views and opinions expressed in this article are those of the author)