Home / Politics / Policy /  Covid-19 shows why we need a healthcare reboot for India

The cholera epidemic in mid-nineteenth century London and the Spanish flu in the early part of the twentieth century made people and governments all over the world realize the importance of public health, wrote the Nobel-winning economist Angus Deaton in his 2013 book, The Great Escape: Health, Wealth, and the Origins of Inequality.'

The growing awareness that germs caused disease, and the consequent investments in public health systems involving sanitation and disease surveillance played a bigger role in improving life expectancy in the twentieth century than gains in income, Deaton noted.

Yet, the improvements in health systems were not uniform with some developing countries such as India lagging behind others in ramping up their public health systems. At a time when Japan was borrowing from the best European practices to create a world-class public health infrastructure across its colonies (Korea and Taiwan), the British were content to limit such investments in British residential areas and cantonments, wrote the demographer Monica Das Gupta of Maryland University in a 2005 Economic and Political Weekly research paper.

Even after the end of the British Raj, successive governments in post-independent India did not consider it a priority to beef up defences against contagious diseases. While specific containment measures were launched to contain diseases such as malaria or tuberculosis, there were very little investments in an overarching public health infrastructure (involving things such as waste management, sanitation, water, food safety etc.). Given that the success of such measures is inherently negative (epidemics prevented, deaths averted etc.), it has been difficult for politicians to sell such investments to the public in a noisy democracy, noted Das Gupta.

But the costs of such inaction, even if not fully visible, were already quite high, even before the novel coronavirus landed up on our shores. Deaths from contagious diseases in India are much higher than the global average, latest data from the Global Burden of Disease Study shows.

According to the National Health Profile 2019, over 50 percent of all deaths due to communicable diseases in 2018 were because of respiratory diseases and pneumonia, symptoms common with those of COVID-19.

The 2019 Global Health Security Index measures countries’ pandemic preparedness on a score of 1-100 based on their ability to prevent, detect, mitigate and cure diseases. The index ranks India at 57 out of 195 countries, indicating that we may be more vulnerable than China (at 51) and Italy (at 31), which have seen the highest number of Covid-19 related deaths till now.

If a wrong public health strategy is one reason for India’s vulnerability, the lack of resources is another. At 3.6% of GDP, India’s overall health spending is among the lowest compared with peer and advanced economies. Of this, government spending on health accounts for an abysmal 1%. Unsurprisingly, out-of-pocket health expenditure for households is extraordinarily high in India. About 65% of all health expenditure in India (approx 2.5% of GDP) is borne privately by households.

The low priority accorded to health has translated into limited investments in both health infrastructure and health data. Since it was first introduced in the country in 2004, the Integrated Disease Surveillance Programme (ISDP) has been ‘relaunched’ more than once as India’s first line of defence against epidemics. But it continues to struggle for manpower and resources and has failed to create a robust and decentralized data collection system involving the district health system across states.

The Health Management Information System (HMIS) which was supposed to plug some of the data gaps has also been found wanting. Nearly a decade after it was set up, a Comptroller and Auditor General (CAG) report in 2017 found that the HMIS data was often of poor quality, riddled with gaps, and contradicted by the physical records maintained by health centres .

Finally, it is not just government apathy that has made India so vulnerable to health shocks. India’s elites may have also played a part in demanding greater funding for big hospitals (tertiary care) rather than seeking more investments in preventive public health interventions, as Das Gupta argued in her research paper.

Of all healthcare functions, only 7% is spent on preventive healthcare, while more than 80% is spent on treatment and cure as of FY17, the latest year for which National Health Accounts data is available

The costs of such myopia were restricted to the poor and indigent earlier. Covid-19 has changed that, showing that the health of each member of a society impacts that of the other. And without health, it is not possible to create wealth, the current lockdown to fight the pandemic shows.

After this phase of lockdown and social distancing comes to an end, will the world's largest democracy demand measures to promote ‘health for all’? Our resilience to future pandemics will depend on the answer to that.

*This is the eighth of a 10-part series on India’s budget priorities.

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