Covid-19: Converting a Public Health Crises into a Humanitarian and Economic Crises

It’s now over 4 months into the Covid-19 global pandemic with cases in India touching 117000 and over 3500 deaths (as on 21^st May 2020) and there seems to be no light at the end of the tunnel. This is because of the tunnel vision of our governments, policy makers and a wide variety of experts. What was essentially a public health crises has been converted into an economic and humanitarian crises.

We have had similar pandemics in the past like SARS in 2003, H1N1 in 2009 and later years etc. They were all dealt with as a public health crises and managed by each country within the context of their healthcare system capacities. Infact in 2019 India saw 28798 reported cases of H1N1 with 1218 deaths, a case fatality rate similar to Covid-19 and we have forgotten about it. There was no lockdown for this and neither in 2017 and 2015 when H1N1 cases were 38817 with 2270 deaths and 42592 and deaths 2990, respectively, with case fatality higher at 6 and 7 percent was there any lockdown. H1N1 is here to stay like tuberculosis, malaria, chikungunya, leptospirosis, encephalitis, pneumonia and many other diseases. We have probably developed some level of herd immunity to it. So what seemed to have changed that a complete lockdown over a prolonged period became the main solution to tackle covid-19?

Generating a psychosis of fear amongst people so that they become obedient subjects of the state and those in power, especially the right wing regimes, can control their thinking, actions and behaviour. Events like clapping and banging thalis, lighting lamps and torches and showering petals from aircraft are mechanisms to test such obedience and build a false sense of solidarity instead of focusing on the problem at hand which is the public health crises and the lack of capacity to handle it due to the gross deficits from which the public health system suffers. This fear psychosis is daily perpetuated by debates and discussions on news channels wherein government representatives and various experts are issuing advisories to people as to how they should behave and face the crises but in terms of services which people need there is not much being done to meet the demands and needs of people. So this perpetuates further fear. As the infection spreads to poorer clusters like slums and the poor communities and Dalits, social discrimination is clearly visible where increasingly people are being denied access to medical attention not only for covid-19 but also non-covid cases. For example tuberculosis detection has fallen drastically as has access to treatment for existing patients where drug supplies and nutrition supplements have been drastically affected. Or people with other medical emergencies are being sent away from hospitals and such denials have resulted in unnecessary deaths as reported widely in the media.

If we had invested in a robust comprehensive primary healthcare system and that was in place when covid-19 hit us the healthcare system would have been better placed to respond to it effectively and such a complete lockdown would not have been necessary – perhaps highly infected clusters could have been identified for containment and locked down with appropriate planning and support for testing, contact tracing and treatment, and access to essential supplies. Kerala is clearly an outstanding example where the well-developed primary healthcare system and coordinated efforts of various government agencies helped to contain the spread of infections. Similarly Goa, Puducherry, Sikkim, Mizoram and other Northeastern states (except Assam) have controlled and contained the covid-19 attack because of their well-developed primary healthcare systems. There is clearly something for other states to learn from these states – but most importantly that these states spend more than twice the national per capita average public health expenditure. And consequently have robust public health systems.

The total lockdown for over 8 weeks now has created havoc across the country and transformed what was essentially a public health crises into an economic and humanitarian crises. With the lockdown businesses and establishments shut down and given that over 80% of the workforce in India is daily wage dependent and a large proportion of them migrate to large cities across the country for employment, this workforce lost their means of livelihood, were displaced and made completely insecure and pushed into a humanitarian disaster. The migrants without work could not continue to sustain themselves in the place of their calling and had no choice but to go back to their origin states. The states response was very weak in dealing with the lakhs of such stranded people despite sitting on millions of tonnes of food grains and vast amounts collected in PM Cares and CM relief funds. State agencies completely failed the people and created a humanitarian crises of unprecedented proportions. The civil society response – peoples movements and collectives, trade unions, NGOs, religious groups, community groups, afew corporate foundations and even individuals and resident groups all pitched in with collecting food and rations, cooked meals and other essentials like soaps and masks and distributed them widely and prevented catastrophic hunger deaths. The Union government and most state governments failed in their humanitarian response and were only making announcements and proposals of schemes which as yet have not been seen working on the ground in any significant way.  Tax resources from the Centre have not reached states and with states’ own taxes like alcohol excise duties, VAT and fuel taxes, amongst others reduced substantially due to the shut down of the economy the states are running into a fiscal crises and many may not be able to pay salaries in the coming months let alone providing benefits to those economically battered.

The Atmanirbhar Bharat Abhiyaan announced by the PM and explained by the FM has no direct benefits to severely affected people – those who have lost jobs/livelihoods, migrants, homeless and those living in conditions which do not allow physical distancing. No social wages, food security and social security measures beyond what already exist under the targeted schemes for the vulnerable groups. Even MGNREGA is largely non-functional and there is nothing of similar equivalence for urban populations. So the vast majority’s survival is threatened and all the government responds with is sorting out liquidity matters for businesses and financial markets and calls for self-reliance. If each one of us must become self-reliant then why do we need to pay taxes or for that matter why do we need the various economic and social sector departments of government?

The gradual exodus of migrants who were treading hundreds of kilometres is now moving towards a huge exodus with many states in a hugely delayed decision allowing transportation of migrants to their home states and making some arrangements for that. But on the other hand the opening up of the lockdown in the green and orange zones wherein many categories of industry and services are being allowed to reopen their businesses has put the migrant workforce and the businesses in a quandary. Where will the workforce come from if the exodus continues? For example Panjab has 8.5 lakh migrant workers and if they all leave what will happen to the current crop season and the forthcoming kharif season and large number of MSMEs. A similar situation will be in play in states like Maharashtra, Tamil Nadu, Karnataka etc.. which have even larger number of migrants.  Again Kerala stands out as they did provide adequate support to the migrants which has prevented a large scale exodus from Kerala. And when many of these migrants experiencing a humanitarian and economic crises reach their home states there is a public health disaster of unimaginable proportions waiting to happen as most of these “home states” have very poor public healthcare systems and don’t have the capacity to cope with such a health crises. Odisha, Bihar and UP have already started to feel the impact of returning migrants. When well endowed cities like Mumbai and Delhi which have highest number of cases and deaths attributable to covid-19 are not able to manage this crisis effectively the other states would just collapse under the burden.

A Comment on Maharashtra’s Public Health Expenditures

Maharashtra is one of the most developed states in India with an income of over 1540000 crores (per capita 130,000) but despite this it is projected to spend only Rs. 7400 crores on public health services (including medical education and capital expenditure) in 2013-14 or a mere 0.48% of the total income of the state. This is in sharp contrast to the peak that Maharashtra had reached of 1% of SDP and 6% of government expenditure for public health expenditure in 1985-86. Since then the trend has been downwards declining rapidly through the nineties and the new millennium, which was contradictorily the period of high economic growth. (see Table below for trends in public health spending).

Maharashtra Public Health Expenditure Trends and  Key Ratios

	1985-86	1995-96	2001-02	2006-07	2008-09	2010-11	2011-12	2013-14 BE
Public Health Expd  Rs.bill	2.77	9.06	15.82	23.24	32.05	46.5	54.1	73.9
Per capita Rs.	63.73	105.95	163.89	220.28	294.31	413.70	474.15	629.47
% to Govt exp	5.97	5.18	4.22	2.96	3.21	3.74	3.83	4.11
% to SDP	1.0	0.70	0.74	0.40	0.42	0.45	0.45	0.48

Source: Maharashtra Civil Budget Estimates, various years; Maharashtra Economic Survey, various years

While we do see a small upturn presumably due to NRHM in the last few years it is certainly not commensurate both with Maharashtra’s high income growth as well as with what is happening in a number of other states who are catching up with Maharashtra in their health outcomes. Infact Maharashtra’s rank in key health outcomes has declined in recent years. For instance Maharashtra’s rank among all states with respect to IMR is 12 but its neighbor Goa with an IMR of 10 in contrast to Maharashtra’s 28 has the lowest IMR in the country.  Goa’s extraordinary performance is due to its much better endowed public health system as well as a high level of public health spending of Rs. 2213 per capita in 2010-11 which was over five times of what Maharashtra spent in the same year. Within Maharashtra if we look at the Mumbai Municipal Corporation we see that it has budgeted to spend as much as Rs. 2509 crores or about Rs.1800 per capita (this excludes what the state government spends in Mumbai) in 2013-14 nearly three times of what the state government spends on average in the state.

So what is very clear when we look at Maharashtra’s health  budget is that too little is being allocated and this then gets reflected in the pathetic situation of public health and public health facilities – huge vacancies in Rural Hospitals and other hospitals as well as PHCs, especially of doctors, specialists and nurses, gross inadequacy of drug supplies in public facilities, poor maintenance of public health facilities and key equipment etc.. The CBM (Community Based Monitoring) process is Maharashtra which is exerting demand side pressure is a good opportunity to pressurize the state government to raise substantially public health budgets. To begin with if Maharashtra is able to reach the national average of 1% of SDP immediately it will be a great step and then it can gradually move towards the UPA goal of 3% of GDP.

Ravi Duggal 

Comment on Aamir Khan's episode on medical practice

Dear Aamir

Happy to see you raise the issue of medical malpractice and lack of ethics in the medical profession. The natural corollary of this should have been a strong message for regulation of medical practice and the profession. It was heartening to see that the failures of MCI projected. For your information the Maharashtra Medical Council took away the license of one doctor, Dr. Shriram Lagoo, incidentally who never practiced medicine! Was happy to see Dr. Gulati but was disappointed that you were advertising for Dr. Devi Shetty and the model of the Arogyashri/Yeshahswani types of insurance which is further destroying the public health model and encouraging huge malpractices like the unnecessary surgeries  of hysterectomies, cardiac bypasses for very low level of blockages by misreporting results, or sometimes the surgeries only happening on paper similar to the basin tests you talked about. The height of malpractice was in UP where insurance passed claims for hysterectomies in men and prostrate surgeries in women!!

Further while it was great to see Dr. Samit Sharma and his outstanding work, It would have been better if you had also discussed the Tamil Nadu model where the focus is on strengthening public health facilities and assuring that all medicines are available free to those who come to the public health system. The Rajasthan model is important to the extent that it helps regulate markets but it cant be an ultimate solution. You yourself agreed with Dr. Gulati that the same kind of healthcare should be available to all whether poor or rich. It would have been great if you had projected some success stories of the public health system.

UPA's Public Health Performance

UPA’s all flagship programs are under stress. During their previous tenure the UPA formulated their strategy and had 3 to 4 years for the various flagships to build their foundation. But we see that success has eluded them, especially in the social sector arena of health, education and welfare. The National Rural Health Mission attempted to do what the Minimum Needs Program did way back in the eighties. The MNP succeeded in creating the rural health infrastructure – the PHCs and subcentres - as per the 1981 National Health Policy to support the goal of Health For All by 2000 AD. This even pushed the public health spending upto 1.6% of GDP, the highest ever for the country. While the physical infrastructure was in place, the human resources, medicines, equipment etc were far from adequate and failed the strategy. And then we were subjected to SAP and the macroeconomics that followed spelled disaster for the social sectors, halving the public health spending from the MNP peak to a mere 0.8% of GDP. To stem this collapse of the public health system the NRHM was launched with a target of pushing public health spending to 2 to 3 percent of the GDP by making architectural corrections.

At the end of their first tenure the UPA managed to take public health spending barely to 1 percent of GDP, no where close to their target. The rural public health system continued to suffer from the same malaise as earlier – not enough doctors and nurses, inadequate medicine supplies, poor maintenance etc. What was worse is that the reasonably robust urban public health system also began to collapse with rapid private sector growth and expansion, including the support of private health insurance. Thus the inadequate public investment in health during the previous UPA regime actually led to the boom of private healthcare which had now jumped to 5.5% of GDP. Since private insurance covers barely 2% of the population, most of this expenditure is out-of-pocket indicating a huge burden on households who often had to sell assets or take loans for their hospitalization needs. Thus the UPA government failed to make any significant impact in the public health domain.

The failure is both political and bureaucratic because there is a complete lack of political will to push radical reforms or the architectural changes the NRHM strategy document talked about as well as the inadequate capacity of the bureaucracy to facilitate the structural changes. During the period of the UPA regime we saw in Thailand a major transformation where social insurance and increased public financing catapulted Thailand to the status of a universal access country assuring equitable access to basic healthcare for all. If Thailand could do it given a very similar historical trajectory to that of India then why can’t UPA facilitate the same for India? The answer lies in viewing the entire health system, both public and private, as a single system and creating a regulatory mechanism and a financing strategy of a single-payer instrument and to accommodate that under a single umbrella. Well the first 100 days of the second UPA regime does not show any inclination towards that end. Hence civil society has a long struggle to get the UPA on track to achieve the goals of universal access to basic healthcare.