As the gravest health emergency to overwhelm the globe in a century continues to rage, the unbridled Covid-19 virus has laid bare the abject failure of India’s health system to secure even elementary levels of health-care for its people.

Everything fell short disastrously, sometimes catastrophically: hospital beds, doctors, nurses, testing kits, medical oxygen, vaccination, PPE kits, ICU units, ventilators and essential medicines. Funeral pyres grimly lit up for over a month the night skies in most Indian cities, and rotting half-eaten bodies floated in rivers in the countryside.

It has become imperative that we ask – how, where, when did we go so badly wrong? The Inequality Report 2021 of Oxfam India tries to find some answers. Titled India’s Unequal Healthcare Story, the report is a sobering account of the consequences of policy choices made over many decades, choices that favoured the rich and the private for-profit health sector, starved the public health sector and for all practical purposes abandoned the poor in sickness and in death.

Looking at the numbers

In the earlier decades after Independence, the country haltingly built its public health system, even though inadequately resourced with funds, infrastructure and trained health personnel. But in the years of neo-liberal economic policies, policy-makers effectively cast away the public health sector, and instead placed all their bets on the private sector.

India today allocates just 4% of total government spending to health-care, against a global average of 11%. Public health spending by Central and state governments combined is a trifling 1.25% of GDP, the lowest among BRICS countries. Brazil spends 9.2% of GDP; South Africa 8.1%; Russia 5.4%; and China 5%. In the global ranking of health spending by Oxfam in 2020, India fell to a lowly 152nd position, fifth from the bottom.

Is it a surprise, then, that we have fallen so spectacularly short of health resources and infrastructure during the pandemic? India also has the lowest number of hospital beds per 1,000 people, at just 0.5. Russia, by contrast, has 7.12; China 4.3; South Africa 2.3; and Brazil 2.1. Even Bangladesh does better than India, with 0.87 beds.

The World Health Organisation recommends minimally five beds for 1,000 people. India has just one government allopathic doctor for 10,183 people; and one state-run hospital for hospital for 90,343 people. Why were we astonished there were no hospital beds available for so many patients when Covid-19 infections surged?

The exclusion of the poor from health services is aggravated further because the highly strained allocations for public health have been spent mainly on secondary and tertiary health-care, with large allocations for super-tertiary facilities like the All Indian Institute of Medical Science, all to the further neglect of primary health facilities, which global experience indicates is most crucial for the poor.

In 2019, less than 10% of Primary Health Centres were funded to the threshold recommended by the Indian Public Health Standards guidelines. Populations in large swathes of the countryside, and almost all cities, are uncovered by functional and well-equipped primary health centres.

Even in normal times, what choices do persons in poverty then have when they fall sick? They can either fall back on whatever exists of a weak, poorly functioning public system, or raise money for expensive (often even extortionist) private health services. 64.2% of health expenditure in India is borne privately out-of-pocket, compared with 18.2%, the global average.

This place catastrophic burdens on working poor populations, and more so on destitute families. Even government estimates that 63 million people fall into poverty due to health expenses in normal times. Think then of how more calamitous would be the burden of the rampaging health emergency amidst a largely absent state health system on the working poor?

Reliance on private sector

As noted earlier, from the 1990s, the government increasingly relied on the private sector to extend health services, cutting back from its already low investments in public health. At Independence, the private sector provided just 5%-10% health services. Today it provides 66%, a lot of this through urban corporate hospitals and solo practitioners.

Oxfam reports that (unsurprisingly) the formal private sector has a distinct socio-economic base: the elite and organised workforce. The private sector is motivated by profit, while the public sector is mandated to secure equitable and affordable (and preferably free) quality health services to all, including the poor, close to their homes.

Despite this, governments in recent decades have chosen to not spend its limited health allocations on bridging the massive infrastructure and workforce gaps in public health (and even less on primary health). Instead, they have opted to rely on health insurance, arguing that these will enable the poor to access high-quality private health services.

As the Oxfam report reminds us, this is what has created such a vast chasm between universal health coverage and the minimalist health financing that the government has opted for. Governments have failed to heed the warning of Amartya Sen, that “no country has ever successfully provided UHC without the strong support and commitment of the public health sector”. When significant public resources from an already too-small pool of public funds are diverted to government-funded private health insurance, these offer no real alternative to public provisioning.

Firstly, these insurance contracts do not cover both out-patient care and diagnostics, which constitute the major part of health expenditure. Second, many studies show that the poor find it difficult to negotiate private health insurance companies, and even parts of hospital expenses are uncovered.

Health inequalities in India are even more skewed in India because of historically embedded social inequalities of caste, religion, gender, disability, ethnicity, class and geographical location. The Oxfam report reveals how advantaged-caste Hindus have better healthcare access and better health indicators across the board than Dalits and Adivasis, Hindus more than Muslims, men more than women, and urban residents more than rural people.

Compounding the exclusion

These vintage entrenched health inequalities in India – some of the widest in the world – compounded the exclusion and suffering of the masses of the poor in India when Covid-19 lashed them. As the Oxfam report notes, even rich countries with well-funded and organised outstanding public health systems like Canada, Sweden and Germany struggled to cope with the pandemic. The global experience is that most health systems were grossly unprepared to face the pandemic, and the burdens of health care exclusion fell most on populations that even in normal times were disadvantaged by poverty or social discrimination in accessing health services.

Health inequalities in India, with decades of starving public health and nurturing for-profit private health care, led to a situation of massive exclusion in the first wave of the urban poor, and in the second wave even of the middle classes and the rural populations. The public health system was completely overwhelmed to cope with humongous increases in case-load for its weak and under-resourced infrastructure and workforce.

The private sector, on the other hand, focused even in this time of national (indeed global) emergency on maximising super-profits, charging exorbitant fees, weakly regulated (indeed mostly unregulated) by the state.

The working poor were anyway more vulnerable to infection because they had no space where they could keep distance during and after the lockdowns. The average family size in India is of 4.5 persons, with 59.6% of families living in one room or less, making safety protocols difficult to follow. Without employment security and social security, job losses were mammoth, forcing people to risk infection while finding work to keep their families alive.

The poor were also rendered even more neglected because much of the limited public health infrastructure and health personnel were diverted to Covid-19 duties; depriving persons with chronic ailments and women requiring immediate medical care such as pregnant women. Disruptions in supply of essential medicines such as for TB and non-communicable diseases also took a heavy toll of additional sickness and death.

Are there signs that as a people we are learning from the still unfolding catastrophe of the pandemic to at last reduce health inequalities by far greater investments in public health, especially primary health services? Sadly, no, at least not so far. We waited carefully – with perhaps unfounded optimism – for the allocations in the 2021-’22 Union budget for public health, hoping that the colossal and often preventable loss of life to the pandemic would force the hand of the union government at last to announce a significant hike in health budgets.

Instead, 2021-’22 budget allocations for health actually fell by 9.8% as compared to the revised estimates of 2020-’21 (to Rs 76,901 crore from Rs 85, 250 crores). Even more worryingly, these low allocations were still for secondary and tertiary health and not for strengthening belated primary health services. Governments still rely on promoting private health insurance as the preferred pathway to health provisioning over public health strengthening, even though when the health tsunami hit us, private health care barely joined the national effort of saving lives forsaking profit.

If even the burning pyres and floating bodies of the sombre 2021 summer do nothing to stir unbearably our collective conscience, we in the rich and middle-classes will reveal ourselves one more time as a people comfortable and secure in a social and economic order scarred by giant inequality, one in which people of privilege ensure their personal protection through expensive private provisioning and abandon millions of the working poor to their customary fate of precarious survival.

Harsh Mander is a human rights and peace worker, writer, columnist, researcher and teacher who works with survivors of mass violence, hunger, homeless persons and street children. His Twitter handle is @harsh_mander.