More than 29 ambulances lined up on a sticky May afternoon outside a leading public hospital, the Rajiv Gandhi Government General Hospital, in Chennai. A team of doctors was outside, frantically checking the patients one by one inside the ambulances. All 1,618 beds in the hospital were occupied. There was no room to admit more patients, despite the entreaties of the patients.

Two patients died in the ambulances even as the doctors were checking them. The dean of the hospital Dr E Theranirajan told reporters, “Private hospitals are referring the patients in the terminal stage.”

The surge of patients, in ambulances, private cars, in three-wheelers and sometimes on foot, continued to rise in hospitals around the country. Sometimes, as in the Lok Nayak Jai Prakash Hospital in the national capital, two patients were forced to share a single bed.

A retired judge in Uttar Pradesh Ramesh Chandra wrote with his hand a note in Hindi, a letter immersed in despair. “My wife and I are both corona positive”’ he said in his open letter. “Since yesterday morning, I called the government helpline numbers at least 50 times, but no one came to deliver any medicines or take us to hospital”.

“Because of the administration’s laxity my wife died this morning,” he added. He pleaded for help from ordinary people after the authorities failed to help remove his wife’s body from their home.

A woman in Noida had travelled with her family to their traditional home in Bhagalpur to celebrate the festival of Holi. But the second wave of Covid-19 struck, and soon both her husband and her mother were admitted to a small local private hospital with the Covid-19 infection, the Indian Express reported.

A hospital attendant molested her as she tried to stay the night in the hospital to tend to her relatives. Her husband’s condition worsened, and the family took him to another private hospital in Bhagalpur. Here too he did not improve, and in desperation, they shifted him finally to a private hospital in Patna. There was no oxygen supply in the hospital, the soiled bedsheets were not changed, there was not even any drinking water. Fifteen days later, he died.

Chaos outside hospitals

Dipankar Ghose, a reporter for The Indian Express, described chaotic scenes outside the Muzaffarnagar District Hospital in Bihar, where “the workload in the hospital is such that doctors are overworked, nurses have become doctors, ward boys have become nurses, and the families have become ward staff”. An ambulance drives up, with a man with an oxygen mask, his wife clasping his hand. The nurse turns them away: there are no hospital beds, she said.

The reporter also meets Gurvinder Singh, 35, caring for his mother, his mask is hanging around his chin. “There are so many people inside this room”, he told Ghose. “At least 20 patients and 30 family members. It is hot and suffocating. I have not even stopped to think if I have Covid-19. If my mother lives, I will think about myself.”

In a primary health centre in Uttar Pradesh’s Bargaon in neighbouring Saharanpur, Ghose found every room with a lock on it, completely empty. The ward boy told him, “The doctor in charge is unwell himself.”

Covid-19 patients at a hospital in New Delhi. Photo credit: Danish Siddiqui/ Reuters

“Some months ago, the nurse was transferred out,” he said. “If someone comes to get vaccinated, we tell them to go to the community health centre in Nanauta.” But he found that the community health centre, which caters to 80 villages, is empty as well. Where he does find patients milling is at a one-room private clinic with six cots separated from where he sits by a wooden screen, of an Ayurveda doctor VK Sharma.

Ghose described the scene he witnessed: “The patient is weak and gasping for breath…[the doctor] puts his hand on the patient’s chest, checks the makeshift saline drip on a rickety pole, and utters the same words of reassurance that he says he has most often used throughout his 45-year practice. ‘Bas sardi-khansi hai, thik ho jaoge [It is just a cold and cough, you will be fine].’ He knows this is not true. ‘Should I tell them [instead that] they could die?’ he asks.”

How did people cope with this chaos, with the absent doctor, the absent state? Families in the middle- and richer- income groups hired nurses at hefty fees to take care of the patients at home, and bought or hired oxygen concentrators (that draw oxygen from the air) or oxygen cylinders and meanwhile kept looking for hospital beds often until it was too late.

Many hospitals refused to admit patients both because they said they had no “free beds” left, and because they did not want to fill even the available beds because of the uncertainty over the supply of oxygen. Matters were further complicated because hospitals refused to even consider admission unless you were certified Covid positive. There were long waiting lists to get Covid tests done, and longer waiting times for the test results.

“Home-based care”, such as it was, was of course no guarantee for survival. And the large mass of people could not afford the cost of hiring home nurses or oxygen cylinders and had no option except to keep the patient home and hope that ephemeral good fortune, or a miracle, to save her life.

A preventable disaster

The Parliamentary Standing Committee on Health and Family Welfare in its 123rd report in November 2020 studied “the outbreak of pandemic Covid-19 and its management”, and had warned about the not just the inadequate supply of oxygen – as we have observed – but also “grossly inadequate” government hospital beds.

But to little avail. As the gravest health emergency to overwhelm the globe in a century continued to rage, the unbridled Covid-19 virus laid bare the abject failure of India’s health system to secure even elementary levels of healthcare for its people. As we have seen, everything fell short disastrously, sometimes catastrophically: hospital beds, doctors, nurses, testing kits, medical oxygen, vaccination, PPE kits, ICU units, ventilators and essential medicines.

Patients suffering from Covid-19 during India's second wave wait to get admitted outside the casualty ward at Guru Teg Bahadur hospital in New Delhi. Photo credit: Danish Siddiqui/ Reuters

Why did hospital beds – with or without oxygen supplies and ventilators – fall so disastrously short especially during the second wave, taking a sombre toll of uncounted numbers of precious lives, lives that could have been saved only if they could have accessed hospital beds?

It was a time when both wealth and political connections – the robust twin currencies of influence and power in new India – mattered little as you vainly, desperately sought a bed to save the lives of people you loved.

Public health expert Anant Bhan told the BBC, “We did not learn any lesson from the first wave. We had reports of some cities running out of beds even in the first wave and that should have been a good enough reason to be prepared for the second wave.”

The shortage of beds spurred state governments into a highly belated mad scramble to build extra capacities in hotels and stadiums. But as Dr Fathahudeen observed, adding beds alone was not enough. “We need to ensure that most of these beds have oxygen facility,” Fathahudeen said. “We need more doctors and nurses to manage extra ICU beds.”

But the numbers of doctors and nurses in public health care were severely limited, with more than 75% of trained doctors in the country working for the private sector. The only solution could have been to nationalise, at least for the period of the pandemic, private health care services. But there was no chance of the union government taking such a step: as I have often argued, the government seemed at every stage of the crisis to be much more concerned to protect private corporate interests, even within health services, rather than to uphold the public good.

The Inequality Report 2021 of Oxfam India tries to find some answers to the puzzle of India’s spectacular failure to organise hospital beds for Covid patients. Titled “India’s Unequal Healthcare Story”, the report is a penetrating and 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 working and destitute poor in sickness and in death.

In the earlier decades after Independence, the country haltingly built up 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.

Inadequate healthcare spending

India today allocates just 4% of total government spending to healthcare, 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 155th position, eighth 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 few countries with fewer beds than India per 1,000 people include Afghanistan, Burkina Faso, Mali and Madagascar.

India has the lowest number of hospital beds per 1,000 people. Photo credit: Punit Paranjpe/ AFP

The World Health Organization recommends at least five beds for 1,000 people, ten times more than what India had accomplished in 75 years of freedom. India had just one government allopathic doctor for 10,183 people and one state-run hospital for 90,343 people. Why were we astonished there were no hospital beds available for so many patients when covid infections surged?

The situation was vastly graver in the countryside, which is even more poorly served with hospital beds – both in public and private hospitals – than cities and towns. At the start of the pandemic in 2020, the India Today Data Intelligence Unit examined carefully the health infrastructure data published in the National Health Profile 2019 and found that government hospitals would run out of beds in rural India even if 0.03% of the rural population would be infected with the virus. Their predictions were sadly borne out by the experience of the second wave, as the virus engulfed many parts of India’s countryside.

The Data Intelligence Unit noted that according to the National Health Profile 2019, of India’s 26,000 hospitals, roughly 21,000 were in rural areas and 5,000 in urban India. Of the country’s government hospitals, 73% are located in rural areas, serving around 69% of the country’s population (relying on the Census 2011). On the surface, this appears equitable. But when we look more carefully at the distribution of hospital beds and doctors across geography, a very different – and much more alarming and unconscionable – story emerges.

Rural-urban divide

Firstly, hospitals in the countryside have much fewer beds than those in cities. There were, at the time the pandemic struck us, a total of 7.1 lakh hospital beds in government hospitals in the country. Of these, only 2.6 lakh were in hospitals in rural India compared with 4.5 lakh in urban areas.

What this adds up to is that for nearly 70% of the population that inhabits rural India, just 36% of the government hospital beds are available. India has one bed for almost every 1,700 people in government hospitals. In rural India, this is 3,100 people per bed – almost twice as much as the national average.

The report found conditions most alarming in Bihar, where more than 16,000 people have access to every one bed in a rural government hospital. For 10 crore people living in rural Bihar, there are only 5,500 beds available in the government hospitals.

For urban India, on the other hand, there are 800 people per bed, which is almost half the national average and four times less than the average for rural India. This means that the queue for getting a government hospital bed in the countryside would be four times longer than the ones in towns and cities. And urban residents – if they can afford these – also have an even much greater share of private hospital beds.

The rural-urban inequity is as stark in the availability of doctors. For every 10,000 people in the country, there is one allopathic doctor on an average in India. But for rural parts of the country, one doctor is available for every 26,000 people.

This means that the workload pressure for a rural doctor is around two and a half times higher than for any average doctor. Doctors are most scarce in rural Bengal, where there is one government doctor for 70,000 people, followed by Jharkhand and Bihar, where one doctor is available for more than 50,000 people.

Dr Pavitra Mohan, a Udaipur based public health specialist explained to the data news portal India Spend that virus spread much more rapidly in the second wave compared to the past wave, with “no divides between urban and rural, or rural and deep rural, or deep rural and tribal areas”.

“The infection has spread in the [remotest] areas, which was not the case the last time,” Mohan said. “So in some ways, it is actually the first wave for the deep rural and tribal areas”.

File photo of Covid-19 patients at the casualty ward in Delhi's Lok Nayak Jai Prakash hospital. Photo credit: Danish Siddiqui/Reuters

The situation in rural India was even more devastating because of the long distrust and fear of the public health system among rural residents. This mistrust, he said, was “partly guided by the fact that services, especially curative services, have not been responsive… The [mistrust] was further accentuated by the fact that last year when people, especially the migrants returning from the cities, were isolated and forcibly quarantined, that led to a fear of the government and public health systems in particular, and of the disease”.

“[The fear was that] if you said you had Covid-19 or were found to have the disease, then you will be shifted away,” Mohan said. But because of this fear and mistrust, “people stayed indoors. They would not go out to access healthcare, and especially not from the public healthcare systems at all”.

They feared disclosing anything about the disease or going to a public health system, which in any case they had limited access to or response to. “That led to quite a bit of delay or absence of care-seeking,” Mohan said. “A lot of people continued to be indoors even when deaths happened. When they had started slipping, they would still want to stay where they were rather than going to a government hospital in a far-off city.”

“Because of the fear of being found out that they are Covid-19 positive and therefore being isolated and separated from the family, even when frontline government health workers like ANMs or ASHAs would visit their homes, they would withdraw and not disclose [their illness] and would not want to even receive the medication or advice that was being given,” he said. “But where people were moderately or severely ill and started slipping and could reach the hospital, the whole fear of going to a hospital was huge.”

He explained that this is why you did not see so many visuals of people in a hospital in rural areas asking for beds or oxygen, as you did for cities. “The reason is that they did not reach the hospitals and often would become severely ill [and] either recover or die at home,” Mohan said.

Primary healthcare neglected

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 healthcare, with large allocations for super-tertiary facilities like All India Institute of Medical Sciences, all to the further neglect of primary health facilities, which global experience indicates is most crucial for the health care and survival of the poor.

In 2019, not even 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 places catastrophic burdens on the working poor populations, and more so on destitute families. Even government estimates that 6.3 crore people fall into poverty due to health expenses in normal times. Think then of how more calamitous would have been the burden of the rampaging Covid-19 health emergency amidst a largely absent state health system on the working and destitute poor?

As noted earlier, from the 1990s, the government increasingly relied on the private sector to offer health services (at a price, often very high price), cutting back from its already low investments in public health. At Independence, the private sector provided just 5%-10% health services. Today it accounts for 82% of outpatient visits, 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 the 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 their 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 this would 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 economist Amartya Sen, that “no country has ever successfully provided universal health coverage 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 that constitute the major part of health expenditure. Second, many studies show that the poor find it difficult to negotiate with private health insurance companies, and even parts of hospital expenses are uncovered.

Health inequalities

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.

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 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.

A Covid care facility in New Delhi. Photo credit: Tauseef Mustafa / AFP

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 creaking public health system was completely overwhelmed when called upon to cope with humungous increases in case-load, to be treated within 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 4.5 persons, whereas 59.6% of families live 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 duties, depriving persons with chronic ailments and women requiring immediate medical care such as pregnant women.

Disruptions in the supply of essential medicines such as for tuberculosis and non-communicable diseases also took a heavy toll of additional sickness and death. They also could not ensure regular hand-washing because piped water supply is rare in their tenements and their poorer nutrition condition also made them more vulnerable to infection.

No lessons learnt

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 what proved to be 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 (Rs 76, 901 crore to Rs 85,250 crore). Even more worryingly, these low allocations were still predominantly for secondary and tertiary health and not for belated strengthening of primary health services. Governments still choose to 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.

Even in Chhattisgarh, a forested state with large Adivasi populations, the Congress government announced that the government would give grants for the establishment of private hospitals in villages. The state’s health minister TS Singh Deo (a rival of the Chief Minister Baghel) publicly voiced his opposition to the proposal, describing as “objectionable” a situation in which private sector players would charge people for essential services.

“If we are short of funds we should strengthen public infrastructure,” he said. “If we are giving money to private players, then ensure that treatment is free of cost.”

Dr Yogesh Jain, who runs a large and well-respected community hospital in rural Bilaspur, Chhattisgarh observed, “The private formal system only cannibalises on an ineffective public system but it does not go where the public system does not exist.”

The government was “hoping that private hospital doctors will go to villages where there are no public systems, but it never happens”, he said. Sulakshana Nandi, the national joint convener of Jan Swasthya Abhiyan agreed that private agencies do not want to go to rural areas.

If even the burning pyres and floating bodies of the sombre 2021 summer do nothing to scar 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.

Read the other parts of the “Tsunami of suffering” series here.

Harsh Mander is a Richard von Weizsacker Fellow, Chairperson of the Centre for Equity Studies and convenes the Karwan e Mohabbat, a people’s campaign to fight hate crime with solidarity and atonement.