After Covid-19, what can India learn from the universal healthcare systems of its neighbours?

The frequent online advertisements for healthcare crowdfunding platforms are heart-wrenching: distraught families beg for money with folded hands and tears to be able to pay for the treatment of their loved ones battling critical ailments.

These became especially visible during the three waves of the Covid-19 pandemic, when millions of families were left anguished as they were overcharged by private hospitals.

But why should any family be brought to their knees to be able to treat their loved ones? Why is healthcare not free for all Indians?

Each year, approximately 63 million Indians are pushed into poverty due to healthcare expenses. Millions more have been affected due to the pandemic. But, less than 12% of hospitalised Covid-19 patients received free treatment under the government’sAyushman Bharat-Pradhan Mantri Jan Arogya Yojana scheme, also called AB-PMJAY.

On the other hand, millions of people were treated under international universal healthcare models, from the completely free Beveridge National Health Service in the United Kingdom to the Bismarck model of social health insurance in Germany.

As Rajasthan, Tamil Nadu and other states deliberate the contours of their right to healthcare legislations, which is a state subject in the Indian Constitution, these developed world models may appear overambitious. But few are aware that closer home, most South Asian countries already provide universal healthcare – some guaranteed by law.

Nepal has consistently prioritised healthcare, despite being a poor country. After the end of the Maoist People’s War in 2006, all the 25 political party manifestos in the Constituent Assembly elections were committed to universal healthcare. The 2015 Constitution guarantees all citizens not only equal access to healthcare, but also the right to food, employment, clean water, housing, privacy and the right to live with dignity.

The Public Health Service Act, 2018, specifies that every citizen shall have “access to and certainty of” vaccinations, maternal, paediatric, emergency and mental healthcare. The progressive law also imposes penalties and imprisonment along with simultaneously protecting health workers from “physical, mental and gender violence”. For patients, not only are more than 70 essential medicines free, but also the elderly receive entirely free care.

To overcome the shortage of doctors, all private colleges are encouraged to provide some medical seats for free in lieu of a two-year mandatory bonding service contract after graduating from rural government hospitals. But the real backbone of the Nepali healthcare system is the government-appointed swashtya sebikas, or health volunteers, who deliver contraceptives and medicines door-to-door.

Historically, Bangladesh has also built the foundation of healthcare on doorstep delivery to subvert strict purdah norms that restrict the mobility of women. Since the ’70s, an army of government and non-governmental organisation health workers have distributed free contraceptives, medicines and preventive healthcare to every home.

Since 2009, in every third Bangladeshi village, the Awami League government has also constructed 14,000 community clinics stocked with free medicines, medical equipment and even laptops and computers. These clinics are run by trained nurses rather than doctors, on community-provided land. Bangladesh also has a thriving pharmaceutical industry for generic drugs, which even donated the anti-viral Remdesiver to India during the devastation of the second wave of the pandemic.

The Sri Lankan healthcare network, which is one of the best in the developing world, dates further back. By 1928, Ceylon had the most extensive hospital system in the British colonies with a network of rural dispensaries, maternity homes and cottage hospitals. The 1952 Health Act established free healthcare. There is no private medical education in Sri Lanka and all graduates from government universities have mandatory rural internships and are absorbed in government hospitals.

Also, rural postings for doctors are encouraged and government doctors are permitted to carry out private practice after duty hours. This flexibility has improved doctor retention despite low salaries and provided citizens with 24-hour access to health services. Of course, the current post-pandemic economic crisis has upended even the Sri Lankan healthcare system with acute shortages.

On the other hand, Bhutan astonished the world with one of the fastest immunisation drives against Covid-19: within two weeks, 95% of the country’s adult population had been vaccinated by the “Guardians of Peace”, the national volunteer health corps. This vertical service delivery capitalised on the network of free government outreach clinics, with only one private health facility available nationwide in the capital Thimpu.

Since the ’70s, Bhutan has offered free universal healthcare for all citizens. In the 2008 Constitution, health was recognised as a human right and one of the nine domains of Gross National Happiness, which measures well-being and non-economic aspects of development.

Since 2012, Maldives, the tourism haven for celebrities, has adopted a “Husnuvaa Aasandha” universal health insurance scheme that provides “healthcare for all without a ceiling protection limit”. The plan includes annual medical checks, diagnostics, surgeries, inpatient and outpatient treatments.

The plan even pays for citizens to go abroad for specialised healthcare not available on the islands with emergency transportation by sea ambulance, air or speedboats. Nine per cent of the country’s gross domestic product, or GDP, is devoted to healthcare, which is more than most countries across Asia.

The Covid-19 pandemic has single-handedly amplified the centrality of healthcare as a public good and human right. No country in South Asia has suffered a more devastating effect of the pandemic than India. The central government, too, plans to enact a National Public Health law, but the focus is only “public health emergencies”. In contrast, India’s South Asian neighbours have veritable histories of deep commitment to the universal right to healthcare.

Beseeching donors and doctors with folded hands to save lives should not become the symbol of the fragile healthcare system in India. As writer Albert Camus depicts in his novel, The Plague, with searing clarity, “…There’s no question of heroism in all this. It’s a matter of common decency.”

Swati Narayan is an academic and social activist.