Humans tend to limit memories of horrors faced in the past as a coping mechanism. In our hurry to return to normalcy, as the world and India learns to live with Covid-19, we should not forget the lessons this crisis taught us. The most important of these is the urgent need for investment and infrastructure-building in our health systems.
The pandemic showed that India’s health system is in tatters. Despite having a doctor-population ratio that exceeds the World Health Organization’s recommendation, the Indian health system is overburdened and overworked. This is possibly due to a lack of homogeneity in access to doctors across the country, the disparities in the access to private versus public healthcare, and the unaffordability of healthcare to a majority of Indians. The availability of doctors to serve all seems to constantly surpass need.
Access is key and often unaffordable to millions of Indians who struggle on a daily basis. This struggle was magnified during the Covid-19 pandemic. In public hospitals, the number of beds available per 1,000 people is 0.5 while 12 states, which account for 70% of the country’s population, lie below the national average. The number of ventilators and critical-care beds is even lower.
Should this lack of universal access come as a surprise? India’s health budget is just above 1% of the Gross Domestic Product, or GDP, ranking 107th of 188 countries. It is time that the country prioritises its citizens’ most valuable asset – health. The public health system is overburdened and private health care is unaffordable. Here, funding implementation through robust systems and accountability are the pillars of change in policy decisions and overall health system overhaul. This is the first lesson.
Many people died of Covid-19 because of poor underlying health. The second lesson is simple: without investing in health, we will not break the cycle of poor health, mortality and disease. This should be a political priority.
Even now, testing services remain limited and inadequate at best. In the private sector, diagnosis and treatment is inaccessible and often overused. If the public system is overburdened and the private unaffordable, where do people go?
The third lesson is that we need to stop viewing health investment as welfare. Health is a human right, and one we pay for with our taxes. As citizens, we need to demand healthcare as a priority in election manifestos. There is a need for a long-term investment strategy in health determinants and health systems.
But where do we start? We need to ensure political commitment to health investments and the transformation of current health infrastructure. The state should provide either free or affordable testing and treatment, accessible right up to the grassroots. If we cannot test everyone or treat them, we are already losing half the battle. Even today, thousands with Covid-19 remain untested, and thus, under-reported. Investment in diagnosis and treatment is urgently required.
Initiatives, like the Jan Aushadi Kendra – which provide generic medicines at affordable prices – have not had the required reach as out-of-pocket expenses for healthcare are more than 60% in the country, reiterating the need for affordability but also accountability.
Being a global leader in affordable drugs and vaccines is not enough – transparent decision-making, public trust and access is critical. Despite being a major vaccine leader, India’s provision of vaccinations and building public trust was slow. These efforts were hit by decision-making delays and low public trust. As the deadly second wave in the summer of 2021 demonstrated, delays and poor public trust extracted a heavy cost.
Perhaps the most critical lesson is to invest at the grassroots. To ensure last-mile reach, well-equipped Public Health Centres are needed. There is a need for innovation within the system, and experimenting with public-private partnership models so that the state can concentrate on ensuring delivery everywhere.
Those working at the grassroots must be recognised for the significant impact they have on provisions of healthcare services and public health as a whole. Perhaps, the most important person is the unrecognised ASHA worker – Accredited Social Health Activist – who is not a mere volunteer, but an agent of change. They must be compensated for their work with pay at par with at least minimum wages.
Another important lesson is that health is unattainable in the absence of a social security net. The lockdowns highlighted the need for social and economic security from the government. With the collapse of the informal economy, millions were left without any safety net, spurring desperation.
Small businesses, migrant labourers, and daily wage workers could not work, nor did they have alternative sources of income. This illustrates the importance of investing in food security as a preventative tool. The lack of proper implementation of welfare measures, and the unclear nature of social, economic and health-related decisions help understand the bigger picture of what can go wrong during a crisis.
Finally, innovation is key. In India, technology was used for enabling work from home across sectors and also for availing essential services like medicine delivery and even doctor consultations. While mostly applicable in urban areas, this could be a game-changer for rural areas as well, where telemedicine made healthcare more accessible. Such innovations need to be introduced on an ongoing basis and the idea of a healthcare innovation council could help facilitate and track and help introduce such innovations in the healthcare sector.
The pandemic taught us health is core to our growth as people and a nation. This needs long-term political will and investment in health, but also accountability. It requires building public trust in the health systems and create a process where people have a say in their health policy. The most important lesson is to learn from the crisis and transform policy and systems. Because if we do not, we are destined to repeat our mistakes.
Chapal Mehra is Director at The Rahaat Project and a public health specialist.
Dr Lancelot Pinto is a pulmonologist and epidemiologist.