The novel coronavirus pandemic is the most devastating public health emergency in the last century of human history. It is making countries around the world take a hard look at their health systems.
In India, instead of just planning a “return to normal” once we are past the immediate crisis, it is time to begin a society-wide debate about the need for a paradigm shift in our health system.
In a two-part series, I have attempted to distill ten key lessons for India’s health system. The first part focussed on why it is imperative to recognise the importance of public health services and the need to upgrade them. This part looks at what lessons can be drawn from the epidemic for better engagement of the public and private sectors.
1. Tertiary healthcare schemes must not be given primary importance.
The much-projected Pradhan Mantri Jan Arogya Yojana under Ayushman Bharat was supposed to be a game changer: it allows patients to access private hospitals using a government insurance scheme.
However, one month after National Health Authority offered free Covid-19 testing and treatment in private hospitals under this scheme, only 300-odd patients had used this insurance scheme for Covid-19 treatment. This is a miniscule number, considering that around 10%-15% of Covid-19 cases – around 9,000 to 13,000 patients – might have required hospitalisation until now.
While accepting that private hospitals have a role to play in caring for severely ill Covid-19 patients, the health insurance scheme mode of engaging private providers appears inadequate. No wonder several state governments have decided to requisition private hospitals to supplement public health facilities, as a more dependable arrangement.
It is also notable how certain “medical superstars” from prominent corporate hospitals, who regularly speak on TV programmes championing such schemes, have nothing substantial to offer during this unprecedented health emergency. If we compare the responses of public health services and health insurance schemes in the current epidemic, we might agree that actions speak louder than words, especially during a crisis.
2. The market never regulates healthcare in public interest. States must ensure this.
While the public health system has gone into overdrive to tackle Covid-19, the response from private healthcare providers – responsible for 70% of healthcare provisioning in India – has been muted. There have been reports of massive overcharging of Covid-19 patients, with rates charged in Mumbai by certain private hospitals being up to Rs one lakh per day.
Many private hospitals and clinics have shut down or have been refusing suspected Covid-19 patients. This has highlighted once again that unregulated markets invariably fail in case of healthcare, being unable to allocate this essential service rationally or equitably.
In light of frequent overcharging, it is notable that the Maharashtra government issued an order requiring all private hospitals in the state to cap rates for over 170 medical procedures, based on the charges agreed upon with insurance companies.
Regulation of private hospitals, on the backburner in the state for six years, is now back on the agenda. As we move past the epidemic, it is important that comprehensive regulatory measures, resisted by influential private sector lobbies until now, be systematised and legally institutionalised through implementation of appropriate Clinical Establishments Acts.
Concerns over overcharging, problematic quality of care, and unnecessary procedures by unregulated private hospitals require long term solutions. The Covid-19 crisis can open opportunities for change.
3. Private healthcare providers must fulfill public health obligations, now and in future.
For decades, governments encouraged private healthcare to run as a lucrative “industry” led by profit-maximising corporate hospitals. During the epidemic, it became obvious that commercial private players cannot be left to their whims as they need to fulfil important public health obligations. However, there is hardly any legal framework to ensure that these obligations are routinely ensured.
For example, the Maharashtra government has invoked the archaic Epidemic Diseases Act 1897, among other laws, to ensure that private doctors mandatorily treat Covid-19 patients. State governments in Rajasthan, Madhya Pradesh and Chhattisgarh have taken over private hospitals for Covid-19 care. While requisitioning private hospital beds for Covid-19 care in Maharashtra, officials emphasised that “charitable” private hospitals running on government-subsidised land have public obligations.
Emergency measures, like requisitioning private hospitals highlight the fact that private healthcare providers have public health obligations that should override commercial considerations if required. These include notifying cases of communicable diseases, cooperating for implementing public health measures, observing patients’ rights, and treating poor patients free of charge in case of “charitable” private hospitals. Now is an opportune time to discuss robust frameworks to ensure that these obligations will be observed by private hospitals even in “peacetime”.
4. Public health demands active public involvement. States and people must work in synergy.
Kerala’s Covid-19 control experience demonstrates that outreach-based public health strategies became effective due to proactive social engagement. Panchayat representatives, community volunteers and women’s groups worked with public health staff to implement public health activities. Pending any vaccine or definitive treatment for Covid-19, the main plank of epidemic control currently is various forms of modification in social behaviour that can be ensured only with high-level social awareness and people’s informed participation.
Hence, public health services need to develop platforms for health system-community interface, including active community members, panchayat representatives and civil society groups, from village and primary health centres to district and state levels.
These participatory bodies, relevant during and beyond public health emergencies, must foster “broad spectrum involvement” – not just implementing official programmes, but also promoting awareness campaigns, facilitating entitlements for vulnerable and excluded groups, monitoring delivery of services towards addressing service gaps, and providing inputs for local health planning. Frameworks such as community-based monitoring and planning in Maharashtra, and social audit-based models in several states need to be generalised as core components of public health initiatives, since health programmes initiated from above are most effective when working in tandem with social mobilisation from below.
5. Illness can attack anyone. We need Right to Healthcare to protect everyone.
The Covid-19 epidemic is concentrated in cities and has affected the middle class. Therefore, “public opinion” – often another name for middle class opinion – is currently focussed on health concerns. With the critical role of public health services highlighted and “ailments” of commercialised private healthcare further exposed, this epidemic might change the way society views healthcare. Since Covid-19 affects everyone, it holds potential for building social solidarity around health concerns, traditionally weak in most of India.
This setting is appropriate for taking forward Right to Healthcare, which by definition must be universal. Legal provisions for ensuring this would primarily involve revolve around state governments, while national frameworks must be supportive. Health system transformations required to support the Right to Healthcare would involve developing Universal Health Care systems in various states – based on expanded public health services, massive increase in public health spending, and regulated involvement of private providers – organised to provide free, quality healthcare for everyone.
Assuming action upon the lessons outlined in this two-part series, there is no reason why the Right to Healthcare and Universal Health Care cannot be achieved in most states across India in the next five years. This can become reality, provided political will is generated within governments from above, and is mobilised among wide sections of people from below.
It may soon be an opportune time to launch a massive and sustained social movement, demanding sweeping health system reforms and health rights for all. This should involve diverse sections of society, which together constitute the silent majority – working people in rural and urban areas, socially oppressed sections of the population, groups among the middle class, health workers and professionals – who all have a stake in transforming the health sector.
These 10 lessons could be signposts while developing the movement for a new kind of health system in India, which ensures universal health care based on health rights for all. We owe it to ourselves, and to coming generations of Indians, to draw lessons from this once-in-a-century pandemic, and do our best to act upon hard earned lessons. We may not experience such a turning point again in our lifetimes.
Read the first part of this series
This is the final article in a two-part series by Dr Abhay Shukla, a public health professional and national co-convenor of Jan Swasthya Abhiyan. The author would like to acknowledge the contribution of Ravi Duggal.