As India enters the second week of a national lockdown imposed in response to COVID-19, it is still unclear how well prepared the healthcare system is in dealing with the pandemic. Given the resource constraints of both the Central and State governments, it is clear that government hospitals alone will not be able to manage the fallout. Moreover, even within the government system, tertiary care and public health are the weakest links.
A preparedness plan has to address all levels of care in terms of infrastructure, equipment, testing facilities and human resources in both the public and private sectors. However, so far, the Central and State governments have given little indication of bringing an increase in public expenditure on health. So, an already overburdened public health system will be unable to meet the increase in moderate and severe cases of COVID-19 that would require hospitalisation. While some individual private sector companies have come forward with offers of creating capacity and making it available to COVID-19 patients, there is a need for a comprehensive national policy to ensure that private healthcare capacity is made available to the public. Some States like Chhattisgarh, Rajasthan, Madhya Pradesh and Andhra Pradesh have already roped in the private sector to provide free treatment.
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The government’s silence
The governments at the Centre and in States have to take responsibility for providing universal health services free of charge and accessible to all. This will require governments to not just expand the capacity within the public sector, but also to tap into the available capacity in the private sector. Faced with a serious health emergency, the silence of the government on the expected role of the private sector is intriguing.
The National Health Authority has recommended that the testing and treatment of COVID-19 be included in the PM-Jan Arogya Yojana (PM-JAY) but this proposal is still awaiting clearance. The governance of the health service system is clearly fragmented and has created anxiety among the public. There is lack of a visible central command, which should be created under the supervision of the Union Health Minister, aided by a team of experts. They should be tasked to make policies as and when required and communicate them to State governments, taking into account an evolving situation.
There have been some tentative measures taken by States to allow individuals seeking testing for COVID-19 to access private laboratories at subsidised rates. At present, the government has put a cap on the cost at ₹4,500 per test, which is a burden for even a middle class patient. The poor will clearly have no access to this and the government itself does not have adequate facilities to meet the increasing demand. It is here that the government needs to ensure that there is no cost to the patient.
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At this point, and certainly before the lockdown is lifted, it is absolutely essential that adequate testing and quarantine facilities are created. The Central government has already taken over some private hotels to accommodate persons quarantined for COVID-19. One way of expanding such facilities would be for the government to ‘take over’ private corporate laboratories and hospitals for a limited period. A graduated approach to this is possible by asking tertiary private hospitals to create ICU facilities and isolation wards to care for the moderate and severe cases under the supervision of the government. The political directive for such a move needs to come from the Central government while ensuring that the Ministry of Health provides standard treatment protocols for health personnel.
The Spanish parallel
This may not be as impossible as it sounds. Consider the experience in Spain. The Spanish government issued an order bringing hospitals in the large private corporate sector under public control for a limited period. This tough decision was taken with the understanding that existing public healthcare facilities would not be able to cope with the sudden, if short-term, rise in COVID-19 cases.
In Britain, given the rise in the number of COVID-19 cases, the health workforce in the National Health Service has been under a lot of pressure. British trade unions have demanded that the government make the 8,000 beds in 570 private hospitals in the country available. They have argued that while beds in private hospitals are lying empty, there is severe shortage of beds in the public hospitals. The unions have also been critical of the U.K. government decision to rent these beds at an exorbitant cost to the exchequer.
In India, private corporate hospitals have, in the past, received government subsidies in various forms and it is now time to seek repayment from them. They are also well poised to provide specialised care and have the expertise and infrastructure to do so. So, why is it that the government does not deem it fit to bring them under public control? Does less government mean no accountability even amidst this humanitarian crisis? Is it that the overburdened public health service should be made to care for the rising number of needy patients, while most private hospitals remain reserved only those who can afford to pay?
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The government may argue that treatment for COVID-19 has been included under Ayushman Bharat, and this will take care of the poor. But, what about the large, differentiated middle class, many of whom are employees in the services sector? They do not have secure employment, nor do they have insurance cover. Crisis situations help reveal deeper realities to societies. Universal public healthcare is essential not only to curb outbreaks, but also to ensure crisis preparedness and the realisation of the promise of right to health.
Rama V. Baru is Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University