Eight months into the COVID-19 epidemic , there is an understandable longing for a return to normalcy in our everyday lives. With the slowing of the growth of infection we want to go about our business and social life in a way that we are used to. However, there is one area in which we cannot afford to return to the old normal and that is the attention paid, actually the lack of it, to health in public policy. We are by now in a position to at least tentatively quantify how much its neglect has cost us in the past eight months.
Public expenditure on health
Repeated reference to the relatively low death rate in India compared to parts of the Americas has meant overlooking the wide variation in the death rate across the States of India. In our work we have tried to see whether it is possible to make sense of this pattern. As there is variation in the per capita income of States, we commenced by looking for a relationship between income levels and deaths. We found that far from income contributing to the prevention of death from COVID-19, States with a higher per capita income often had higher death rates. It suggests that the wealth of a State has not acted as a shield against death for a section of its population.
So what then can explain the varying death rate across India? Data suggest that it is the level of public expenditure on health . There is high variation among India’s States in the public expenditure on health as a share of the domestic product, and the death rate is negatively related to it. This even having allowed for the possible impact of the age profile of the population and its density. In the interest of communication, we have suppressed all technical details relating to methodology and measurement. The study is available from us on request.
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A small additional detail in our findings may be mentioned. While there is a strong relationship between the death rate and public health expenditure, there is much less between the death rate and medical infrastructure in the public sector, be it hospitals or hospital beds per person. The clue to this most likely lies in the observation made by the well-known surgeon, Dr. Devi Prasad Shetty that: “it is doctors who treat patients, not hospital beds” (NDTV, October 2, 2020).
Funding is important
Actually, during an epidemic, much needs to be done beyond treating patients in intensive care units at the final stage of the disease. There is detection, contact tracing and isolation needed even before treatment. Now, an effective combination of medical expertise, protocols and management practices becomes central to the effectiveness of the response to an epidemic. Health professionals at the World Health Organization have observed that sufficient funding is what enables this to occur within the short span afforded by a health emergency.
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The data that is by now available on the progress of COVID-19 across India allows us to at least take a view on whether some deaths may have been prevented even at the income level that we have. If we apply the death rate in the State with the median level of public health expenditure to the national population we would get an estimate of what would have been the number of deaths were public expenditure on health across the country the same as that of the median Indian State. The difference between actual deaths and this figure gives us an estimate of how many deaths could have been saved had the laggard States spent more of their income on public health.
Growth over health
When this computation is done, we find that approximately 72% of the 1.25 lakh deaths that had occurred till November 7 could have been saved. This estimate should be treated with caution. It is possible that the State with the median health expenditure has some unique characteristics that reduce the death rate from COVID-19. It is also possible that its death rate is underestimated. As there is no certainty on these issues as of now, we treat our estimate of lives that could have been saved as indicative of the potential of a well-funded public health system rather than being definitive by itself.
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A secondary finding of our study is that the State-wise pattern of public expenditure on health is inversely related to the per capita income of the States. Simply put, the health spend of the richer States in relation to their domestic product is lower than that of the poorer States. So the neglect of health in public policy can be termed a choice made by these States. They prioritised economic growth over the health of their populations.
The example of the northeast
We tested our hypothesis on the role of public health expenditure in preventing death from COVID-19 over diverse fields. We first took it to north-eastern India, which has registered much lower death rates than the rest of the country. This pattern has led to speculation on the innate characteristics of the population of this region and claims of its lower exposure to the virus. On the second of these, actually the percentage of the population infected in the northeastern States is not much lower than that in the rest of the country. On the first, no reference to population genetics is needed to explain the northeastern experience. The States of the northeast are among the highest spenders on public health in the country. Only the State of Jammu of Kashmir, prior to its dismemberment, was in the same league.
Next, we tested our finding across the eight countries of South Asia. Here, there is a particularly marked negative relationship between public expenditure on health and the death rate from COVID-19. And, generally, the richer countries spend proportionately more on public health. Apparently, the inverse relationship between national income and public health expenditure is a pathology peculiar to India’s States.
Finally, whatever may be our findings on the role of public health expenditure in preventing death from COVID-19, it would be naive to imagine that health security can be achieved by throwing money at the problem.
The governance challenge
Even once the COVID-19 virus has become less deadly, we are likely to continue to suffer from air pollution , a medically recognised threat to life. It is significant that again it is the richest part of the country that is most threatened by it. But Delhi’s battle with poor air quality cannot be overcome through more money with its government. It is closely related to the governance challenge at the heart of Indian democracy. Air pollution in Delhi is caused by a combination of stubble burning in the neighbouring States and rampant construction activity, motor vehicles and garbage burning within its own territory, all of which can be mitigated through public policy interventions.
With respect to the first, it has actually been suggested that public funds be used to pay farmers to stop burning their stubble. This would not just be a reversal of the commonly accepted principle in environmental economics that ‘the polluter pays’ but untenable from the ethical standpoint. In most of the cases mentioned above, it is a relatively better-off section of the population that is impairing the lives of the rest by their pursuit of personal gain. Economic policy that prioritises growth, even by default, can lead to environmental damage, and a political process without ethical awareness cannot confront it at its source.
Pulapre Balakrishnan is Professor of Economics, Ashoka University and Sreenath K Namboodhiry is Academic Associate, Indian Institute of Management, Kozhikode