“When we fall sick, we die.” The villager who said that to a student of mine may have got unpleasantly close to the truth about the condition of healthcare in India. The current surge in COVID-19 infections has exposed problems amounting to near-chaos throughout Indian healthcare, even if the pandemic has also brought to light Herculean attempts by medical staff, patients’ families, and governments to try and cope with what has been called a tsunami, one which is rapidly getting worse.
While those involved in the clinical response are clearly doing their often-desperate best — care staff are at high risk of contracting COVID-19 — the Central and State governments are now coordinating measures within and across their respective jurisdictions. For example, the railways are running special trains carrying oxygen supplies, and the military is also involved in supply chains. The Karnataka government has ordered private hospitals above a certain size to reserve 75% of their beds for COVID-19 patients who will be paid for under a public scheme. Other States have taken similar measures. The Supreme Court has, suo motu , called for a national plan to deliver oxygen and vaccines.
The responses to the worsening COVID-19 crisis are, nevertheless, not free of tensions. Some private healthcare providers have objected to public authorities’ orders on widened patient access, and the Supreme Court’s call for a national supply plan has been publicly criticised in the political sphere. Some of the problems have occurred on previous occasions. At least one private hospital chain has lost a court action over its failure to treat a government-specified quota of poorer patients; the quota was a condition of help with land allocation to build a hospital.
System under strain
Yet the current crisis may well redirect national attention to what is only barely recognisable as a system of healthcare. India’s fragmented, often corrupt, urban-centred, elite-focused and wretchedly underfunded agglomeration of clinics, hospitals, and variably functional primary health centres can look like no more than an accidental collection of institutions, staff, and services. India’s public spending on health is set to double in the 2021-22 financial year, but that is from a figure that has long been only a little over 1% of GDP. In certain rural areas, the doctor-population ratio is over 1:40,000.
India’s healthcare providers, however, have the task of serving 1.4 billion people, for the overwhelming majority of whom sickness or serious injury of any kind is a matter of lifelong dread. Medical expenses constitute the major reason for personal debt in India, whether the causes are episodic afflictions or, for example, those caused by environmental conditions which none can escape, such as air pollution (which the journal Lancet Planetary Health says this accounted for 1.7 million deaths in India in 2019; the annual business cost of air pollution is currently estimated at $95 billion, which is about 3% of India's GDP).
An idea whose time has come
In effect, COVID-19 may bring about serious consideration of an Indian national health service. National public discussion of that would be almost unprecedented in India, but the idea itself is not new. In 1946, the civil servant Sir Joseph Bhore submitted to the then government a detailed proposal for a national health service broadly modelled on the British National Health Service or NHS, which was on the way towards legislative approval in Britain. Bhore went further by recommending that preventive and curative medicine be integrated at all levels. The British plan had been drafted in the 1930s, as problems worsened in healthcare services. The fact of the Second World War, in the darkest hours of which a plan was prepared to transform Britain into a post-war social democracy with a comprehensive welfare state and a universal free public health service supporting a mixed economy, may therefore have been catalytic rather than decisive in the creation of the NHS.
The result is a mighty achievement in public policy, politics, and the provision of top-class universal healthcare, including training, research, and changing engagement with the public as society changes. The service is funded entirely from general taxation. The budget includes payment to general practitioners, most of whom remain private providers but are paid by the state for treating NHS patients. Items listed in general practitioners’ prescriptions incur no charges in the devolved regions of Scotland, Wales, and Northern Ireland, and in practice only a proportion of patients in England have to pay for prescription items. All hospital treatment and medicines are free, as are outpatient and follow-up appointments. The British public share the costs through their taxes, and almost without exception receive treatment solely according to their clinical needs. With about 1.1 million staff, the NHS is the largest employer in the U.K. Its current budget is about 7.6% of GDP, but despite its size and scale, it provides highly localised access to care.
Problems in the NHS
Of course, problems have arisen. Among them are largely unintended inequalities in the time and attention given to patients of different social classes (this discovery resulted in substantial changes), huge and frequent reorganisations imposed by Central government, and often ideologically driven underfunding. Nevertheless, many senior hospital consultants who were opposed to a public health service when the NHS started have declared unreserved support for it in at least one national conference resolution. An authority on the NHS has said that it is the most loved and trusted institution in the country and is held in even higher regard than the monarchy.
India now faces a very serious health crisis, possibly the worst since Independence. By all accounts, several areas of the Indian healthcare provision are under severe strain. The precise structure envisaged by Bhore may need some adaptation for today’s society and conditions but dealing effectively with the pandemic may itself require the urgent creation of an Indian National Health Service.
Arvind Sivaramakrishnan is a former Visiting Professor in the Department of Humanities and Social Sciences at IIT Madras