India has never spent more than 2% of its GDP on healthcare. And healthcare facilities across the country straddle different levels of efficiency and sufficiency. The impact of COVID-19 has shaken even States like Kerala and Tamil Nadu that traditionally did well in the area of healthcare. In a discussion moderated by Ramya Kannan , public health experts Abhay Shukla and T. Sundararaman discuss whether healthcare for all can be a fundamental right. Edited excerpts:
The COVID-19 epidemic has been unprecedented in its impact on society. While we can argue that no country in the world can actually be fully prepared to handle an emergency, do you think the time is ripe to push the agenda of healthcare as a fundamental right for all citizens ?
Abhay Shukla: I would say that one of the most positive impacts of this otherwise very damaging epidemic has been that it has opened the eyes of people to the importance of universal and robust public health services and the need for everybody to be covered by quality healthcare, or for health services to be accessible to everyone. And this epidemic, because it has been concentrated in large cities and has also affected the middle class, has become a matter of high priority.
So, this is a ripe time to actually take forward the agenda of right to healthcare and because the right to healthcare, if it is to be real, it always has to be universal. In that sense, right to healthcare is very much on the agenda and I think we all need to push for that.
T. Sundararaman: Yeah, so, in some sense, this notion of right as different from a commodity that can be purchased on the market must be made. In classical economic terms, this is a public good, it is a good with a very high degree of externality. So perhaps you can get away politically by not providing healthcare for a lot of our population. Or if you believe the theory that it is enough to provide them a minimalist healthcare, the rest is left to the markets. But here, you actually have paid a huge price for doing so. Everybody has, but the poor have paid the most. Because, at some point, there is a huge amount of the cost of this whole pandemic, total lack of preparedness for it and that it can strike everybody. And it doesn’t affect only health, but all sectors of the economy.
The idea was that if we give immunisation and some antenatal care, that’s enough, but that’s not the case. We need very good disease surveillance, we need an integrated primary care system that can deliver in the field. We need tertiary care with the most sophisticated of ventilators. And we need surge capacity, meaning we need an excess redundant capacity that can take care of any health emergency that happens.
During the pandemic, there has been a great deal of imagination in dispensing healthcare and stretching the limits to cover as many people as possible, more than before. Does this give you hope that India can deliver quality healthcare for all? And what range would be sufficient as a percentage of GDP?
Abhay Shukla: So, if we see the situation today across the country, despite the fact that public health services [have been] historically understaffed, under-resourced, [and don’t have] sufficient number of doctors and other resources, they have really stretched themselves to meet the challenge of the COVID-19 epidemic. And I would say reasonably creditably. And in States such as Kerala of course, public health services have done a remarkable job of containing the spread of the epidemic, especially through their primary healthcare activities.
So, what we are seeing is that until now in the public imagination, at least the middle-class imagination, the model of healthcare has been [of] large private hospitals. And generally, public health services, especially primary healthcare, have been kind of invisible and mostly neglected.
But now, we are seeing with the COVID-19 epidemic a completely different kind of situation coming forth. And, the public imagination is also beginning to change.
So, this is leading to, or it can lead to, a change in people’s perception and it can lead to a rejuvenation of public health services, because political will flows from the public. And, if the public takes a greater interest, then obviously, governments also have to respond.
If this trend continues even after the epidemic has died down, then there’s no reason why we cannot achieve access to quality healthcare for everyone in the coming 5-10 years in most States across the country. And, as for a budget, around 3-4% of the GDP for public healthcare, and publicly organised healthcare, would be a good starting point for putting in place at least a basic kind of universal healthcare (UHC) system.
T. Sundararaman: So, I think the pandemic is still, in India, in an early stage, and it will play out. I am concerned about the way our country handled the economic crisis. In the West, for example, lockdown means a huge burden on the state because you have complete social security commitments, unemployment benefits to give, but over here, there is a lot of relief being distributed, but it is just not the same. On the other hand, much of the burden is shifted to the poor.
Similarly, in healthcare, there are States whose main approach has been to re-purpose existing hospitals providing comprehensive, tertiary, secondary healthcare for COVID-19. And the patients that are therefore pushed out because of this, have to either seek care in the unaffordable private sector. And, I don’t think our democracy has yet reached that stage of maturity or robustness where we are able to say “Oh, you need to build new hospitals, you need to create extra beds,” like China, or Spain did. You just can’t use the public system as residual care. But in India, we need to be much more articulate about human rights and the fundamental issue, or else this burden will get unfairly pushed on to people. The ₹15,000 crore allotment for the health sector that was sanctioned, along with the first lockdown, is a welcome step. My only point is that much more was needed in the routine annual budget of this year, and over the past four years.
And I am worried that, as July approaches, it might slowly spread into the hinterland. This is the way the Spanish Flu started in India. It started as an all-Bombay problem from the ships. It was in Bombay for a long time, then spread slowly through the country, and then you had all places affected.
I hope that at some point the government does get into strengthening the public services because the private institutes are not even offering care, many of them are preferring to stay shut till the worst of the pandemic is over.
Both of you seem to have experience with drafting universal healthcare policies. Professor Sundaram and Dr. Shukla, I believe you worked on the draft proposal of healthcare for all for the government. And Dr. Shukla, you’ve done some work on this in Maharashtra. Can elaborate on what constitutes a universal healthcare policy?
T. Sundararaman: I think there are three big issues that in our last effort held us back. And I think we need to have a closure on all these three issues before we can actually go ahead. On the first, I think it is an easy one, that the right to health and the right to healthcare are different things. The right to healthcare is enforceable in a certain way, but in this context, the right to healthcare is something that should be done immediately.
In doing so, there is one fundamental issue. Healthcare is a State subject. Should we make it a Central subject, because then the Central money will flow? But even the response to this pandemic shows that actually that doesn’t work.
Well, for many of these decisions the States have to take, and they need a high degree of cooperation. So, whereas the Centre and the States must have an agreement on the funding, a lot of it will need to remain a State subject. Definitely, one of the problems is inherently constitutional — but it should not lead to over-centralisation. And the third issue is of course, the most fundamental one. You have to put your money where your mouth is, you have to actually get the resources that are required for it and that requires a transfer of resources. Again, a transfer of resources without populist shaming or saying that you are giving subsidies. We have to recognise that if you want a metric of equal health quality, you need to invest more on the healthcare of the poor, the middle class, the upper class, the ruling privileged persons will have to pay a price.
Abhay Shukla: About the issue of universal healthcare, we need a system for universal healthcare, which is a complement to the right to healthcare kind of scenario. A group of public health experts and health activists in Maharashtra has over the last three years, developed a framework that... could be achieved in the next five years, and in a very realistic kind of scenario. So, this is not a pipe dream, it is something which is possible provided that there is political will for it.
But to develop this kind of a system, there are a few constraints which we need to overcome. Right now, we have a fragmented health system. We have one health system for the poor, another for the middle class and another for the rich and the super rich. What we need to do is to move from this fractured system towards a single healthcare system for everyone.
So, even after the epidemic has receded, the idea that the government can regulate private hospitals, harness them in public interest will remain, and I think that opportunity, which is being opened up in the period of the COVID-19, should not be lost. It has to continue till we reach a system of universal healthcare, which involves regulated private providers.
Prof. Sundararaman, can you weigh in on the private healthcare angle? Clearly, the private healthcare sector, which was all powerful, has sort of stepped back to play a supportive role in COVID-19. Does this mean the role of the private healthcare sector in India may actually change in future?
T. Sundararaman: Even the Prime Minister’s health insurance scheme [allowing people to access insurance cover for treatment in private hospitals] has been such a failure today. It is only the high-charging patients without insurance cover that are using the private sector.
Today, it is the public system, with all its problems, that has risen to the occasion. So, in this sense, even the ‘worst public health States’ have stood by the people. But it doesn’t mean that the private sector has no role. We need for the private sector, a much clearer regulatory regime and ways of contracting that are useful and it is most important that they supplement, not substitute, the strengths of the state.
T. Sundararaman is former executive director, National Health Systems Resource Centre; Abhay Shukla is the national convener of Jan Swasthya Abhiyan
