South Asia’s healthcare burden

Despite the debilitating pandemic, state investment in the health sector remains deeply inadequate.

June 10, 2021 12:23 am | Updated 12:55 am IST

Nepalese Army personnel in PPE suits salute to pay tribute to COVID-19 victims before cremating their bodies near the Pashupatinath temple in Kathmandu on May 7, 2021.

Nepalese Army personnel in PPE suits salute to pay tribute to COVID-19 victims before cremating their bodies near the Pashupatinath temple in Kathmandu on May 7, 2021.

On May 18 this year, India recorded 4,529 deaths from COVID-19, the highest daily death toll recorded in the world after the United States in January saw 4,468 deaths. As India combats the pandemic, its neighbours are experiencing spillover from the menacing second wave. The virus has swept through Nepal, while Sri Lanka added as many as 78,218 cases in May. Pakistan crossed over 200 daily deaths in April, its highest since the pandemic started. The situation in Bangladesh is precarious, given the recent detection of the highly contagious Delta variant. Bhutan is the only exception, with only one death and 1,724 cases so far. The country’s success stems from a well-funded and prepared public health system with stringent measures, responsible citizenship, and an accountable government.

As bodies piled up at overcrowded crematoriums in India in the last few months, several things were to blame — “super spreader” events, a fragile health infrastructure neglected for decades, citizens not following health protocols, and logistical mismanagement. What has exacerbated the situation is a subpar public healthcare system running on a meagre contribution of a little over 1% of India’s Gross Domestic Product (GDP). While the private medical sector is booming, the public healthcare sector has been operating at a pitiful 0.08 doctors per 1,000 people, falling miserably below the World Health Organization’s (WHO) prescribed standard of 1:1000. India has only half a bed available for every 1,000 people, which is a deficient figure even for normal days.

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Bangladesh and Pakistan fare no better, with a bed to patient ratio of 0.8 and 0.6, respectively, and a doctor availability of less than one for every 1,000 people. While ideally, out-of-pocket expenditure should not surpass 15% to 20% of the total health expenditure, for India, Bangladesh and Pakistan, this figure stands at an appalling 62.67%, 73.87% and 56.24%, respectively.

The situation in rural India, where people largely rely on threadbare healthcare facilities, is disconcerting. Numerous distressing reports have emerged in the media, from patients being treated on the hospital floor for lack of beds, to some walking hundreds of miles just to get to a hospital, let alone one with oxygen or drug supplies, and many being left to resort to homemade concoctions and local quacks. Further, the fact that hundreds of healthcare workers have succumbed to COVID-19, unable to seek a bed in the very hospitals they serve, is telling.

While India has the world’s third-largest military expenditure, its health budget is the fourth-lowest. In Pakistan, even amidst the pandemic, the defence budget was increased by 12% in the fiscal year 2020-21, to $7.85 billion, while the spending on health remained around $151 million. Not too far behind is Bangladesh, with decades of underfunding culminating in a crumbling public healthcare system, pushing people to opt for private medical care even if it means exorbitant health payments. Major public sector investments by the ‘big three’ of South Asia, i.e., India, Pakistan, and Bangladesh, are towards infrastructure and defence, with health taking a backseat. A quick look at pre-pandemic sectoral allocations explains the chronically low status of human development indicators in the three countries.

(Recent budget allocation as % of GDP)

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Learning from Southeast Asia

South Asia can take lessons in pragmatic healthcare policy from Southeast Asia, which has prioritised investments in healthcare systems while broadening equitable access through universal health coverage schemes. From Vietnam’s preventive measures focused on investments in disease surveillance and emergency response mechanisms, to even countries like Laos and Cambodia making a constant effort towards improving the healthcare ecosystem, all have done much better than their South Asian peers.

It took a debilitating global pandemic to push South Asian policymakers to direct special attention and resources towards strengthening the health systems. But is it too late? Though the Indian government in this year’s budget highlighted an increase of 137% in “health and well-being” expenditure, a closer look reveals a mismatch between facts and figures. Learning from the devastation unleashed by the pandemic, South Asian countries must step up investment in their public healthcare sectors to make them sustainable, up to date and pro-poor; most importantly, the system should not turn its back on citizens. Given the high chances of another wave or even the impending crisis of climate change, stopgap measures ought to be replaced by a well-thought-out vision and political commitment for long-term healing.

The author is Chairman of The Institute for Policy, Advocacy, and Governance (IPAG), an international think tank with presence in Dhaka, Delhi, Melbourne, Vienna and Dubai. Email:

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