June 14, 2020

Despite the Pandemic No Will to Public Health in India

T Jayaraman

IT is extraordinary that the current pandemic has not brought forth a wave of support for enhancing India's public health infrastructure. While a section (only a section, mind you) of the intellectual class, and some leading figures of industry and commerce, have expressed their support for the idea, the extent to which the idea has not caught the public imagination is truly surprising. Surprising because everywhere else in the world, public health has become a real demand, echoed widely by many sections of public opinion.

Why is public health not yet a demand in India? There are possibly three reasons why this is so. One, the section with the most to lose, the working people at large are (a) completely preoccupied by sheer survival, such that all other demands recede from priority (b) have become inured to the absence of public health that they don't even expect it, except as last resort and (c) in the current state of affairs (from pre-Covid days) even the poor avoid public health resources because of the way they are maintained and run. Where it is working, people use it and are happy. Elsewhere, if it is not there, that is something that they have to work around.

However, among the chatterati, representative of middle-class prejudices and opinions, there is simply no significant move demanding the gearing up of public health in the country. At best, the public sector in health is there as healer of last resort, to be invoked and to bear the burden at the time of emergencies and crisis interventions. But there is to be no real shift to public health provisioning with genuine ramping up of public health expenditure.

This is part of the reason why the Kerala model is largely popular only within a certain politically progressive section – a popularity that now extends a little beyond to sections of the media, as something of a curiosity but not as the way to go. Even Kerala has a substantial dependence on the private health sector thanks to central and state government health policies over the years, that the Left has had to cope with.

As for the voice of private enterprise and the State, especially the central government, but also several state governments, public health as the future of health in the country is hardly on the agenda. Despite the pittance of an allocation to public health (and indeed it is not even directed at public health, it is simply health and a hefty boost to the private health sector packaged in) there is no interest whatsoever in any large-scale investment in the public health sector. Mumbai, which dominates the Maharashtra Covid-19 tally, is the classic example of the failure of public health in the country. It is also the example today, par excellence, of how little we have learnt through the course of this pandemic.

Even for those states where past public health sector expenditure has stood them in good stead now, a renewed focus on public health is not the issue that draws their attention as they contemplate recovery. The lack of a public health focus is also glaringly visible in the large-scale side-lining of regular health care, to the extent available, in maternal and child care programmes. This neglect has not drawn the widespread investigation and comment that it justifiably should have.

Corporate health care has possibly had an important say in determining part of the nature of the central and state government response to the pandemic. Possibly, one must say, because of the utter lack of transparency in the manner of government decision-making and the particularly un-transparent role of the private health sector in the committees, task forces, advisory groups and consultations that have mushroomed around the pandemic effort. Anecdotal evidence and scattered media reports suggest that the private sector in fact abandoned the frontlines of the anti-pandemic effort and that the bulk withdrew from even non-Covid health care.

The corporate health care sector has seen the pandemic as an opportunity for windfall profits rather than sacrifice for the greater good. Two months after the lockdown began, the centre and states haltingly placed some caps on the charges of private hospitals for Covid-19 treatment. These have ranged from a bare charge for access to beds alone beginning at Rs 5000 per day to Rs 9000 per day with ventilator use. With all the peripheral/auxiliary charges that such hospitals are adept at devising, the final costs for even middle class patients are forbidding, not to speak of the poor. It also seems that the centre and state governments have been keen to persuade rather than force the hand of the private sector for cooperation in making available beds for public sector use.

The current state of affairs in public health in the country could not have been reached without the complicity of an important section of the medical profession as well as the tacit attitude of fait accompli of the rest of the profession. The medical and nursing professions have understandably been focused on the lack of safety and their general working conditions during the pandemic. But the absence of a strong articulation of the need for public health from their ranks even when matters have reached a crisis, points to a malaise at the heart of the profession in India.

The situation in India is in striking contrast to the discourse in the rest of the world, particularly in countries like the UK and in European nations. Every person with access to the media now knows that countries that have cut back on public health have suffered grievously. In the UK sections of public opinion have virtually made a public mea culpas, acknowledging the indispensable role of a public health system. If there is one thing that one can look forward to in post-Covid UK, it is perhaps a renewed emphasis on the National Health Service. After years of extolling the virtues of private health care, mainstream economists and public policy experts are acknowledging the importance of public health. This is not to argue that the dominance of private health care or the push for it across the world will be reversed in short order, without serious political battles. But a definite challenge is being mounted to the notion of the privatisation of health care and a push emerging for renewed emphasis on public health care.

The tragedy is that even such a push is not really to be seen in India. Even where we welcome the renewed global emphasis on public health, we seem strangely unappreciative of how important it is to India. Let us be very clear. A dramatic increase in expenditure on public health is indeed the litmus test of our having learnt anything, as a nation, from the pandemic. Fighting for such an increase, and throwing all our resources into this battle, will also be a litmus test for all democratic and progressive political forces in the country.