Hard knocks

The biggest learning of COVID-19 for India has been the imperative of focusing on public health. Policymakers, experts, doctors and intellectuals need to sit down and urgently apply their mind on responding to this challenge. There is no doubt that public health infrastructure in India needs a lot of improvement and the worse is that there are huge regional variations with the southern states being in a far better position as compared to states like UP and Bihar. This is borne out by the differences in the figures of infant mortality, maternal mortality and total fertility rate where the southern states can compare with the best in the world while the backward ones are in the same quadrant as Sub-Saharan Africa. The nation is indebted to the sagacity of its political leadership, acumen of the administrative machinery, the brilliance of the scientists and the dedication and courage of the doctors and paramedic staff along with the remarkable patience and fortitude shown by the common citizen, which has helped it handle the seemingly insurmountable challenge of Corona reasonably well. Looking at the huge population that we have, our figures for the total number of people infected, recovery rate and crude fatality rate compare favourably with the best in the world. Of course, a young population and a naturally high level of immunity have helped matters but you cannot take away the credit from all those involved in fighting the Corona menace.

At the moment, it appears as if the threat of Corona is slowly declining and with two vaccines having been approved, it is possible that sometime towards the middle of 2021 we should have come out of this crisis. Mercifully, the economy is also rebounding faster than anticipated largely due to the innovative spirit and courage of entrepreneurs and farmers. We can heave a sigh of relief but there is no room for complacency to set in. One does not know when another pandemic might invade our lives and we have to be ready to respond to it keeping in mind the learnings of the battle against Corona. The Corona crisis has also led to a situation where because of the focus of our limited resources on the pandemic the other health care problems suffered including immunization of children and battle against diseases like TB. It is now clearly written on the wall that India has to accord the highest priority to public health in the years to come so that we can handle any emergent situation and bring about a vast improvement in the quality of life of its people. The first intervention can start with the current Union budget likely to come within a month which should focus on the health care sectors and come out with innovative schemes and above all significantly raise the percentage of expenditure on public health in general and as a percentage of GDP. In the year 2020-21, the budget allocation for health as a percentage of total expenditure was 5.4 per cent (65,001 crore) which was only 1.6 per cent of GDP. This figure has been more or less constant for the last five years since 2016-17 though the overall amount has gone up from 37,061 crore in 2016-17 to 65001 cr in 2020-21. India has been targeting an expenditure of 2.5 per cent of GDP on public health by 2025 but this was a vision when things were moving normally. The Corona pandemic has been a huge shock necessitating a total re-think and reconsideration of priorities. Even the 15th Finance Commission has highlighted this issue and called for an increased allocation on public health. We should now aim to reach this figure of 2.5 per cent at least two years in advance of our original target and this intent has to be brought out in the budget priorities for 2021-22. It is significant to point out that the figures for public health expenditure are 17 per cent of GDP in the USA, 11.7 per cent in Germany, 11.2 per cent in France & 11.1 per cent in Japan and I read somewhere that even Bhutan and Ethiopia spend more as a percentage of GDP than India. The per capita public health expenditure for India in 2020-21 is only Rs 1,944.

The areas for concern are quite clear. We have to significantly increase the number of beds per 1000 people from the current figure of 0.6 and fully equip and modernize as well as operationalise our 1.5 lac primary health centers (PHC) and 29,144 health and wellness centers. For this purpose, significant investment is required to upgrade the infrastructure of the PHCs. Above all, we need many more doctors as our current ratio is 1 doctor for 1,457 people against the WHO norm of 1:1000. This means that many more medical colleges will have to be opened and in particular, the scheme of converting district hospitals into medical colleges has to be given a major fillip. We need to add many more seats to existing medical colleges by upgrading their infrastructures. A peculiar feature of India is that the private sector share in health care is far more than the public sector amounting to 78 per cent in urban areas and 71 per cent in rural areas. There is a definite need for increasing the share of public health spending and there is also a huge need for regulating the private sector to enable it to cater to the needs of the weaker sections of the society. Innovation and regulatory reform hold the key.

The out of pocket expenditure for citizens in India is 62.4 per cent against the governments spend of 30 per cent. Compare this with the UK where the corresponding figures are 9.7 per cent and 83.1 per cent; for the US the figures are 11 per cent and 48.1 per cent, for Brazil 25.5 per cent, 46 per cent and for China 32 per cent and 55.8 per cent. Almost 52 per cent of this out of this pocket expenditure goes for medicines, 10 per cent for diagnostic labs and 22 per cent on private hospitals. This is quite an anomaly for a developing nation where almost 15 per cent of people are still living in absolute poverty. The situation has to be remedied on an emergent basis. Otherwise, low-income people would be pushed further into poverty by spending more on health. A strange phenomenon I have noticed is that even people with low levels of income do not avail of the free facilities being provided by government hospitals as they have no faith in them and spend huge amounts in consulting private doctors or even quacks.

Increasing public expenditure is only one part of the solution. My experience of more than three decades of governance has clearly shown that the absorption capacity of these funds is an area where huge improvement is required. Significantly, it is the less developed states where the capacity to spend the funds is constrained by issues relating to governance and poor management leading to poor quality of public health delivery and huge leakages of funds. One can just analyse the working of the National Health Mission to prove this point where a lot of funds were year marked for the states but the quality of spending and even the amount of money spent varied from state to state. There is, in my opinion, a great need to bring about governance reforms in the health sectors which would require a lot of training and orientation in issues related to public health as well as the qualities of leadership, planning, coordination and execution amongst the officers involved in the process. Robust institutional mechanisms for service delivery have to evolve and be nurtured; and technology has to be used in a big way to prevent corruption as well as to increase the range of quality health care facilities. Unless we look after our human capital by making them healthy we cannot expect them to participate equitably in the process of democratic governance as well as economic growth. A healthy nation is a happy nation and that is the goal that we must aspire for.

The writer is an ex-Chief Secretary, Govt of Uttar Pradesh. Views expressed are personal