COVID-19 has thoroughly exposed inequities in the healthcare delivery system

The warning by WHO Director General Tedros Adhanom Ghebreyeses to make greater investment in public health system so that ‘world is better prepared to meet the future pandemics’ must be taken seriously. For a sustainable world, we definitely need better public health.

Soviet Union was the first country in the world to give constitutional right to the people for free healthcare. This was affirmed in the Soviet Constitution of 1936 as one of the basic rights of the Soviet people, along with rights to education and right to work.

The National Health Services (NHS) in England was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth. At its launch by the then minister of health, Aneurin Bevan, on 5 July 1948, it had at its heart three core principles: that it meet the needs of everyone, that it be free at the point of delivery and it be based on clinical needs and not ability to pay.

In India, Bhore committee under the chairmanship of Sir Joseph Bhore in its report in 1946 had recommended that “the health programme should be developed on a foundation of preventive health work and that ‘If the nation’s health has to be built, such activities should proceed side by side of those concerned with treatment of patients’.” The report further said that no individual should be denied adequate medical care because of inability to pay; health programme must lay special emphasis on preventive work; health service should be located close to the people; medical services should be free to all without any distinction and doctor should be a social physician.

The committee also observed that health and development are inter-dependent and improvement in other sectors like water supply, sanitation, nutrition, employment lead to improvement in health status.

This is how C E A Winslow, a seminal figure in the field of public health, defined it: “It is the science and art of preventing disease, prolonging life and promoting physical and mental health and efficiency through organized community effort for the sanitation of the environment, the control of community infection, education of individuals in principles of personal hygiene, the organisation of medical and nursing services for the early diagnosis and preventive treatment of diseases, and the development of the service machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health”. This till date is the key definition accepted worldwide.

In the first few decades of post-independence period, healthcare was based on these principles. During that period, much of the health care was developed in state sector with a special emphasis on the need of basic healthcare services at the community level.

But from this holistic perspective there occurred a policy shift towards health, that treats health as techno-dependent and amenable to commodification. Under the influence of international monopoly corporate, the WHO took a position of increasing partnership with multinational companies. As a result, the institution which was supposed to work for inclusive healthcare policies took lead in destroying its own agenda set at Alma Ata in 1978.

In our country, influence on the policies by the World Bank is evident in 1980s whereby health came to be viewed as a profitable business.

Thus in our country we find that the public sector is now responsible for the preventive services while the private sector on the other hand is taking lead in advanced tertiary care. We have seen exorbitant growth of corporate hospitals. This advanced care is out of reach of low and even middle income group. It is being projected that the public sector health institutions have failed in providing the services, thereby justifying the need for corporate entry. There is little talk to improve health determinants like improved sanitation, clean drinking water supply, housing, job security and increase in capacity to spend on nutrition.

No wonder the government recognises the fact that every year, 6.3 crore people are pushed below poverty line because of Out of Pocket Expenditure (OPE) on health. Even Ayushman Bharat scheme covers only 50 crore people out of 138 crore and that too only for those who are admitted for indoor care in the hospital. The patients requiring only OPD care are not covered. As a result the already marginalised sections of the society have been further excluded from quality healthcare benefits.

Various studies have concluded that to ensure comprehensive primary healthcare there is need to enhance public spending on health to a minimum of 5% of the GDP. As per the National Health Accounts (NHA) Estimate for 2014-15, the Government Health Expenditure (GHE) per person per year is just Rs.1108/-. This is in contrast to the Out of Pocket Expenditure (OPE) of Rs.2394/- which comes out to be 63% of total health expenditure which is Rs.3286/- per person. Even this expenditure is not homogenous. The spending on health varies on socio-economic status, gender, religion, caste and geography.

To improve the health of the people, drastic steps need to be taken at various levels. Health should be declared a fundamental right irrespective of religion, age, sex, caste and socio economic status. The government owes its responsibility to deliver health to all by ensuring universal access to quality healthcare, education and other day to day needs. For this there should be continuous evaluation of health status of the people. Health should get due place in the political agenda, and the policy making bodies.

COVID-19 has thoroughly exposed inequities in the healthcare delivery system. It has exposed the level of poverty and exclusion. It has exposed our unpreparedness to meet big health challenges. In the pursuit of profit making we have drifted away from our real goals in health. It is time to change our priorities.

(IPA Service)