As a billion Indians watch with horror as the pandemic sweeps the land, many look with envy to countries to the east of us where the virus originated, and to the west of us in Europe which were devastated just a few months ago but appear to have beaten the bug and are starting to repair their societies. We can only draw some consolation from the fact that, thankfully, we are not alone in our spectacular failure to contain the pandemic: we have Trump’s U.S. and Bolsonaro’s Brazil to give us company.
The poison of inequalities
Others have also noticed the curious composition of this country club, perhaps the only one in the world which no one wants to be a member of, and have begun to wonder what features these three countries might have in common, apart from the fact that they are all populous, federal, diverse and democratic. No prizes for guessing which is the most common theory which crops up in the fertile imaginations of perceptive observers. But that is not the theory which I believe tells the whole story. My proposal is that what these three countries share is the toxic levels of historic inequalities which affect every structure of society including, most importantly, the health-care system.
The value of investing in a just public health-care system has never been as starkly obvious, for never before have entire countries been brought to their knees by one disease. To be sure, there have been far deadlier epidemics which continue to kill many more people than COVID-19 but they, like HIV, diarrhoeal diseases and tuberculosis, have mostly killed the poor and the marginalised, outside the conscious radar of those in power. More to the point, no previous epidemic brought the engines of the economy to a standstill. If some poor chaps died of a horrible disease in some godforsaken slum, C-grade town or village in the back of beyond, the stock market could not care less. However, on this occasion, for the first time, the wealthy and the powerful in their urban palaces have found themselves marooned. And their high-tech doctors and “super-specialist” hospitals can do little to rescue them.
On universal coverage
What differentiates countries which have been able to pick themselves up and start walking within a few months after their first case was detected from those, like ours, which remain mired in the muck, is the commitment by both the state and civil society to the principles of universal health coverage. To be fair, if universal health coverage was conflated with the simple existence of a publicly financed health-care system, then India, like the United States and Brazil, can already boast to have met this goal. However, this is not what universal health coverage means in spirit: only a system which all people, rich and poor, those in power and those who are powerless, can rely on to be given care with the same quality regardless of their station in society, can be truly considered “universal”.
A question of quality
Such a universal health coverage system does not exist in India, or the U.S. or Brazil, where more than half the population, concentrated in the upper income groups, seeks health care in the fee-for-service private sector. The private sector in India provides almost 80% of outpatient and 60% of inpatient care, as a result of which falling ill is one of the most important contributors to indebtedness in the country. While the government’s much heralded insurance scheme does buffer a segment of our population, the very poor, from impoverishment due to hospital admissions, outpatient care which comprises the bulk of health-care expenditure remains untouched. Whereas universal health coverage is recognised by many countries as a strategy to empower people to lift themselves out of poverty and as a foundation of sustainable development, health care in India has become a leading cause of poverty. The fact that, despite this knowledge, the majority of our people prefer private care, is a damning testimonial to their experiences of the public health-care system.
I have often heard the titans of corporate medicine in India justify their costs by arguing that these are much cheaper than in the U.S. or Europe; such comparisons are ridiculous as they are oblivious of the fact that India’s per capita income places us as one of the poorest countries in the world. But beyond the clearly visible ills of the wholesale commercialisation of health care, there are a host of other challenges to realising universal health coverage, from the standards of our infrastructure to the honesty and competency of health-care workers which contribute to the abysmal quality of care, in both the private and public sectors.
The pandemic has brought the scandalous quality of our health-care system into sharper relief as our daily diet of front-page headlines alternates between the numbers of dead on the one hand with stories of pigs roaming freely and the absence of doctors in public hospitals to shameless profiteering and refusal to care by private hospitals on the other. The proclivity of doctors to irrational medical procedures and drug prescriptions, the lack of dignity with which the poor are cared for, and the legendary levels of corrupt practices across the health-care system are well documented.
At the heart of this pathetic state of affairs is the complete lack of accountability of either the private or public sector, and the absence of the stewardship role of the state in ensuring justice and quality of health care for all its citizens. It comes as no surprise that there is a fundamental breakdown of trust between civil society and the health-care system, exemplified at its most extreme by violence against health-care providers. Fixing the rot will need structural reforms far beyond the top-down “missions” and knee-jerk punitive actions which have dominated our policy-making for over 70 years. But for this to happen, we will need a broad coalition across the political establishment and civil society, in particular the wealthy and ruling classes, to demand change.
A historic opportunity
For the first time, I see the possibility of this happening, as economists, business leaders and politicians who were wont to view the public health-care system as a charitable cause to address disease and death of the poor, to be attended to as a footnote to the task of building our economy, can finally witness as clear as daylight how a dysfunctional, fragmented and unaccountable health-care system will ultimately destroy the economy itself. Even if the pandemic has hit the poor the hardest, it has also crippled the nation. But we need more than just new money for while health care is the wisest investment for the economy, such an investment must be accompanied by a social compact that the same system caters to all. This philosophy of universal health coverage is already practised in diverse ways, including engagement of the private sector, by scores of countries. I cannot imagine a more historic opportunity for India to join that illustrious club.
Vikram Patel is the Pershing Square Professor of Global Health at Harvard Medical School
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