Written by Bharat Dogra& Kumar Gautam
India is known to have a highly unequal health system which creates problems even in normal times. However, in Covid times these problems created by inequalities and unequal access in health systems were greatly accentuated , reinforcing the need to reduce inequalities in health system.
A report by Oxfam released very recently on January 25 on inequalities in Covid times, titled The Inequality Virus ( and its India supplement) has highlighted this aspect and called for strong steps to reduce inequalities and to help the poor and marginal sections who have been suffering many more problems in recent times in the context of health-related issues.
The Oxfam Inequality Report has emphasized that while elites could afford to stay indoors, overlapping vulnerabilities, deprivations with regards to water, sanitation and cooking fuel among the poor have placed millions at risk. Only 6 percent of the poorest 20 percent has access to non-shared sources of improved sanitation. 37.2 percent of scheduled caste (SC) households and 25.9 percent of scheduled tribe ( ST ) households have access to non-shared sanitation facilities. It is the poor and marginalised groups that have been much more exposed and vulnerable to virus.
This report 43 states that the experience of the pandemic has highlighted consequences of chronic neglect of the public healthcare systems, particularly for people living in poverty. Underfunded and weak public health systems lack the capacity to effectively control the spread of the virus, or to provide appropriate and timely healthcare for everyone who needs it. India has the world’s fourth lowest health budget in terms of its share of government expenditure. This has resulted in a fragile, weak and understaffed public healthcare system where people pay 58.7 percent of their total health expenditure out of pocket.
A study of PHC (Primary Health Centre) facilities indicated that 57 percent reported inadequate ventilation, 75.5 percent had negligible airborne infection control measures while N95 masks were unavailable in 50 percent of the facilities. These factors often contribute to suboptimal patient safety and infection control measures during the COVID-19 pandemic.
The Oxfam report based on a wide range of studies argues that the difficulties in accessing transportation facilities and diversion of health-care resources due to managing the pandemic were major factors behind the disruption of non-COVID-19 related essential health services.
Expectant mothers had to face challenges in accessing health care due to the closure of doctors’ clinics, outpatient departments (OPDs) of hospitals and Anganwadi centres. Several districts in Uttar Pradesh like Lucknow, Moradabad and Agra witnessed a drop in C-section deliveries by up to two-third. Pregnant women belonging to poor families were often left unassisted as most public health care institutions were turned into COVID-19 testing facilities and hospitals.
The Oxfam report says that the disruption of health services was significantly higher in rural compared to urban areas. This can be attributed to the closure of all primary health centres and deployment of the staff on COVID-19 duties in rural areas, which already has comparatively sparse health infrastructure and human resource availability compared to urban counterparts. The rural, poor and vulnerable population were often left without reliable alternatives for addressing their non-COVID-19 related health needs.
On the other hand, of those who managed to access healthcare found many found that the costs of treatment, the price of medicines and other indirect costs had increased manifold while supplies declined. This resulted in an outrageously high healthcare cost burden on them, which may have resulted in catastrophic expenditure for many. According to the Oxgam report, if India’s top 11 billionaires are taxed at just 1% on the increase in their wealth during the pandemic, it will be enough to increase the allocation of Jan Aushadi Scheme by 140 times, which provides affordable medicines to the poor and marginalized.
Due to exponential rise in cases, government hospitals in areas with high case-load were soon overwhelmed. Due to this, state governments asked private hospitals to reserve beds for COVID-19 positive patients. The number of beds reserved in private sector have varied across the states depending upon the patient load.
In many instances, private hospitals were slow and reluctant to respond. In Bihar, the Principal Secretary Health had expressed concern at the “almost complete withdrawal” of the private health sector in providing its services to the people of the state. He wrote, “The almost complete withdrawal of the private health sector in the state is palpable and thought-provoking. Private sector has 48,000 beds as compared to 22,000 in public and does almost 90% of all OPDs (outdoor patient department). Forget Covid-19, even regular services have become unavailable.”
Moreover, the Oxfam Report points out, the urgent need for healthcare resulted in massive profiteering from many private health establishments. The rates of health services and facilities increased manifold overnight, making it difficult for even the middle-class to afford them. For instance, Max Healthcare in Delhi set the cost for ICU with ventilator at INR 72,500 a day; and that’s just the cost of ICU with consultation fees, medicines and consumables being billed over it. This growing unaffordability of private healthcare, even for the middle class forced the government to cap the rates of COVID-19 tests and treatments.
Despite the capping of prices for private hospitals across the country, treatment at a private hospital remained unaffordable for the poor and uninsured leading to catastrophic out-of-pocket expenditure and debts. According to the Oxfam report, the cost of treatment of COVID-19 at a private hospital can go up to 24 times the monthly income of the 13-crore people in India that are living in extreme poverty.
The government did take steps to make COVID-19 services affordable by including them under Ayushman Bharat- Pradhan Mantri Jan Arogya Yojna (PMJAY). However, the scheme only covers the BPL population leaving out the uninsured poor and the middle class. Moreover, its beneficiary list is based on the SECC (Socio-Economic Caste Census) data, which is outdated. As a result, thousands of people could not avail COVID-19 services under PMJAY. The Parliamentary standing committee on COVID-19 Outbreak raised concerns on the scheme’s exclusion criteria, which caused many of those eligible from marginalized sections of society to lose out on the benefits of PMJAY and hence to pay out-of-pocket for COVID-19 treatment. Moreover, 66 percent of the SC and 79 percent of the ST households lacked awareness about free testing and treatment provisions under the Ayushman Bharat Scheme. Only 14 percent of both SC and ST households are registered with the scheme, excluding those most in need.
The Oxfam Report says that while the middle class and poor alike were struggling to get admitted, the rich, elite and powerful of the country were ‘booking’ ICU beds, even when they did not show COVID-19 symptoms. Patients who merely needed home quarantine booked ICU beds denying lifesaving care to poorer patients. This massive unavailability of beds in Maharashtra led to health minister taking cognizance of the situation and directing authorities to not admit patients without symptoms in ICUs.
Bharat Dogra is a veteran journalist and author. Kumar Gautam teaches Economics at The Lawrence School, Sanawar