Primary health to insurance: Five non-Covid-19 areas to focus on in 2021

Covid-19 demanded the single-minded focus of India's entire healthcare infrastructure all through 2020. In fact, the pandemic hogged so much attention across all aspects of our lives that most other issues of public health were put on the back-burner.

Issues such as tackling tuberculosis and health insurance, which could have been addressed in 2020, were sidelined. As India's entire healthcare system was forced to forego all issues other than Covid-19, the nation would have to catch up on matters overlooked in the last year while facing new challenges such as mass vaccination and ramping up health infrastructure.

"The Covid-19 pandemic is a crisis," said Chandrakant Lahariya, public health expert and author of Till We Win, a book on the current pandemic. "Many things were beyond our control but it will be tragic if we do not learn. This is an opportunity... everyone's attention is on healthcare, from the general public to elected officials. Never let a crisis go to waste."

"Until mid-2021, understandably, global attention would be fixed on Covid-19 vaccines. But, we should also bring into focus the strengthening of other aspects of healthcare," said Lahariya.

TB neglected

"In 2021, again there is a threat that all health services and issues will be seen only through the lens of a pandemic response," said T. Sundararaman, former dean of the School of Health System Studies at the Tata Institute of Social Sciences. "If the focus in 2020 was on Covid-19, 2021 would be about the vaccine to fight it. India would struggle to carry out large-scale vaccinations especially without a parallel increase in financial and human resources." Within that narrow focus, most things may be seen in relation to accessing a Covid-19 vaccine. However, there are many other diseases India also needs to simultaneously tackle, he added.

Tuberculosis (TB) programmes were disrupted globally, including in India, in 2020, according to the World Health Organization in its Global TB Report. TB services, infrastructure and staff were heavily diverted to Covid-19 care.

Across the world, India had the highest number of new TB cases in 2019, according to the Global TB Report 2020. India had three times as many persons with TB in 2019 as Indonesia, which has 8.5% of the world's TB cases. India also has 27% of the world's cases of drug-resistant TB, again the highest in the world. Between January and June 2020, India showed "large drops in the reported number of people diagnosed with TB", recorded the Global TB Report.

India has committed to eliminating TB by 2025 but the pandemic could set back India's efforts by nearly a decade, experts told IndiaSpend.

"We cannot blame Covid-19 for everything," said Blessina Kumar, CEO of Global Coalition of TB Activists. "We were lagging behind on tackling TB even before this pandemic hit. In 2021, I want TB services back. And I do not want things to be where they were before the pandemic. I want things to be improved and better. We have seen how quickly a response can be planned during this pandemic, how different sectors can come together. I think there is scope for us to do better work on TB in 2021."

Services that were disrupted and the diverted lab technicians and equipment, all need to come back to the TB programme, Kumar said. The government and civil society also need to work on removing barriers for TB patients, making treatment affordable and accessible, boosting the patients' nutrition and addressing wage losses, added Kumar. "We need to get a grip on things. We need to get our focus back."

Public and primary health, private insurance

"In 2019, one of the issues that I was tracking was the rolling out of Ayushman Bharat," said Sundararaman. "One component of this, the Pradhan Mantri Jan Arogya Yojana (PMJAY), was getting a lot of attention, acclaim and financing. The other component, health and wellness centres, had great scope for strengthening primary healthcare."

However, despite the focus and funding for the PMJAY scheme and the plan for primary health centres, everything fell short in the aftermath of the Covid-19 pandemic, he said. "It was the public sector that had to provide the bulk of Covid-19 care. [Public] Health and wellness centres lost attention and, perhaps, also funds. Most public health services got re-purposed as Covid hospitals or care centres. This pushed many poor patients towards the private sector or into a no-care zone. Many essential public health services got disrupted, and will probably set back past achievements in disease control programmes and reproductive and child health," added Sundararaman.

Critics of the government's decision to invest in universal health insurance for Indians hope that there would be a reversal going forward, that more would be allotted to public health systems rather than private healthcare or private insurance. "As opposed to health insurance, I hope that the Centre and the states move more towards health schemes which are universal in nature and at the same time help make healthcare services more accessible and affordable for everyone," said Chhaya Pachauli, director at Prayas, an organisation that works on health equity.

"There needs to be greater focus on universal healthcare schemes rather than health insurance," added Pachauli. "Rather than diverting huge money to health insurance schemes, which are mandated to support a small section of the population, are based on stringent inclusion and exclusion criteria creating more barriers to access and depend heavily on private providers for their execution leaving a huge window open for patient exploitation, it would be much wiser if governments invest the same resources on expanding their own infrastructure and making quality services available to people free of cost or at affordable rates."

More reliance on the private sector would be disastrous, warned Sundararaman. "Other essential and non-Covid health services would be undermined if the government does not step up."

Hunger and growth in India

There has been an increase in child undernutrition in 2019-20, according to new data from the fifth National Family and Health Survey. In 18 of the 22 states for which data has been released, over a quarter of children are stunted. India already has the largest number of stunted children in the world.

India's progress in the National Nutrition Mission took a hit in 2020, said Purnima Menon, senior research fellow at the International Food Policy Research Institute. "For a few months, the health and nutrition frontline workers also supported Covid-19 efforts on surveying, tracking, tracing and more. Various other services were stalled."

Many of the nutrition mission activities, including counselling, measuring children and organising group gatherings, require person-to-person contact. "All of these were deeply affected by the pandemic and the resulting lockdowns," Menon said.

Going forward, she said, it would be necessary to restore health and nutrition services. "But more difficult will be addressing food insecurity which is a consequence of the economic impacts of the pandemic," added Menon. This food insecurity exists in many forms--from the poor quality and quantity of food to reduced number of meals and abject hunger.

Not only is undernutrition a problem in general, it specifically hits people in vulnerable communities hardest, such as those in tribal or oppressed caste communities, said Sylvia Karpagam, a public health doctor in Bengaluru. "Food distribution schemes in India are weak and were already stretched. The pandemic and lockdown further dealt a blow to them. Covid-19 has been an excuse for the government to neglect its responsibilities," said Karpagam.

For example, "there are already several issues with organisations like Akshaya Patra refusing to give eggs to children in their midday meals due to their religious beliefs despite the nutritious content of eggs," Karpagam pointed out. Some governments have also stopped giving dry rations, even though it is mandated in the National Food Security Act 2013.

Price of healthcare

Healthcare in public hospitals in India is largely free. Private healthcare, on the other hand, is a blanket term covering everything from small clinics to super speciality hospitals. In the last few years, there have been instances where private hospitals inflated prices of some items by up to 1,737%. In 2020 too, many aspects of pricing were distorted by the pandemic which was reported in IndiaSpend's The Price of Covid series.

Although patients have often suspected that they were being fleeced by private hospitals, and public health specialists have called for price regulation, the lack of action on this front meant that during the pandemic many patients struggled to pay for private treatment in 2020 too.

"I hope that the governments take their lessons well from the Covid-19 experience and get serious about private sector regulation now," said Pachauli. "The Clinical Establishments Act, which could regulate this sector and its prices, has been adopted by many states. But this seems tokenistic as there has been virtually no implementation on the ground."

Spending on health

In the Union budget for 2020-21, Rs 67,111 crore ($9.18 billion) was allocated to the health ministry, including funds for research. The state governments have their own outlay for health in their budgets.

The National Health Mission, which oversees core areas of public health such as maternal and child health, was allotted Rs 33,400 crore ($4.5 billion), a 1.15% reduction from the previous fiscal's revised budget. Ayushman Bharat, the government's new insurance scheme, was allotted Rs 6,400 crore ($870 million).

The Union budget presented on February 1 did not, of course, factor in a pandemic or its expenses. The actual expenses on healthcare this fiscal year might have been beyond the allocations formally listed in the budget. Money was spent to tackle the pandemic in different ways--directly on the treatment of thousands who were admitted to public health facilities for Covid-19, on staff deployed for testing and tracing, ration for the poor, and on migrant workers who traveled to their hometowns during the national lockdown.

The actual expenses incurred by the Centre in tackling the pandemic would be clear only when revised estimates of the 2020-21 Union budget are presented. In 2021, more money needs to be allotted to healthcare, not only to fight Covid-19 but other diseases too, experts told IndiaSpend. "We need to see an increase in the budget allotted to healthcare," said Pachauli. "This is an old demand that we, in public health, have been raising even before this pandemic. The pandemic has accentuated the very need for an increased health budget. One cannot expect much from a health system which spends just about 1.2% of its GDP on healthcare."