Administration in intensive care

On July 5, the Defence Research and Development Organisation opened a 1,000-bed facility for Covid-19 cases which it set up in, reportedly, a record 11 days. On the same day, the Delhi government inaugurated a 10,000-bed facility which, we are told, is the largest in the world. No doubt the late Sardar Patel, the Congress leader the Sangh Parivar has appropriated as its hero, would be gratified that both hospitals have been named for him. 

What’s more, we have shown those encroaching Chinese that anything they can do —such as building a hospital in a week — we can do better, jolly good show and all that.

Beyond the back-patting indulgence, the wider implications of two new mega-medical facilities in the capital demand consideration. The first: The delayed response time. Why did the decision take so long? Delhi has been an acknowledged hotspot of the pandemic since April, one reason the borders with neighbouring National Capital Region cities remained more or less closed till June. By then, the shortage of hospital beds was manifestly evident, prompting that absurd order (since reversed) from Chief Minister Arvind Kejriwal banning non-Delhi-ites from access to state hospitals. For all the fuss over these two facilities, Maharashtra, the leader in the number of Covid-19 cases, had started by late May jumbo treatment centres in Bandra-Kurla, Mahalaxmi Racecourse, Goregaon and Mulund. 

Anticipating crises is not the strong suit of Indian governing institutions. If that were the case, similar facilities with military help could have been set up already in those more remote parts of India where the availability and quality of medical facilities are dire at the best of times. 

This raises the bigger point. Why can’t this model of impressive asset creation at short notice be replicated as a standard operating procedure for health policy throughout India? In fact, the military’s knowhow of running and maintaining field hospitals in inhospitable conditions could have been leveraged long before Covid-19 struck. 

True, Covid-19 has now surpassed other infectious diseases except TB in terms of its death toll. But before this pandemic, India suffered a raft of medical conditions that would count as crises in any developed country. Some three million Indians contract TB alone (almost certainly an underestimate) and 40 per cent of the population has “latent” TB. Then, a host of respiratory diseases such as pneumonia, diarrheal ailments and mysterious untreatable flus, plus chronic non-communicable diseases such as malaria, heart ailments and diabetes carry off large numbers of Indians each year. 

Many of these illnesses and deaths could be avoided if India had a functioning health system. The figure of hospital beds per 1,000 population — the ratio is probably worse in rural India — has been bandied about by shocked commentators for decades without much change. The health policy of 2017 mandated at least two beds per 1,000 (which is still below the World Health Organization standard of three beds). This would mean adding roughly over two million beds over the next decade. But governments since the 1960s have kept health expenditures low — just over 1 per cent of gross domestic product. As always, it is the poor who suffer the inadequacy of medical care most. The Ayushman Bharat medical insurance scheme has undoubtedly expanded their access to medical care but, as the Covid-19 pandemic has shown, even the best insurance scheme cannot substitute for medical infrastructure on the ground nor the availability of doctors, nurses and basic equipment. That message is still to penetrate the thick-walled bhavans of Raisina Hill. 

Covid-19, the experts tell us, offers an opportune moment for “second-generation reforms”. But so far, the reform has taken the familiar form of loan moratoriums and interest rate subventions. Humungous expenditures are being planned for roads and highways as a means of creating jobs. Spending similar amounts on building primary, secondary and tertiary medical care in underserved areas could also create just as many jobs. 

The pandemic could have also offered good opportunity to augment medical services in rural and moffusil areas. We know most medical personnel are unwilling to serve in the more remote areas of the country. There are ways around this, such as Kerala’s barefoot doctor network. But the government needn’t go so far south in search of solutions. The ability to roll out top quality care in challenging situations is on display every 12 years at the Kumbh melas. At the Prayagraj (nee Allahabad) ardha-kumbh last year, a makeshift 100-bed “central hospital” (complete with path labs, ultrasound, x-ray and ICU units) treated 50,000 patients a day for the duration and even attracted patients from surrounding areas. 

The Kumbh administration’s ability to create decent civic facilities that most Indians can only dream of in ordinary times has been famously documented in a Harvard study. The bigger question is why this cannot be the norm rather than the exception for civic administration and medical infrastructure. In other words, why are the abilities of India’s governing institutions geared for short-term measures?