COVID-19 and a country club India must leave

COVID-19 and a country club India must leave

By, Vikram Patel is the Pershing Square Professor of Global Health at Harvard Medical School

Context

• This article is about the performance of India, USA and Brazil in handling the COVID-19 pandemic.
• These three countries share the toxic levels of historic inequalities which affect every structure of society including, most importantly, the health-care system.

Stark inequalities

• The value of investing in a just public health-care system has never been as starkly obvious during the COVID-19.
• 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.
• However, on this occasion, for the first time, the wealthy and the powerful in their urban palaces have found themselves marooned.

On universal coverage

• The countries which were able to handle this pandemic well and revive their economy like Singapore are because of their 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, investment in public-health infrastructure 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.
• 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.
• 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.
• 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

• Even if the pandemic has hit the poor the hardest, it has also crippled the nation.
• 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.