Tag: health expenditure

Healthcare for the Elderly: Is Insurance the Best Solution?

With an ageing population, these are issues that need to be considered before expanding insurance-based healthcare for the elderly rather than direct provision of services through public hospitals.

The government has recently announced an extension of the Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme for all old persons above 70 years of age. The AB-PMJAY was so far available only for the bottom 40% of the population, thereby covering about 12 crore households (based on the deprivation lists according to the Socio-Economic Caste Census, SECC 2011 and some additional groups such as anganwadi workers and ASHAs).

With this development, all old persons except for those who are getting health benefits from other government schemes, will be eligible for the health insurance under the PMJAY. The benefits remain the same, i.e. a cover of up to Rs 5 lakh per year per household towards hospitalisation expenses. While it is welcome that the government is acknowledging geriatric health needs bringing attention to issues of an ageing population, it needs to be examined whether the publicly funded health insurance (PFHI) schemes is the best route to achieve access to health for the aged. 

There is abundant research on the experience of PFHIs in India, many based on earlier state schemes and few recent ones since the launch of the PMJAY, which raise a number of issues. The PFHIs, including PMJAY, include only inpatient expenses, whereas a significant proportion of out-of-pocket expenses is on outpatient care and within that on medicines. The latest National Health Accounts (2019-20) for instance estimates that of the current health expenditure (CHE) in the country, 19.3% is on outpatient curative care and an additional 22% is on over the counter and prescribed medicines. 

Also read: Wasting is the Blind Spot of Child Malnutrition in India

As far as hospitalisation is concerned, issues of equitable access to accredited hospitals across the country, continuing OoPE despite being covered by PFHIs, problems of cherry-picking of cases and unnecessary procedures in private hospitals etc. which have been seen in the context of these insurance schemes remain. Further, it has also been seen that such insurance schemes tend to escalate overall healthcare costs for the economy. With an ageing population, these are issues that need to be considered before expanding insurance-based healthcare for the elderly rather than direct provision of services through public hospitals.

The American model, where through the Medicare and Medicaid programmes health insurance is provided to the elderly and the poor while the rest of the population depends on private health care usually financed through employer-provided or privately purchased health insurance is a case in point. America has one of the highest health expenditure to GDP ratios in the world at 16.6% compared to about 11.3% average for EU countries and yet has greater exclusions and poorer health outcomes overall. The government health expenditure in America, despite the lower coverage is 9.62% compared to the EU average of 8.38% (despite most countries in the EU having wide-ranging public health systems with varying financing models compared to the mostly private health care model of the US). 

Further, while the extension of PMJAY to all people above 70 years might ease the burden of hospitalisation to an extent for some people, the pressure of outpatient expenses remains even on those who are covered. The Longitudinal Ageing Study in India (LASI) conducted in 2017-18 shows that 7.7% of those above 60 utilised inpatient care over the last one year and 29.3% of them utilised outpatient care in the one month prior to the survey.

The mean out-of-pocket expenditure (OoPE) of those above 60 years of age on inpatient care for the last hospitalisation during one year prior to the survey was Rs 8028 in public hospitals and Rs 31,933 in private hospitals. Private hospitals are much more expensive and almost 60% of all hospitalisations among those above 60 were in private hospitals (43.7% among the poorest). There is hence a huge gap in access to good quality and affordable inpatient care in government hospitals. 

For outpatient care, in one month prior to the survey the expenditure was Rs 1,149. Therefore, while the out-of-pocket expenses are indeed higher per episode for hospitalisation cases, the burden of outpatient care expenditure is also substantial and affects a larger number of people. The old age pensions that poor old people receive through the social security schemes of the government hardly covers for even just the outpatient curative care expenses.

Also read: Algorithms of Exclusion: Why Start-Ups Are Not Solving Our Mental Health Crisis

Most states give old age pensions of only Rs 1,000 or less per month (with the central government contributing Rs 200 for those in the 60-79 age group and Rs 500 for those above 80). Over 55% of the old people are covered by these schemes but most other old people are not covered by any employment-related sector pensions given the very high levels of informal employment in India.

The burden of chronic diseases which require care and attention is also high amongst the elderly. These expenditures are not accounted for in the usual health expenditure surveys which capture data on hospitalisation and recent out-patient visits. According to the LASI survey, for example, among those aged above 60, 34.6% self-report having cardiovascular diseases, 32% hypertension or high blood pressure and 14.2% diabetes or high blood sugar. More than half report eye or vision related problems, 26.7% are underweight. There is a need for comprehensive health, nutrition and social security services designed for the elderly. 

There is the National Programme for Health Care of the Elderly (NPHCE) which needs to be supported with adequate budgets and support. Its success, however, depends on the overall strengthening of the public health system at all levels from the primary to the tertiary. It is well known that the public health expenditure as a proportion of the GDP in India remains very low. The shift in priorities towards insurance schemes weakens the system further and in the long run is taking us away from building an equitable, good quality health system for all. We must pause and rethink the direction in which we want to take our health system so that we achieve universal health care with inclusion of the most marginalised. 

Dipa Sinha is a development economist.

‘Pushing More Money into Education Will Achieve Nothing’: Finance Secretary

Even for higher education, according to the finance secretary, pushing more funding will only be “a sop to the conscience of the intelligentsia that we are doing something for it”.

New Delhi: In an interview to The Hindu where he defended the Union government’s decisions in this year’s budget, finance secretary T.V. Somanathan seemed to suggest that the quality of education in India will not improve even if the government puts more money into the sector.

India has more than enough school teachers, Somanathan argued. “It’s not quantity in education. It is quality, whether the teacher attends the school. Does he teach well? Does he make the child do homework? Does he not just pass the child whether the child has learned or not? These are not money. So actually pushing more money into education will achieve nothing.”

Even for higher education, according to the finance secretary, pushing more funding will only be “a sop to the conscience of the intelligentsia that we are doing something for it”. What is really required, he said, was to “depoliticise the university”.

While the government’s outlay for health has increased this year, in the last two financial years, the government actually spent less on education than it had originally planned.

Chart: The Sharp Decline in Total Expenditure on Social Security Schemes

On health, Somanathan claimed that the government is putting money in the “right places”, and the funding may seem low but that was fine as these schemes are “frugal”. “In Health, we have to put money in the right places. I think the National Health Mission is doing pretty well and are pretty frugal. That frugality is good as money is scarce. Throwing money at private insurance is not a good idea. We are setting up 150 nursing colleges that will expand supply of nursing for both domestic and international markets and create jobs. So in health, also there’s not much to be concerned. Yes, if we had more money, of course… ,” he told The Hindu.

The planned expenditure on health has gone up for the upcoming year, to Rs 88,956 crore. What is worth noting, however, is that the revised estimates for the last year (Rs 77,351 crore) is substantially lower than what was planned (Rs 86, 606 crore).

While agreeing that India’s export outlook didn’t look great for the coming year because of the global economic situation, Somanathan said that in fact this was a good thing, since India has a weakness when it comes to exports anyway. “Exports, with the global situation, no… But again, the positive side for us is our weakness as an export powerhouse is our strength when exports are declining. Because we are not so intensive in exports, unlike East Asia or somewhere else. United States’ recession hits East Asia pretty hard, much harder,” he said.

The finance secretary also said that he believes the “current account situation will be manageable through an easing of import costs on petroleum particularly, and easing on gold, silver, platinum through customs duty action, which has happened, and possibly some reasonably favourable capital account inflows”.

The remarks by Somanathan on education drew criticism from the Akhil Bharatiya Vidhyarthi Parishad (ABVP), a student body affiliated to the Rashtriya Swayamsevak Sangh.

“The comment of the Union finance secretary is not only contrary to the collective understanding on the subjects of education from the extensive discussions held at the time of National Education Policy 2020, but it also ignores the concern expressed by Prime Minister Modi from time to time regarding the subject of education,” a press statement issued by ABVP said.

The student body said his remarks “shows his lack of adequate understanding on the subject of education and his statement is highly irresponsible”.

Health Spending, COVID-19 and Desired Outcomes

To understand how vulnerable a country to a pandemic is, it is necessary to create an index that not only consider existing level of health infrastructure but also ability of a country to spend, to create more healthcare assets.

The COVID-19 pandemic has crippled the global economy and showcased the urgent need for better health infrastructure and efficient accessibility to healthcare services.

India’s healthcare system is not in great shape. There are gaping holes when it comes to availability of hospital beds, doctors, and paramedic staffs to react to a health emergency. What is true for India is true for many other countries – a poor healthcare infrastructure may make it difficult to react to a health emergency.

However, as COVID-19 has shown, merely spending more on health may not necessarily lead to a desired health outcome.

For instance, data reveals that the US government spent almost double the amount on medical care in comparison to eleven other wealthier nations. The higher amount spent by the US (and this excludes money spent by the private insurers) is mostly on account of high costs of labour, pharmaceuticals, and administrative costs, and this do not translate to having better health outcomes. Life expectancy is still lowest and infant mortality rates still the highest in the US, in comparison to the 11 developed countries in the OECD group.

To understand how vulnerable a country to a pandemic is, it is necessary to create an index that not only consider existing level of health infrastructure but also ability of a country to spend, to create more healthcare assets.

We create a new index – Health Infrastructure Index (HII). HII ranks countries based on availability of physicians, dentists, nursing and midwifery personnel, pharmacists, hospital beds, number of hospitals, and skilled health care professionals – such as anaesthesiologists, radiologists, etc. – all of which are normalised with respect to the population. Additionally, HII accounts for variables such as money spent on account of healthcare activities by the governments.

Also read: How Chhattisgarh Is Deliberately Inviting COVID-19 To Stay Over

India gets a lower rank, 113 out of 184 countries, putting her in the vulnerable category in the fight against COVID-19. Luckily though, the COVID-19 fatality rate is low. This may be because of factors such as tropical climate (virus are less active in hot and humid climate), young population (less likely to be comorbid), and universal vaccination program (administering Bacille Calmette-Guérin “(BCG)” vaccination).

South Asian neighbours offer a mixed bag: Bangladesh (120), Pakistan (160), Nepal (109), Sri Lanka (108), Bhutan (135).  In general, we find the high-income countries scores well in terms of HII (Figure 1). Western European and Scandinavian nations have high HII scores, which is not surprising. Monaco (1), Switzerland (2), Norway (3), Iceland (4), and Germany (5) are the among the countries with highest HII scores. Number in the parenthesis indicates the rank. It implies these countries are better equipped to handle pandemic. Whereas African countries such as Somalia (184), Niger (182), Guinea (181), and Central African Republic (180), have a very low HII score making them most vulnerable. Afghanistan ranked 183.

Figure 1: HII Score and Log Income

Among the middle-income countries, Cuba (10), Uzbekistan (21), Kazakhstan (25), and Russian Federation (27) performed well, making them less vulnerable. Per-capita availability of doctors is highest in Cuba, making it less vulnerable. The erstwhile Soviet block scores well in terms of availability of hospitals and hospital beds, and money spent as a percentage of GDP on healthcare.

The HII index highlights critical areas where domestic or multilateral interventions are required. For instance, multilateral organisations such as WHO, IMF, or World Bank, may want to give more funding to the countries, which are more vulnerable in terms of HII. Even within a country, HII showcases the areas where a government, or multilateral organisations, should intervene, and how they may prioritise such interventions.

It is to be noted, although, COVID-19 is equally likely to affect all the low, middle, and high-income countries in terms of spread of the virus. Plotting HII against the number of COVID-19 deaths (Figure 2), reveals a horizontal trend suggesting that COVID-19 is equally likely to affect countries irrespective of their level of per-capita income.

Figure 2: HII and number of COVID-19 deaths

However, the lower-income households, within a given country are more to be severally affected thus far. Evidence suggests 5% of the poor income-households residing in the low- and middle-income countries, spend disproportionately more than the rich as a percentage of household income on health care. For a rich nation, like US, life expectancy for the bottom five percent of poor people did not change between 2001 and 2014. However, during the same period, the life expectancy of people in the high-income bracket showed improvement. Poor health outcomes for individuals with lower income directly result from exposure to harmful environments. In Europe, it was found for the disadvantaged, unmet need for medical care tended to be higher in countries with larger income inequalities, regardless of the average economic standard in terms of GDP per capita.

Irrespective of what the HII suggests in terms of disbursement of COVID-19 fund, some world leaders are demanding that China should pay the price. China’s actions in combating the pandemic are in violation of Article 6 and 7 of International Health Regulation (IHR). If any government wants to sue China, must do so by identifying the jurisdictional basis for such action. Article 56 of IHR allows such punitive action but it can only be executed when China agrees to the wrongdoing on its part. Similarly, to protect their economic and tourist activities, some countries such as Turkey, Indonesia, Russia, etc., have under reported number of COVID-19 cases. Governments of the affected countries can also ask for compensation. To play it safe, WHO had to introduce a total cross country travel ban.

Also read: What NFHS-5 Says About Violence Against and Empowerment of Bihar’s Women

There can be a spillover effect. Many governments are imposing sanitary and phytosanitary sanctions and imposing restrictions on goods originating from China. This has seen an increase in the number of lawsuits, especially, under Article XI of WTO (dealing with quantitative restrictions). Investment arbitration to settle disputes between foreign investors and host States can come in handy.

International Investment Tribunals, and other tribunals can be asked to review the States’ guidelines against the pandemic and thus can address many disputes related to the same. Peru, for example, has developed online digital platform aimed at providing public access to key pieces of information about arbitration. With more countries following the suit and COVID-19 fatality waning, we may be heading for a better time.

Nilanjan Banik is professor, School of Management, Bennett University, Greater Noida. Julien Chaisse is professor, School of Law, City University of Hong Kong; and President, Asia Pacific FDI Network.

Activists Slam Reducing Budget Allocation for Critical Women and Child Nutrition Schemes Amid COVID

Allocation for children, who constitute 40% of the population, is the lowest in a decade; new schemes make comparisons difficult, and real term expenditure is down on most heads.

New Delhi: The right to food campaign activists on Wednesday slammed the Union Budget 2021 for cutting down allocations for critical nutrition schemes such as integrated child development services (ICDS), midday meals and maternity entitlements, despite there being “alarming evidence of extreme food insecurity” ever since the national lockdown due to COVID-19 pandemic began in March 2020.

Speaking at a press conference organised at the Indian Women’s Press Corps (IWPC) in New Delhi, the activists highlighted how the allocations have been reduced despite recent data suggesting that the impact of the lockdown was still lingering among the informal sector workers and their families.

On health and nutrition

Dipa Sinha of the campaign said that “children and child malnutrition have once again been neglected in this current budget that was presented on February 1. Despite this being a longstanding issue in the country, over many years we have seen that children under six, pregnant and lactating women and adolescent girls, who constitute the critical age group to address the issue of malnutrition, have been invisible and been neglected.”

She said, “There was some progress, particularly after 2005-06 and following the Supreme Court orders and with the ICDS getting universalised. The data between National Family Health Survey (NFHS) 3 and 4 shows a 10 percentage point decline in stunting. This is good, but too slow compared with the global standards. But, between NFHS 4 and 5, out of the list of 22 states and UTs, we see that in most there is either a stagnation or there has been a decline in cases of malnutrition.”

Giving out the NFHS findings on stunting, wasting and undernutrition, she added that in the last one year due to the pandemic, the lockdown and economic distress, the incomes in the informal sector have not come back. A number of primary studies show that this has resulted in increased hunger and food insecurity. Also, that did not last only up to to the lockdown in April-May, but it still continues.

Also read: Child Nutrition Levels in India Worsened Over Last Five Years, Finds NHFS Survey

The right to food campaign conducted a survey on food insecurity along with a number of other groups, between the period of October and December 2020.

Giving out the brief findings of this survey, Sinha said, this survey focused on poor and marginalised communities. They reported that their level of food consumption – cereals, rice, wheat and pulses – in October was even less than what they were consuming pre-lockdown. “So we know that there is a situation of hunger and food insecurity. We know that the gains that we were making on malnutrition have not been continuing. And because of this overall economic slowdown, we hoped that this budget would take some bold steps to address this problem of child malnutrition and contribute to reducing childhood hunger,” she said.

But, she added, it was very disappointing to see that the allocation has reduced for most of the schemes that address these problems.

In the beginning of her speech, the finance minister appeared positive because she announced a flagship programme ‘Poshan 2.0’ despite ‘Poshan 1.0’ being quite a failure. “So it seemed that some more money would be put into the schemes. But what it actually means is that while earlier there was an umbrella ICDS, now two new terms have been brought in – Saksham and Samarthya – and basically the schemes have been clubbed together.”

Also read: Does Mission Poshan 2.0 Have the Ammunition It Will Need to Be Successful?

So, Sinha said, it is not easy to compare the Anganwadi budget of last year to this year. “But what we can compare is the Anganwadi budget of last year with the Anganwadi plus Saksham budget of this year. However, even that has declined.”

Reduced allocation for essential nutrition schemes

The budget allocation for Anganwadi services last year was Rs 20,532 crore whereas the allocation for Saksham, which along with Anganwadi includes the National Nutrition Mission, is now Rs 20,105 crore. So, there has been an actual allocation of over Rs 400 crore less for a programme which now clubs three other schemes along with Anganwadi, Sinha added. A lot could have been done to improve supplementary nutrition if more money was given.

What is also alarming is that if you look at the data on the number of beneficiaries being covered under Anganwadi, then that too has also come down consistently in the last five years, she added.

Another scheme implemented by the Ministry of Women and Child Development is the Pradhan Mantri Matru Vandana Yojana (PMMVY). This was started after the National Food Security Act (NFSA) included an entitlement of at least Rs 6,000 for all pregnant and lactating women. Considered path-breaking, for the first time it provided universal maternal entitlement for supporting women during pregnancy and the six months of exclusive breast-feeding. This again has been clubbed with Samarthya, Sinha said.

A woman and her child wait to receive food during a 21-day nationwide lockdown to slow the spreading of COVID-19 in Kolkata, April 3, 2020. Photo: Reuters/Rupak De Chowdhuri

The allocation for PMMVY last year was Rs 2,500 crore but the allocation for the clubbed scheme this year is Rs 2,522 crore, she added. “So it would not be enough to cater to all the eligible beneficiaries. Also, while the Act says ‘all women’, the scheme only covers the ‘first birth’. And while the Act calls for providing Rs 6,000, the scheme only provides Rs 5,000.”

In the midday meal scheme, there is a nominal increase in the allocation from Rs 11,000 crore last year to Rs 11,500 crore this year, she further added. “But in real terms that is not enough to make up for inflation.” Here too the number of beneficiaries have declined over the years.

If we don’t put funds behind these programmes, there is no point in announcing new schemes every year.

Last year, hardly 50% of the allocation was spent because the Anganwadis and schools remained closed for most of the year due to COVID-19. So, this year, one expected an even bigger push, she further added.

Also read: India Ranks 94 Among 107 Countries in Global Hunger Index 2020

Nothing much for the informal sector, and other vulnerable groups

Jean Dreze, visiting professor at Ranchi University and food rights campaigner, said this year’s budget reflects the central government’s denial of the livelihood crisis that continues to devastate the informal sector in India. According to a survey by Azim Premji University, he said, informal sector workers today are still earning about half of what they were earning before the lockdown.

“For many of them the lockdown continues in one form or the other – the passenger trains are still not running, the schools and anganwadis are closed, jails are not accessible for visits, the district courts are functioning at half capacity. All kinds of services and facilities are still not functional and that affects huge sectors of the economy,” he added.

Informal sector workers rush to board a train in Thane. Photo: PTI

This situation called for bold measures that served the dual purpose of putting money in people’s hands and stimulating the economy. “But,” Dreze lamented, “few measures of that kind can be found in the budget.”

There was also a need to pay special attention to vulnerable groups such as children, pregnant women, the elderly and others. Children constitute 40% of the population, he said. The campaign pointed out that this year the share of children in the budget was the lowest in 10 years at 2.46% as against 4.76% in 2012-13.

The budgetary allocation for ICDS, maternity benefits, Pradhan Mantri Gramodaya Yojana (PMGY) and even school education has been cut. Likewise, the allocation for the National Social Assistance Programme, the lifeline for the elderly, has been copy-pasted from last year’s, he said.

Also read: This Year’s Budget Is Critical to Ensure a Comprehensive Nutrition Response

Massive budget cut for ICDS, again

Also, Dreze pointed out that this is the second time after 2015-16 that the ICDS budgetary allocation has been cut. “That was the first full budget of the NDA government and there were massive cuts. Also, they were only partially reversed.” In real terms, he said, the ICDS budget was 25% lower than 2014 despite the population growth, and for midday meals, it is lower in real terms by 33%.

“In 2014, the ICDS budget was around Rs 16,000 crore. At today’s prices that corresponds to nearly Rs 23,000 crore. The Saksham budget, which includes ICDS, is around Rs 20,000 crore only out of which ICDS will get around Rs 17,000 crore.”

Likewise, he said, for the midday meal scheme, in 2014 the budget was around Rs 12,000 crore and now it is Rs 11,500 crore. As such it is less than what it was seven years ago while in real terms as per that rate it should have been at least Rs 17,000 crore.

So there is a big attack on these programmes and that has resulted in lower coverage of ICDS services, which have been declining year after year, Dreze said.

He added that the campaign, along with others, can take some credit that India finally has some semblance of a social security system for the informal sector, consisting of six pillars: public distribution system, MGNREGS employment guarantee scheme, pension schemes, maternity entitlements, ICDS and midday meals.

Barring NREGA and PDS, the other four have been severely hit by the cuts in budgetary allocations, he said.

Midday meal scheme in Rajasthan. Credit: Reuters

Schemes such as the midday meal, if implemented properly, can help tackle child malnourishment . Credit: Reuters

‘Blatant disregard for malnutrition, children’

Community pediatrician Dr Vandana Prasad, who is also associated with the campaign and Jan Swasthya Abhiyan, said it was shocking that the budget was so blatant in its disregard for malnutrition and children. She said UNICEF and WHO have been predicting rise in child mortality in India and across the globe, and yet the response to data showing deterioration due to the pandemic has been met with cuts and deduction in budgetary allocation. “What does it say about the intent of the government?”

Focussing on ICDS, she said, “It is not sufficiently understood that the Anganwadi system is the only village-level platform for all schemes, programmes and interventions for women and child health and nutrition. It provides last mile connectivity to whatever you may plan.”

She said there are 1.4 million anganwadis across the country and those are still not fully universalised. “There is only about 50-60% coverage for children. While the delivery of the scheme rests on the workers,” she asked, “what has been done for them.”

“They are still not treated as workers despite their working on pandemic programmes, COVID programmes and even election programmes. They have not received any paisa in this budget whereas Rs 3 lakh crore extra have been earmarked for other government functionaries.”

Combined Fiscal Deficit of Centre, States May Reach 14% in FY21: Rangarajan

According to Rangarajan, the fiscal deficit may further go if the government decides to go in for additional borrowings to meet GST compensation part.

Hyderabad: The combined fiscal deficit of states and the Centre during the current year may go up to 14% against the mandated level of 6%, former Reserve Bank of India (RBI) governor C. Rangarajan said on Thursday.

Speaking at a programme organised by the ICFAI Business School in Hyderabad, the former chairman of the economic advisory council to the prime minister said banks should neither be timid nor adventurous while lending as the loans of today should not become NPAs of tomorrow.

“So therefore we are essentially talking about 13.8% or 14% of the gross domestic product (GDP) as the overall fiscal deficit of the states and the Centre. It is obvious this is twice the mandated level. The mandated level for both the Centre and state is 6% of the GDP.

“It is twice or even more than twice of the estimated figure,” he said.

According to him, the fiscal deficit may further go if the government decides to go in for additional borrowings to meet GST compensation part.

Rangarajan said RBI’s monetary policy is “consistent” under the present circumstances and as a result banks have adequate liquidity for more lending.

He opined that governments need to spend more when the economy is in slump and it is essential to spend on healthcare, relief and rehabilitation and on stimulus to spur the economy.

“There are three types of expenditure required. First, expenditure on healthcare; second, expenditure on relief and rehabilitation; and third, expenditure on stimulus. And it appears that the government both at the Centre and states are somewhat slow in increasing expenditures,” he said.

He said the economic growth of the country and other nations has come to a grinding halt due to lockdown to contain the spread of coronavirus.

However, he said capital flows into India was encouraging during the last three months.

Delhi’s Private Hospitals Now Have a Reason for Inflating COVID-19 Bills – Health Insurance

While the government’s order on price cap is applicable to all COVID-19 patients, private hospitals have found newer ways to overcharge patients.

New Delhi: Expecting their baby in the first week of September, Bidintha Brahma and her husband Biju Mushahary had prepared themselves for the delivery procedures to be conducted at Phoenix Hospital – a birthing and neonatal hospital in Greater Kailash. “We had no idea that our plans would not work, and that we would have to face entirely different consequences,” said Biju.

On September 5, while the two of them were still in Phoenix, they found out that Bidintha had tested positive for COVID-19 and were asked to shift her to a COVID-19 hospital at the earliest. The next afternoon, she was admitted to Moolchand Hospital.

She delivered her child that very day, on September 6, after a C-section surgery. She was kept in the ICU for a night and later shifted to a private isolation ward, while the child was kept away from her.

The couple had been advised by another doctor to get a retest done because Bidintha had no COVID-19 symptoms. The second test reports reached them on September 6, and it was negative. These were both RT-PCR tests done at Noble Diagnostic Centre in Hari Nagar.

Under normal circumstances, she could have been discharged three days after the Caesarean surgery but the COVID doctors suggested she stay put in the hospital for at least two weeks. “While it was all too confusing, we knew that she could very well be taken home as she was asymptomatic. We did feel that it made no sense to keep the mother and child apart for that long,” said Biju.

Also read: We Need to Consider Nationalising Private Hospitals if We Are to Avert a Total Disaster

He insisted that her negative test reports be taken into account and she be discharged after three days. The doctors finally agreed on the condition that Biju would have to sign a ‘discharge against medical advice’ (DAMA) document.

On September 8, Biju got his child released from the hospital and asked for the bill to be paid for Bidintha’s discharge scheduled on the next day. He was told that the bill until then was around Rs 1.23 lakh, and he would need up to an additional Rs 20,000 for a day’s cost (that means Rs 20,000 per day cost for three days after the child was delivered.)

When it was time for her discharge on September 9, the billing department suggested Biju opt for insurance payment. “I refused to pay via insurance for two reasons: first, my insurance did not have a maternity cover and I was not sure if she would be treated as a COVID-19 patient at all; second, insurance processing generally takes a couple of hours and we were not willing to wait any longer,” said Biju. The billing department, however, was persistent and said that the final amount will be lesser with insurance.

When Biju received the final bill, the amount charged for three days of Bidintha’s treatment had now reached Rs 2.17 lakh. He was shocked to note this sudden increase. “That bill was of Rs 1.8 lakh – again a marginal increase from what they had informed me the previous day,” said Biju.

Bidintha was supposed to be discharged at 12 pm, but this ordeal delayed it until 6 pm. “We were tired and had no energy to fight with the hospital anymore. I cleared all payments, but the hospital refused to come clean and give me the provisional bill until the previous day.”

Issues of abrupt and unexplained overcharging in private hospitals are not new. Despite the Delhi government’s June 20 order on capping prices for COVID-19 treatments, private hospitals continue to flout these rules unabashedly and keep the patients in the dark.

The latest in their series of embezzlement is this erroneous and convenient misinterpretation of the applicability of the price capping for insurance patients. Moolchand Hospital itself has far too many examples of this nature.

Also read: The Uneven Decline of Health Services Across States During Lockdown

Inflated medical bills

When Sunny Guliyani found out that his 62-year-old mother Asha had been charged Rs 3.73 lakh for COVID-19 treatment at Moolchand hospital, he wrote a complaint letter to R.N. Das, the Delhi government’s nodal person for complaints against private hospitals. He wrote that he’s mentally disturbed because the insurance company was not ready to make the payment. Therefore, he had to pay through his credit card at a 24% interest rate charged by the bank.

On August 10, Madhu Handa, medical administrator at Moolchand Hospital, responded to this complaint forwarded by Das to the hospital. He noted that the patient was admitted on a cashless/credit basis based on approval by the insurance company and that they could have availed the capped rates if they opted for a self-pay basis instead. His response attributes the hospital pricing to “due to lack of clarity around applicability of capped rates for cashless patients.”

Inayat Singh Kakar, a health rights advocate associated with the People’s Health Movement, however, dismisses such explanations. “There is absolutely no basis for such a claim! The order makes no such exceptions for insurance patients at all. In fact, it is quite clear that the prescribed rates are applicable to all patients,” she said.

A medical worker takes care of a patient suffering from the coronavirus disease (COVID-19), at the Intensive Care Unit (ICU) of the Yatharth Hospital in Noida, on the outskirts of New Delhi, September 15, 2020. Reuters/Adnan Abidi

Along with many others, Inayat has been instrumental in helping patients navigate their way through the murkiness of healthcare systems during the pandemic. They have been highlighting loopholes, discrepancies and violations of the order on price capping in private hospitals.

“It’s one thing when private hospitals violate government directives and overcharge patients, but when the government also refuses to take action, it is very frustrating – more so because the Delhi government came back to power on the promise to provide right to healthcare for all,” Kakar said.

For her, these times have only reinforced the need for a stronger public healthcare system and regulation of private healthcare systems. “These are not new revelations, but demands raised by citizens for ages now. But, without structural repairs, how long can patients just keep running from pillar to post like this?” she asked.

In June, Nitin Gulati had also raised complaints about overcharging by Moolchand Hospital. His mother, Tarun Lata, was billed Rs 2.59 lakh for a 10-day period in the isolation ward for COVID-19 treatment.

The insurance company had initially agreed to pay as per the Delhi government’s price cap directive and not the full bill amount. His insurance covered Rs 1.02 lakh and an additional Rs 80,000 was added to the amount covered when Gulati’s employer intervened, but that still meant an out-of-pocket expenditure of Rs 80,000.

Also read: Despair in a Package: How a Private Hospital in Delhi Tried to Fleece a COVID Patient

Poor grievance redressal mechanism

On August 6, Gulati wrote a complaint letter to R.N. Das which was forwarded to the central government health scheme (CGHS) branch, even though his case had nothing to do with the CGHS. On August 7, Madhu Handa denied the charges and responded to the complaint and the CSO letter on violations by private hospitals saying the billing was done as per the agreement between the hospital and the insurance company.

Inayat explained, “You see, that order is completely silent on grievance redressal mechanisms. In absence of such mechanisms, patients are left on their own.” So far, they have approached several people from the Delhi government for help, and it has been quite ineffectual. “They are all public servants, so why should they not be accessible to the public? Why is the onus on the public to just hunt down email IDs?” she asked.

Das has admitted that hospitals cannot continue to charge insurance patients any differently. “The rate is fixed and there is no ambiguity about this. It is as simple as that. There is no loophole.” he said.

In response to violations by private hospitals, Amresh Kumar of Aam Aadmi Party, had earlier told me that he had done his bit by following the protocol of connecting the aggrieved patient to a higher official in the hospital.

Inayat stated that they have often had to rely on the media to get the government officials to act somehow. “Otherwise, when you contact them [government officials], instead of sharing contact details of bureaucrats, they give contact details of party workers. We do not even know what their official position is or what powers they actually have. My suspicion is that these are fairly junior officials who have been entrusted with the task of “managing” patients and not really helping them,” she said.

More importantly, she observed that the state government has invested their energies in trying to convince the patient to just pay the bills in hospital and make the least amount of noise. “It is as if the AAP wants to only hush everything and not enforce its own order!” she added.

Malini Aisola of the All India Drugs Action Network, who has also been working with Inayat on such cases, said, “More than three months on, the sheer lack of accountability and indifference of the government is just mind blowing. We have been repeatedly asking for audits of bills since June 20. At this point, the tally for the number of patients treated, under the government rates and hospital rates, in each private hospital for COVID should be made public.”

Also read: COVID-19 Patients Caught in the Middle of Tussle Between Private Insurers, Hospitals

Fragmented healthcare financing system

Jashodhara Dasgupta of SAHAYOG noted that these violations by private hospitals are all symptoms of a larger problem. She categorically stated that these problems have to be seen in the context of the need for a universal health coverage – a demand that she and other health rights advocates have repeatedly raised for decades. “We must continue with that demand and what that essentially means is healthcare for all and that it has to be tax-financed and cashless. The government has to raise this funding for all with the option for people who do want to go to the private sector exclusively to opt out,” she explained.

She explained that anyone under the CGHS coverage can access healthcare in a private tertiary hospital. “In the 1950s, that kind of health coverage was to be extended to the whole population but it never happened. It remained only with the fat cats who are a part of the government bureaucracy and the elevated representatives,” she said.

As per the National Sample Survey, 2018, 80.9% of people in urban India do not have any health expenditure coverage. For the masses who remain outside the ambit of these tax-financed health coverage mechanisms, private hospitals and insurance companies continue a free loot.

While the pandemic has only laid bare the inadequacies of our healthcare systems, we cannot lose sight of the principle problem: that the government is in a rush to privatise healthcare in all forms. With that intent, the government has found ways to compel people to pay premiums to private insurance providers. “That has basically two effects: first, because there is an insurance cover, hospitals decide to bleed out the insurance amount to the maximum; second, this private insurance model does nothing to address high out-of-pocket expenditure either,” said Jashodhara.

In absence of any stringent regulation and price standardisation method backed by a reliable grievance redressal mechanism, the collusion of private hospitals, private insurance, and government inaction has driven people to penury. It is, unfortunately, of no surprise that private hospitals and private insurance companies have managed to exhibit steady profit rates even during the pandemic. And, the patients are still hoping for the government officials to do something better than just sending them contact details of another official or forwarding emails.

Sweta Dash is associated with the Right to Food campaign.

COVID-19 in South Asia: India Lags Behind Pak on Stimulus, Lanka on Overall Performance

In each of the four large South Asian nations, the response of the state to the pandemic has been shaped by long standing and underlying political faultlines.

In parts 1 and 2 of this article, we have discussed the spread of the COVID-19 pandemic, preparedness (in terms of health infrastructure), and the government’s public health responses to the pandemic in four South Asian countries. In this concluding part, we discuss two issues: government economic policies and the politics that is shaping the response to the pandemic in these four countries.

There are two components of the economic response to the COVID-19 outbreak: health care spending to build infrastructure (like hospitals, hospital beds, quarantine facilities), procure equipment (like ICU equipment, ventilators) and prepare staff to deal with the pandemic; and expenditures to mitigate economic effects of physical distancing policies adopted to slow down the spread of the novel coronavirus that causes COVID-19. Using data from media reports and from the IMF COVID-19 Policy Tracker, we now present a summary account of the economic measures adopted in the four big South Asian countries.

Bangladesh

On the healthcare side, Bangladesh has so far not devoted much resources. On March 11, the Ministry of Finance increased allocation of $29 million (0.008 % of GDP) to the Health Services Division to support an expansion of healthcare spending. It is to be noted that this is not new budgetary allocation, but only a rerouting of existing expenditure.

Bangladesh’s expenditure on the economic side has been modest too. On March 31, the government announced a stimulus plan of 50 billion taka for exporting industries. The government has also expanded existing transfer programs, for instance those that will make subsidised food available to the poor. On April 15, Prime Minister Hasina announced additional measures: a 21.3 billion taka plan to support the homeless, 7.6 billion taka for those who have lost their jobs due to the pandemic, 7.5 billion taka for a health insurance scheme for government employees most at risk, and a 1 billion taka package to pay bonus to government doctors. Taken together, the total stimulus package is valued at 87.4 billion taka and is worth about 0.34% of GDP (in 2018-19). 

India

Expenditure on the health care side has been modest in India as well. On April 9, the Central government approved a 150 billion rupees package (0.1% of GDP) for states and Union territories to build health care infrastructure. Prime Minister Modi has also set up a fund for fighting COVID-19 called PM-CARES and has invited donations for all over the country and the world. While 2000 crore rupees (0.01% of GDP) from this fund has been earmarked for purchasing ventilators, critics point to lack of transparency in its operations.

Expenditure on the economic side – announced through two stimulus packages – of the crisis is equally small. The first package was announced on March 26 and the details of a second package was made available between May 13 and May 17.

The main components of the stimulus package are in-kind transfer of food and cooking gas, paltry cash transfers to lower-income households, insurance coverage for workers in the healthcare sector, some credit support to the micro, small and medium enterprises (MSME) sector, and wage support to low-wage workers. Taken together the total stimulus package amounts to about 1.1% of GDP. In addition, different state governments have announced their own stimulus measures, which together, account for about 0.2% of GDP.  Summing up the federal and state-level responses, India’s stimulus package amounts to a fiscal support of about 1.3% of GDP to deal with the economic crisis related to the pandemic.

The second stimulus package, which was announced by the Prime Minister on May 12 and details of which were laid out over the next five days by the finance minister, entailed a much smaller demand boost than was thought at first. The prime minister’s announcement on May 12 had raised expectations because it threw up a figure that was over 10% of GDP. Therefore, readers might be surprised to see our estimate of India’s COVID-19 fiscal stimulus at only 1.3% of GDP.

Also Read: Modi’s ‘Stimulus Package’ is a Gigantic Confidence Trick Played on the People of India

The difference between the figure contained in the PM’s announcement, i.e. 10% of GDP, and our estimate comes from three sources. His announcement included liquidity injections by the Reserve Bank – which is not part of fiscal policy. Both packages frontloaded already budgeted expenditures  –  which is just renaming existing budgetary allocations. Finally, most importantly, many expenditure items in the second package relate only to the medium run – they will have very little effect on aggregate demand in the short run. Once these aspects of the two packages are taken into account, the actual fiscal stimulus, relevant right now, turns out to be just 1.3% of GDP. It is striking that despite the mounting evidence of the worsening situation of migrant workers, there are no measures in this package to provide immediate relief to them.

Pakistan

Expenditure on the health side in Pakistan is slightly lower than in India. An amount of 25 billion PKR (0.07% of GDP) has been earmarked for purchasing equipment to deal with the pandemic. In addition, import duties on emergency health equipment has been eliminated. But the fiscal cost of this latter measure is not yet clear.

Pakistan’s expenditure on the economic side of the crisis is the largest among the four countries. A relief package was announced on March 24 worth 1.2 trillion PKR. Since Pakistan’s nominal GDP in 2018-19 was 35.95 trillion PKR, the stimulus package is valued at about 3.34% of GDP. The main components of the package are financial support to daily wage earners, cash transfers to low-income families, accelerated procurement of wheat, relief in fuel prices, support for health and food supplies, and financial support for small and medium enterprises.

Sri Lanka

The expenditure on the health care side of the crisis is comparable to India and Pakistan. The government has allocated up to 0.1% of GDP for quarantine and other containment measures. The government has also donated 0.01% of GDP to the SAARC COVID-19 emergency fund. Much like in India, the president has also established a special fund for containment, mitigation and social welfare and invited tax-free donations.

The expenditure on the economic side has been relatively low. Cash transfers worth 0.1% of GDP to the poor and vulnerable population groups have been planned. In addition, the government has adopted other supporting measures: extension of tax payment deadlines has been announced; price ceilings have been set up for essential food items; and concessional loans and food allowances to low income consumers have been provided.

Conclusion

All the four countries have devoted relatively small amounts of funds to directly deal with the health-related aspects of the pandemic. Bangladesh has the lowest expenditure on this count, at 0.01% of GDP. The other three countries have earmarked similar amounts of funds relative to their economic size – about 0.1% of GDP. Expenditure to deal with the economic fallout of the pandemic is largest in Pakistan – at 3.34% of GDP. Sri Lanka has so far devoted the lowest on this count – at 0.1% of GDP. Bangladesh and India fall in between, with 0.34% and 1.3% of GDP, respectively.

Taking account of population size 

Before we present our overall assessment of the four countries response to the COVID-19 pandemic, we want to discuss one issue. In the first part of our article, where we had discussed the spread of the pandemic in these countries, we had only presented case counts. Since the countries are very different in terms of population size, it is important to take that into account – for a more comprehensive picture of the pandemic’s spread and effect.

Figure 1

Figure 1 and 2 summarize key aspects of the spread of the pandemic and its effects after taking account of population sizes of the four countries. In Figure 1, we plot the logarithm of total COVID-19 case count per million population; in Figure 2, we plot the total COVID-19 deaths per million population.

Figure 2

From Figure 1 we see that, in terms of total cases per million population at similar points in the epidemic cycle, Bangladesh is the worst, followed by Pakistan, Sri Lanka and India. The slope of the curve is lowest for Sri Lanka, suggesting the slowest growth of cases. On the other hand, Bangladesh, India and Pakistan seem to have a much higher slopes.

Turning to total deaths per million population at similar points in the epidemic cycle, we see in Figure 2 that Bangladesh is the again the worst performer. It is followed by Pakistan and India. Sri Lanka is by far the best performer since day 40 of the epidemic, i.e since each country’s total case count crossed 50.

Relative performance record

Based on the study of these four South Asian countries, our overall assessment is that Sri Lanka is by far the best performer. It is more difficult to rank the other three countries. If we use raw case counts and death rates (deaths per 100 confirmed cases), then India is the worst performer; if we use case counts and deaths per million population, then Bangladesh is the worst performer. In both cases, Pakistan falls in between.

Sri Lanka was the best prepared in terms of infrastructure. It also was the most proactive in taking steps to contain the pandemic early on. The early and effective public health interventions by the government has managed to deal with the pandemic in an exemplary manner. One way to highlight this is to note that Sri Lanka has the lowest COVID-19 death rate, at around 1% of total cases (and 0.42 deaths per million population), despite having a relatively older population (while 10% of Sri Lanka’s population is over the age of 65, the corresponding proportion is only 4-5% in the other three countries).

Bangladesh was the least prepared to deal with the pandemic in terms of infrastructure. The government did intervene early on, but its response in terms of testing, and the stimulus package has been poorest. Using case count and death rate data that is normalized by population size, Bangladesh has the worst performance among the four South Asian countries we have studied. A large part of the explanation must surely be that it is the poorest of the four countries.

A common concern about Bangladesh and Sri Lanka relates to the size of their stimulus packages. The relatively small stimulus package, especially in Sri Lanka, might hamper the post-pandemic economic recovery.

The performance of India and Pakistan falls in between those of Sri Lanka and Bangladesh. If we use case count and death rate data, India is the worst performer, and Pakistan does relatively better. But if we use case count and deaths per million population, India performs better than Pakistan (and also Bangladesh). On the economic front, Pakistan clearly outperforms the other three countries, including India. The size of the COVID-19 stimulus package is by far the largest in Pakistan, at 3.4% of GDP, and is significantly larger than the corresponding stimulus in India, which stands at about 1.3% of GDP.

Politics shapes pandemic response

A study of the pandemic would be incomplete if we did not look at the political dimension of the crisis. In each of these four countries, the response of the state to the pandemic has been shaped by long standing and underlying political faultlines.

In both Bangladesh and Pakistan, the relationship of the State to the dominant religion has impacted the former’s ability to enforce necessary physical distancing measures. In Sri Lanka, which has seen the best public health response to the pandemic, civil society activists worry about the growing role of the military in society.

In India, the response to the pandemic has highlighted the grossly anti-working class orientation of the ruling party and the State (which has dealt most callously, in the wake of the lockdown, with the problems of the migrant and informal sector workers). The unplanned announcement of lockdown has created severe hardships for migrant workers, leaving them without any sources of income or means to return to their homes. The pandemic situation has also brought to the fore the continued hold of right-wing Hindu nationalism – the most serious threat to a democratic and secular India – on India’s political life.

The state in India has been using the pandemic to crush dissent. Alongside, the Hindu nationalist forces with active support of mainstream media and members of the ruling party have systematically demonized Muslims​, holding them responsible for the spread of the pandemic and giving out open calls for their economic and social boycotts. The anti-poor and anti-Muslim politics of Hindutva has certainly overshadowed India’s response to the pandemic. In general, the COVID-19 situation has tightened the grip of regressive forces in all four countries and has posed new challenges for democracy and social justice.

(Deepankar Basu is Associate Professor in the Department of Economics, University of Massachusetts Amherst; Priyanka Srivastava is Associate Professor in the Department of History, University of Massachusetts Amherst.)

In South Asia, Lanka Leads and India Lags in Infrastructure, Medical Response to COVID-19

India implemented a lockdown 14 days after it recorded 50 cases. The relatively higher number of cases recorded in India may partly be the result of the government losing two precious weeks before implementing any serious physical distancing measures.

In part one of this three-part series, we presented a picture of the spread of COVID-19 in four South Asian countries. In the second part, we discuss two issues: How prepared – in terms of health infrastructure and income levels – were the four countries to deal with the pandemic? How did the governments respond, in terms of public health measures, to the pandemic?

How prepared were India and the other big countries of South Asia to deal with the coronavirus pandemic? To address this question, we present, in Table 1, data on some indicators of health infrastructure, health expenditure and poverty for Bangladesh, India, Pakistan and Sri Lanka from the World Development Indicators Database of the World Bank.

Let us start by looking at two measures of health infrastructure: physicians and hospital beds. Physicians per 1000 persons is lowest in Bangladesh at 0.5. It is followed by India at 0.8 physicians per 1000 persons. Pakistan and Sri Lanka both have a higher figure: 1 physician per 1000 persons. Hospital beds per 1000 persons is lowest in Pakistan, at 0.6, followed by India, at 0.7, and then Bangladesh, at 0.8. With 3.6 hospital beds per 1000 persons, Sri Lanka has more than 5 times the number for the other three countries.

Next, let us look at two measures of health expenditure: as a share of GDP and in per capita terms. Current health expenditure as a share of GDP is close among the countries – with Bangladesh having the lowest, at 2.3 percent, and Sri Lanka having the highest, at 3.8 percent. But these countries are very different in terms of population and GDP. Hence, a better way to compare healthcare expenditure is to look at per capita figures.

Current healthcare expenditure per capita in purchasing power parity (PPP) terms, and measured in current international dollars, varies widely across the four countries. Bangladesh has the lowest health expenditure, at $94.3 per person, followed by Pakistan, at $160.6 per person, and India, at $253.3 per person. With $ 503.6 per person, Sri Lanka is way ahead of the other three countries in health expenditure.

The picture of health expenditure is incomplete unless we also ask the following question: What fraction of current health expenditure comes from the government (or, relatedly, what is the share of out-of-pocket expenditure on health)? The pattern here is largely consistent with per capita healthcare expenditure. Bangladesh, which has the lowest per capita health expenditure, also has the lowest share contributed by the government (16.7%); Sri Lanka, with the highest per capita health expenditure, also has the government contributing the most (43%). India and Pakistan fall between these two ends with government, with 27% and 32% contributed by the government, respectively. The figures for out-of-pocket expenditure on health are the mirror images of the government share of health expenditure: countries with higher government share have lower out-of-pocket expenditure on health.

The final set of indicators displayed in Table 1 refers to average income and poverty. Per capita gross domestic product (GDP), which measures average income in a country, is lowest in Bangladesh, and highest in Sri Lanka. Pakistan and India fall in between, with India having a higher average income than Pakistan.

Poverty is measured by the head count ratio, which is defined as the proportion of persons who fall below the national poverty line. This is a very rough and imperfect measure of the proportion of people who are vulnerable in economic terms, and who would be most in need of help to cushion any negative income shock due to the pandemic. In terms of poverty headcount ratios, there is very little difference between Bangladesh (24.3% of population), India (21.9% of population) and Pakistan (24.3% of population) – though India’s number is a little lower than the other two countries. The poverty headcount ratio in Sri Lanka, at 4.1% of the population, is about 5 times lower than the other three countries.

Conclusion: How the four stack up on health infrastructure

In terms of preparedness, Sri Lanka is best placed. It is not only the richest country among the four studied in this article, but also has the largest expenditure on health – with the greatest share contributed by the government. Bangladesh is at a disadvantaged position – not only because it is the poorest, but also because of the low contribution of the government to an already low total health expenditure. India and Pakistan fall in between these two extremes.

Government response to COVID-19

Governments in South Asia responded to the pandemic with two sets of policies. The first related to measures for physical distancing in society, which could reduce the speed of transmission of the virus, and increased testing to detect and isolate infected patients.

The second set of policies related to expenditures that were necessary to deal with the health and economic impacts of the pandemic. Using information from the Johns Hopkins University coronavirus dashboard and the International Monetary Fund’s COVID-19 country-level policy tracker, we have summarised basic information about government responses in Table 2, and will now discuss each component in detail.

Physical distancing measures

Bangladesh

In response to the emergence of the virus, the government reduced international flights and imposed thermal scanner checking of international travellers and sailors of freight ships. By March 15, the government imposed a 14 day obligatory quarantine for all travellers entering the country. However, travel restrictions and quarantine programs were only partially effective at this point. The lack of adequate quarantine facilities, for instance, resulted in the unrestricted movement of returning expatriates and travellers. Other crucial non-therapeutic measures of social distancing and sheltering-in have been patchy. Schools were shut down by March 15 but a broader lockdown was imposed only on March 26. According to reports in the media, the lockdown will continue till May 16.

India

Although its first positive case emerged by January 30, India started preventive measures only in early March.  The COV-IND-19 Study Group’s March 23 report has a dated list of initiatives taken by the Indian government. Drawing on this list we see the following sequence of important policy interventions.

On March 3, India banned travellers from China, Iran, Italy and South Korea. On March 11, it suspended visas granted to nationals of France, Germany, and Spain. On March 16, the Central government proposed social distancing measures and recommended closure of educational institutions. On March 22, India observed a day of self-imposed ‘janata curfew,’ and on March 24, the prime minister announced that the country would go under total lockdown for a period of 21 days within four hours! Lockdown on such a short notice generated panic among citizens who ignored all principles of social distancing and  rushed to crowded stores to stock up essentials. The lockdown was extended on April 14, and has been further extended till May 17.

Pakistan

The health ministry of Pakistan introduced screening measures at its major airports by the end of January. But social distancing advisory and caution against public gatherings were issued only by mid-March. From the outset, preventive measures lacked uniformity and there have been divisions within the government about the strategies to contain the pandemic. Although schools and colleges were shut from March 13, Prime Ministerl Imran Khan has consistently argued against a nationwide lockdown, citing its adverse effects on wage earners and the economy in general. Consequently, varying levels of shutdowns have been imposed in different provinces and cities. Apparently, this ambiguity in shutdown policy has sent confusing messages, leading to frequent violations of physical distancing measures.

Sri Lanka

Relative to the other three countries, the government in Sri Lanka acted swiftly to contain the spread of the contagion. The government of Sri Lanka issued a preliminary social distancing advisory on January 20, a week before the first COVID-19 case of a Chinese tourist in Sri Lanka was confirmed. On the same day, screening of international travelers began in earnest. From early March, incoming travellers from Italy, Iran, and South Korea were required to be quarantined for two weeks in government facilities created for the purpose. The country suspended on-arrival visas for tourists on March 11. Schools and universities were declared closed on March 13 and from March 16 onwards, people were asked to work from home.

In addition, the government announced an all-island curfew on March 20, and everyone, except those working in the essential services, were required to stay home. Retailers were instructed to deliver essential goods to the homes of the people. These services were further streamlined by the creation of a special task force to distribute essential items.

Conclusion

In terms of physical distancing measures, all countries initially responded by monitoring incoming international passengers, and by limiting possibilities of congregation and social gathering. Each country eventually moved to a full scale lockdown, the only exception being Pakistan (which has had province-level variations on this count).

There is an on-going debate about the effectiveness of lockdowns in dealing with the pandemic. A recent study in the Lancet argues that a one size fits all approach to the pandemic, centred on strict lockdowns and high technology health care, might subvert two key principles of global health: context and social justice and equity.

In practical terms, lockdowns do not eliminate the virus, but only give time to the government to ramp up testing, prepare health infrastructure and build community networks for tracing and isolating infected patients. If the government does not use the time afforded by the lockdown to address these issues, then a lockdown inflicts disproportionate pain on the poor and already-vulnerable without even containing the pandemic.

While we agree with the conclusions of the Lancet study, we do not pursue that angle in this article. We feign a neutral attitude to lockdowns and instead ask: when will a lockdown slow down the spread of the pandemic? Two factors seem crucial: the timing of the lockdown and the effectiveness of its implementation. While it is difficult to quantify the second, we can much more precisely look at the former. To do so, we only need to ask: At what stage of the pandemic’s spread was the lockdown announced and implemented?

From the information summarised in Table 2, we see a clear pattern. Bangladesh implemented a lockdown several days before it had recorded 50 cases; Sri Lanka announced a lockdown one day after it recorded 50 cases; Pakistan moved towards implementing province-level lockdowns within a few days of reaching 50 cases (March 23 in Punjab, March 21 in Sindh, etc.).

India is an outlier in this respect. It implemented a lockdown 14 days after it had recorded 50 cases. Our conjecture is that the relatively higher number of cases recorded in India is partly the result of the government losing two precious weeks before implementing any serious physical distancing measures – recall that India reached 50 cases on March 10 and the lockdown was implemented (without much planning) on March 24.

COVID-19 testing

An important component of any strategy to deal with the pandemic is the use of testing to detect cases, trace their contacts and quarantine infected patients. Testing has generally been low in South Asia (Table 2), though even here one could see wide variations across countries. On May 8, Bangladesh had the lowest testing rate, at 0.676 per 1000 persons; next was India, at 1.042 per 1000 persons; followed by Pakistan, at 1.165 per 1000 population. Sri Lanka had the highest testing rate, at 1.498 tests per 1000 persons.

Looking at the number of tests per 1000 persons in any country provides only incomplete information about the adequacy of tests. A better way to gauge whether a country is conducting an adequate number of tests is to look at the trajectory of the test positivity rate (number of positives per 100 persons tested). If the test positivity rate is low and stable, or is high but consistently falling, then we can conclude that the country in question is on the right track – so far as testing is concerned.

In Figure 1, we have plotted the test positivity rate for the four countries. The test positivity rate in Bangladesh has been rising and seems to have stabilised at a rather high value of around 11%. Both the high value and its rising trend in Bangladesh is worrisome. It suggests that testing is grossly inadequate in the country.

Figure 1. Test positivity rate (positives per 100 tests) for four South Asian countries till May 08, 2020. Source: The data are taken from the Our World in Data website

In India, the test positivity rate initially rose and has now stabilised at around 4%. This is low by international standards, but India must increase testing further to bring it down to 2% (a benchmark that we derive from the successful example of the Indian state of Kerala). Pakistan’s test positivity rate has been fluctuating a lot at relatively high values. Over the past few days, it has steadily increased above 8%. This is worrisome. Hence, Pakistan must, like India, ramp up testing and bring the test positivity rate down to 2%.

Sri Lanka’s performance in terms of testing is very good. The test positivity rate had fallen to 2.62% by early May (though we have very few data points from the early part of the pandemic). Sri Lanka needs to keep testing at the rate it already is.

To be continued.

(Deepankar Basu is Associate Professor in the Department of Economics, University of Massachusetts Amherst; Priyanka Srivastava is Associate Professor in the Department of History, University of Massachusetts Amherst)

Despite the Clinical Establishments Act, Healthcare in India Has a Long Way to Go

While some states have managed to increase access to affordable healthcare, it remains below par when compared to other developing economies.

While some states have managed to increase access to affordable healthcare, it remains below par when compared to other developing economies.

Representative image. Credit: PTIRepresentative image. Credit: PTI

Representative image. Credit: PTI

This is the second article in a two-part series analysing the asymmetric status of healthcare delivery across Indian states. Read the first part here.

Aiming to ensure the delivery of a minimum standard of services by clinical establishments across India, the central government enacted the Clinical Establishments (Registration and Regulation) Act in 2010. All types of clinical establishments, except those run by the armed forces, fall within the ambit of this Act. The need for such a legislative act was sparked off by wide variation in healthcare delivery across providers, resulting not only in compromised patient safety but also concerns about transparency and accountability in healthcare costs.

The Clinical Establishments Act seeks to ensure that the operative functioning of healthcare delivery systems in states is in compliance with prescribed, transparent guidelines and keep any form of regulatory malpractices in check (related to drug pricing, licensing provisions or procurement, for instance). This Act has been in effect in Arunachal Pradesh, Himachal Pradesh, Mizoram, Sikkim and all union territories except the National Capital Region of Delhi since March 1, 2012.

A closer look at the data on the number and type of clinical establishments across some of the above states clearly indicates a skewed distribution of healthcare providers.

Compared to the other states, Delhi has registered the maximum number of clinical establishments.

In the figure below, looking at the structural composition of the healthcare establishments in Delhi, there is a need for the state to expand government-funded diagnostic centres and nursing homes in proportion to the clinical centres available.

In terms of the total number of government clinical establishments like primary healthcare centres, sub-centres and district hospitals, states like Himachal Pradesh and a few northeastern states have done well in improving access to public healthcare facilities, particularly since the introduction of National Health Mission and National Rural Health Mission as centrally-funded schemes. Still, the delivery of standardised basic medical care services across states remain below par when compared with other developing economies like Thailand, China or Brazil.

Beyond the states listed that have introduced the Act, West Bengal introduced and passed its own legislation called the West Bengal Clinical Establishments (Registration, Regulation and Transparency) Act, 2017. This aims to streamline the procedures of registration of clinical establishments, medical licensing systems and accounting for criminal offences related to medical practice under a prescribed adjudicating, regulatory body called the West Bengal Clinical Establishment Regulatory Commission. One of the critical points raised by this Act relates to identifying criminal punishment for all doctors charged with medical negligence.

According to the newly enacted Bill, doctors or healthcare facilities may face criminal proceedings under Indian Penal Code, including a cancellation of their medical license, if found guilty of medical negligence. The Indian Medical Association (IMA) has raised strong objections to this clause. The IMA wants a single-window accountability for doctors to reduce the scope of harassment and no differentiation in treatment between the private sector and government-appointed doctors.

The implementation of the Act and its outcomes may qualify as a subject of greater scrutiny in the coming months. However, on a more systemic level, the very nature of regulating healthcare service raises two key issues, currently marring the healthcare delivery system in India (previously highlighted in this article). This pertains to the mandate and legality of government agencies – their capabilities and the feasibility of carrying out identified outlays or health goals.

As a case in point, the 2017 National Health Policy proposes the need for strengthening existing medical colleges and converting “district hospitals to new medical colleges to increase number of doctors and specialists, in States with large human resource deficits”. But there is no clarity on the financial feasibility of such a proposal. It is not sufficient to regulate the private sector; the public healthcare system needs to be revamped to serve as a substitute. Setting price ceilings and imposing punitive measures may serve as a disincentive to providers, thereby hampering delivery. This will only make matters worse, whereby neither is the public sector living up to the standard, nor is the private sector incentivised to deliver what it is capable of delivering.

Based on the available data, there remains a strong need by more states to recognise the Clinical Establishments Act with support of the Union government and put in additional financial resources in facilitating more nursing homes and diagnostic centres (in proportion to clinical centres); ensure monitoring of prescribed agency considerations for public health departments; and ensuring affordable healthcare in a transparent way.

It is vital for the Indian state to not only consider increasing clinical establishments in semi-urban and rural areas (where access is sparse), but also to ensure compliance of basic minimum standards of medical treatment by doctors in existing clinical establishments, which is essential for delivering quality medical care services to everyone. From a policy perspective, ensuring affordable healthcare access for mother-child care, reduction in out-of-pocket expenditure due to asymmetric distribution of healthcare services (via public and private healthcare centres), standardised medical training and monitoring of doctors (across states) and healthcare insurance (linked through an Aadhaar-registered scheme) require greater deliberation and focus by the Union government.

Ayona Bhattacharjee is assistant professor of economics at Jindal Global Business School, O.P. Global Jindal University and Deepanshu Mohan is assistant professor of economics at Jindal School of International Affairs, O.P. Global Jindal University.

Making the Right Decisions on India’s Health Spending

The government has decided to move to an ‘explicit’ process of priority setting for health expenditure, which looks at cost effectiveness and equity concerns.

The government has decided to move to an ‘explicit’ process of priority setting for health expenditure, which looks at cost effectiveness and equity concerns.

Representative image. Credit: Reuters/Anindito Mukherjee

Representative image. Credit: Reuters/Anindito Mukherjee

It is a fair assumption to make that everyone, everywhere wants to remain healthy. Sometimes, through no fault of our own, we get sick, and being sick costs us money. This may be an expense towards the cost of treatment or in the form of a missed opportunity to make money by being unable to work. Increasingly, governments across the world are working towards curtailing healthcare expenses borne by its citizens so that we don’t have to take money from our pockets to cover the costs of ill health. This is called providing universal health coverage and has been declared by the UN as a global goal which all countries must strive to achieve.

Dealing with a finite budget

One might put themselves in the position of the government in this scenario, for example a health secretary, who has a budget made available to him or her just for this – providing for health. This budget for health, however, has to stretch itself to meet the needs of the entire population, to cover everything from complex cancers and surgeries to training staff and building medical infrastructure. The district hospitals are demanding money be made available to them to pay for the equipment they require to perform surgeries, for doctors and nurses to staff the facilities, for repairs to make the hospital safe for staff and patients alike. The primary health centres (PHCs) are demanding additional funding – they too are understaffed and cannot afford to pay more skilled attendants or clinicians. In addition, they need an increase in their drug supplies for the growing numbers that come to the PHC each day. The community health centres (CHCs) are in the same position – they demand provision of nutrient-rich supplements for mothers and babies, who each day grow more malnourished as the CHC runs out of necessary supplies. But how can the secretary decide where this finite health budget is best spent? How does one weigh the myriad options to ensure that the money stretches as far as it possibly can?

What we know is this – every rupee can only be spent once. The health budget is finite, paying for one intervention inadvertently means that you are not paying for another. In economics, this is what we call the opportunity cost – taking the opportunity to pay for one area of health means a missed opportunity to pay for another. To treat one women for breast cancer may cost the same amount of rupees required to de-worm one lakh children. But how can the policy maker decide which is a better investment?

Policy makers in India and abroad are faced with these difficult decisions on a daily basis – to decide the best possible way in which the finite resources made available to health can be spent. This is no easy task. At present in India, many of these decisions are made on the basis of what we refer to as implicit rationing. This is the concept of “first in best dressed”, where those at the start of the queue may receive the treatment they need, while those at the back of the line may miss out by the time it is their turn.

Explicit priority setting, as opposed to implicit, refers to the process of making decisions according to clear and transparent criteria based on the best available evidence for effectiveness and cost of a given intervention, as well as taking into account equity considerations for the good of the entire population. This kind of priority setting is largely viewed as the most effective way in which to make decisions as to the best way a health budget is spent, weighing up all options and coming to a fair and just conclusion, towards the ultimate goal of universal health coverage – providing the services people need while protecting them from high out-of-pocket costs.

Moving towards health technology assessment

The positive news is that the government of India plans to move towards a more explicit priority-setting process for health. This form of rational priority setting is underpinned by a process called health technology assessment (HTA). HTA aims to introduce a more transparent, inclusive, fair and evidence-based process by which decisions regarding the allocation of health resources are made in India. ‘Health technology’ can refer to anything from a vaccine to a programme of improving breast-feeding practices to a complex surgical procedure – any intervention or programme related to health. HTA is an internationally recognised methodology, used by organisations such as the National Institute of Health and Care Excellence in the UK or the health intervention technology assessment programme (HITAP) in Thailand, which allows evidence for the effectiveness and cost of all similar interventions for a given health problem to be compared against each other, while taking into account any equity or equality considerations, to make the best possible decision as to which is the most cost effective intervention and whether it is worth the investment of government resources.

Ultimately, this is a very promising step forward towards the government’s agenda of providing universal health coverage to the people of India. This also provides a way to increase the involvement of the Indian public towards the way in which health resources are spent, by encouraging a consultative process underpinned by stakeholder involvement – a process that gives the people a voice and a platform from which to be heard. The Department of Health Research (DHR), Ministry of Health and Family Welfare, had been allocated this responsibility in the 12th five-year plan and have already taken active steps towards formalising this process. On July 25, 2016, a workshop was jointly convened by the government of India and the International Decision Support Initiative (IDSI), a global partnership network led by UK’s Imperial College and Thailand’s HITAP, to raise awareness of this initiative to formalise a system of HTA in India and bring together key stakeholders for consultation. The event was presided over by the ministers of state for health and family welfare, Faggan Singh Kulaste and Anupriya Patel, who expressed their support on behalf of the government of India to establish a system of HTA to inform health decision-making.

Since this important event, a number of significant steps forward have been taken by the government towards institutionalising HTA in India. A concept note for establishing a medical technology advisory board (MTAB) has been approved by the health minister. The DHR has compiled a list of multi-representative MTAB members, due to be approved by the health minister this week. A capacity gap analysis was drafted and sent to over 50 institutes across country to facilitate understanding of both current capacity to undertake health economic analysis in the country and gauge interest in contributing to the MTAB programme of work. From the results of this survey, memorandums of understanding are being signed between DHR and centres of excellence in health economics across country to collaborate in this area. In January 2017, a DHR-led group participated in a study tour to Thailand to understand how HTA has contributed to the country’s achievement of universal health coverage. Plans for undertaking a demonstration case HTA are underway, to be commenced by mid-2017, and DHR has taken active measures towards hiring an MTAB secretariat as a dedicated workforce to oversee the running of this work. Advertisement for positions in this team closed in late January 2017 and interviews are underway to ensure that staff will be in post shortly. Finally, plans for training for health economics capacity building, to be delivered by the IDSI, are underway and this is due take place in mid-2017.

The DHR is taking active measures to bridge the evidence to policy gap and ensure alignment of academic and policy interests through HTA towards the common goal of improving decision-making for health resource allocation to improve the health of the Indian population. The year 2017 will mark an exciting turning point for India towards a fairer, more inclusive, transparent and evidence-based system of setting priorities for the health of India. With more than one-sixth of the world’s population residing in India, this is an important step not only for the health of the Indian population, but for the global health community.

Laura Downey is technical advisor, global health and development, Imperial College London, UK and Soumya Swaminathan is secretary, Department of Health Research, Ministry of Health and Family Welfare, India.