India’s Covid crisis exposes deep-rooted problems in public health after years of neglect


A family waits inside an ambulance with a patient who tested positive for COVID-19 ,for admission at a hospital in Kolkata, India, on 10 May 2021.
Debarchan Chatterjee | NurPhoto | Getty Images

The world’s attention is now on India, the epicenter of the global pandemic as the country battles a deadly second wave of Covid-19.

The unfolding human tragedy has laid bare the deep-rooted problems plaguing India’s public health system after decades of neglect and underinvestment. 

The crisis has brought India’s public health system to its knees. Scenes of hospitals running out of beds, and people searching desperately for life-saving oxygen or critical medical supplies for their loved ones have hogged international headlines.

Low allocations to health care

For a long time since its independence in 1947, health was not viewed as an economically productive expenditure in the country — unlike investments in industry, agriculture and service sectors, K Srinath Reddy, president of the Public Health Foundation of India, told CNBC.

“For several decades, health systems in India have not received the respect and resources they deserve. Public financing of health stagnated around 1% of GDP and out-of-pocket expenditure on health was over 60% even in recent years,” he said in an email. “The central government as well as most state governments had low allocations for health in their budgets.”

India’s spending on health care is comparatively much lower than many other countries.

The U.S. spent nearly 17% of its gross domestic product on public health care in 2018, while France and Germany spent more than 11% of GDP that year, according to data from the World Bank.

Comparing India to the rest of the BRICS nations — Brazil, Russia, India, China and South Africa — India spent the least on health care in 2018. Brazil spent 9.5% of its GDP on health care that year, South Africa 8.1%, Russia 5.3% and China spent 5.35%.

India is now the second-worst infected country in the world, behind only the United States.

The South Asian nation has reported more than 300,000 new daily infections in the past few weeks. Cumulatively, Covid infections reached nearly 24.7 million with more than 270,284 deaths on Sunday, according to health ministry data.

However, health experts warn that the numbers are likely grossly underreported, and the true scale of Covid infections and the human toll may never be officially known.

In a recent report by Fitch Solutions, the research firm said that despite several health care reforms, India remains badly placed to tackle the rapid spread of the pandemic.

“With 8.5 hospital beds per 10,000 population and 8 physicians per 10,000, the country’s health-care sector is not equipped for such a crisis. Moreover, the significant inefficiency, dysfunctioning and acute shortage of the health-care delivery systems in public sector do not match up with the growing needs of the population,” the report added.

The numbers make grim reading for a country like India with a population of 1.4 billion people, making up 18% of the world’s population. 

Lack of political will

India’s second wave began around February and accelerated through March and April. The virus spread rapidly due to complacency on mask wearing at religious festivals and political rallies that attracted large crowds in various parts of the country.

While the pandemic has highlighted the structural weaknesses in India’s public health system, those issues have always existed, said Chandrakant Lahariya, a medical public policy and health systems expert, based in New Delhi.

I believe that the political will is stronger now, after the prolonged and agonizing pandemic experience.
Chandrakant Lahariya
medical public policy and health systems expert

He said this is mainly due to a lack of political will from successive political parties and the government in the power for not making public health a priority.

“Public health has never been a political priority and an election agenda,” he said. “Through the hands-off approach, the government has sent a sort of message that health is an individual responsibility. People do not perceive that elected governments and political leaders should be responsible and held accountable to ensure health care services.”

That’s where the problem arises, Lahariya noted.

“It has allowed the private health sector to grow by leaps and bounds, while the public sector has remained underfunded and underperforming,” he said in an email. “Now, we are in this situation.”

Few Indians have health insurance

India’s private hospitals are largely commercialized and profit-driven, focused on treating disease. What makes the matter worse is that majority of Indians do not have health insurance and pay for health-care out of their own pockets.

According to the Fitch report, more than 80% of India’s population still does not have any significant health insurance coverage and approximately 68% has limited or no access to essential medicines.

While a pandemic can overwhelm almost any health system, including the most well-resourced, the current situation in India wasn’t inevitable, noted Vageesh Jain, a public health physician in training, based in the U.K.

“The fundamental issue remains that the commercially-driven private hospital system does not look to provide long-term ongoing care to people with the aim of preventing and controlling disease,” said Jain, who is currently working with Public Health England on the health protection response to Covid-19. 

Addressing such problems is difficult in any context given the complex and multi-agency solutions needed, he added.

“But it is particularly tricky in India where there may be other quick-wins in public policy, deemed more worthy of immediate attention,” he argued.

A wake-up call for India?

India’s prime minister Narendra Modi has been widely criticized for not acting sooner to suppress the resurgence of the virus.

In a rare rebuke, U.K. medical journal The Lancet, recently slammed the Modi government for squandering the early successes of controlling Covid and “presiding over a self-inflicted national catastrophe.”

“I believe that the political will is stronger now, after the prolonged and agonizing pandemic experience,” pointed out Reddy from the Public Health Foundation of India. He added that the recent central budget and recommendations from the finance commission are positive indicators.

The devastating situation created by the ongoing wave is likely to be forgotten. But should not be allowed to be forgotten.
Chandrakant Lahariya

At the budget announcement in February, India’s Finance Minister Nirmala Sitharaman proposed more than doubling India’s health-care and wellbeing spending to $30.1 billion (2.2 trillion rupees).

That includes strengthening national institutions and creating new ones to detect and cure new diseases. There is also a new federal scheme to develop the country’s capacity for primary, secondary and tertiary care.

Still, whether the crippling crisis will be a wake-up for India to take its public health seriously remains to be seen, experts say. 

“With this prolonged pandemic, there will be a stronger and longer lasting imprint on public and policymaker memories. There has to be a constant reminder, even after the pandemic ends, that the economy will keep slipping on the banana peels of public health failure if we do not invest in public health and strong health systems,” said Reddy.

Lahariya added there have been many public health disasters and health emergencies in India before. But most have resulted in very minor changes in health systems, if at all.

“It is time a robust citizen accountability is enforced in India on the elected leaders. They should be asked questions by people who elect them. Then only we can expect some change,” he said.

“The devastating situation created by the ongoing wave is likely to be forgotten. But should not be allowed to be forgotten.”

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