Public Health in India

[prasen9]

We do not think much about public health in India. At least not as much as the rest of the world has done. Just to prove my point, in this forum too, we did not have a thread. We had only one thread with health in the headline. One post on laughter yoga! So, starting one to keep the discussion related to general public health separate than the coronavirus threads. To start off the discussion, here's a set of numbers (is there anything other than numbers that is interesting? ).

Our life expectancy is about 70 years old. This is the poorest number in the neighborhood with Pakistan and a war-ravaged Afghanistan bringing up the rears. The leader is Maldives and then Sri Lanka. They are a very respectable 78 and 77. Then, there is a gap. Then, there is Bangladesh, Bhutan, and Nepal.

Bangladesh was worse than us until 1990. Since then, their curve did a clear leap and sustained movement upwards. Here is the graph. Life expectancy in countries near India Maldives leaped forward in 1980. Nepal and Bhutan overtook us in 2003, 2004.

How on the world are we worse than a poor country such as Nepal with limited resources?

This is a national shame. And, the curve is very steady for India. So, the failures are across the board, across all governments. No, there is no Modi magic. The way to look at Modi's impact in my mind is to look at these indicators and see if there was a jump in the last 5 years or so. A lot of these development curves are remarkably stable. That is, Modi is as useless as the Congress governments before them wrt human development, small projects here and there notwithstanding. If he was any better, we would have seen a difference in the slopes, something taking off. Of course, he is great at PR and propaganda. Now, if he will only use that to get people to take vaccines, etc. that will be great.

[arjun2761]

FWIW, Maldives has a nominal per capita GDP that is nearly 6 times that of India and Sri Lanka is nearly twice.

Longevity though is a long term indicator, i.e., better healthcare now will expand longevity in the future. The only way it will have immediate impact is if end-of-life care is improved (and I'm not sure that this is a great goal anyways in that prolonging life after a certain stage may not be a top healthcare goal when balancing quality of life with the costs and opportunities). In addition, of course, the black swan events such as Covid will have short term impact.

[prasen9]

A classic example of selective choosing of statistics to warp reality. It is true that Maldives is substantially richer than us and Sri Lanka is about twice than us. But, if that is the case, then we are also about twice as rich as Nepal. So, choosing to mention Maldives and Sri Lanka and not Nepal smacks of biased reporting. If only Maldives and Sri Lanka were ahead of us and if Bangladesh was not going up at the rate they are, then I would not have posted.

[jayakris]

It is one of the (many) things that suffers from our constitution. Healthcare is a state subject. Nothing much that the central government can do. There are some offices called "national health mission" etc, but the central Government cannot open (as far as I understand) health clinics on a large scale and have central govt personnel running it in the states. They will all need to be under state control. So we have Kerala/Goa and UP/Bihar at extremes that have nothing in common. The center can give more money in budget allocation for healthcare to the states, but the states will decide how to do that. They will generally waste it or find a way to use it for other things. Things like road-building that people pay more attention to, than public health. Easy to build a road saying there is medical college coming - and then not build the college, that is ). This is how our state Governments are in our federal system. UP may use the money for ayruveda, WB will use it for research on rasagolla's health benefits... So on...

That is my judgment/feeling, albeit this is not an area I have looked into much. But it struck me only after the pandemic started that we just don't have much of a central government presence in the healthcare area anywhere, as opposed to say food-distribution or transportation or banking. Those are all somewhat standardized in India because of central government's involvement, but on healthcare, there is nothing. All that the central Government does is targeted items like "vaccination for polio" or "condoms for family planning" (at one time). They are like separate missions.

Anyway, my understanding of the problem was that if healthcare was going to be in the public sector (as it generally was before socialism went away in the 1990s), things were not going to work if healthcare was a state-subject. Especially so in public health. That is the stuff the central Government needed to set policies on, but the delivery (and production too, from an economic sense, as it is from the doctors/nurses) is all local in healthcare delivery. That is unlike say food delivery, where the production is elsewhere. The interactions are all rather curious and complex. Socialist systems needed central planning but it does not work with our constitution in healthcare, because of the localized nature of things!!! That is why it remained bad, and we kept spending very little. Nobody in the center or state Government saw enough benefit from doing anything, from a voter standpoint either (compared to more "visible" expenditure).

But since the 1990s, private hospitals (medium and large ones, as opposed to one-doctor or one-compounder clinics) seem to have become a big part of healthcare. So what is needed is to use them for public health. But the Indian hospitals are more profit-motivated than almost anywhere in the world. That brings up a huge problem. The private hospitals charge a lot, and so insurance became very important. It may seem like a problem, but it is actually a good problem because the government will be forced to pay for the insurance for at least the poorer population!... And precisely that happened a decade after private hospitals became big all over the country by early 2000s

It was some 10 years ago (2010?) under Manmohan singh that we finally started some sort of health insurance scheme (some national health bima yojana blah blah)... It was actually an important development under the Congress ministry. Now we have the Ayushman Bharat Bima Yojana blah blah under Modi, which everybody seems to say has really fixed the Manmohan yojana's issues and is going to make a big impact. Too early for it to show, I think.

Bottom line: Healthcare spending from the government needed to go up from 1% of GDP we have kept for decades, to the world average of around 5 percent (we are some 180th out of 200 countries in how little we spend). Modi didn't raise it. Till this year, that is. And he did a bit of it, out of pressure from the pandemic. It is 2% this year. Hope we will keep it up. I think a serious building up of the Ayushman insurance scheme and utilizing the private-sector capacity for public health is the way to go about it, as far as I can see. That is actually much easier done than to spend the money in the public sector and build capacity. Private sector will build it if there is business, and if the government is paying, there will be business even in villages. So from now on, I expect us to spend more - and the vehicle for it is there, as an insurance scheme that is under the Centre's control (so the money won't be wasted by the states and there is no constitutional issue).

The pandemic was a blessing in disguise in a sense. A lot of people are aware of the public health issue. Even us here, who didn't care to start a thread on this, have finally done that!

I am optimistic. The structural deficiency of the constitutional provision being unsuitable for socialism can now be solved through private sector via spending on insurance. Let us see where we are in 10 years. It will be a sea change, in my opinion. We may even think Covid-19 helped.

[jayakris]

^^^ I just found this article last year by retired SC justice Gopala Gowda that mentions some of the items of relevance to what I say above on public health. By Neglecting Public Health, Govts in India Have Abandoned Their Responsibility

Interestingly, he says that the private, and public-insurance model of the US is not as good as the public and investment-driven model of Sri Lanka and some of Europe. I didn't know that dichotomy when i wrote the above post. What I say above as what could happen now, is not the best option, in his mind. He may be correct, but I think he missed the fact that we were too far behind due to the public investment not happening during the socialist governments' 45 years. Then our constitution didn't help either in public investment which had to be mostly centre-driven, while healthcare was a state subject constitutionally. Justice Gowda may know that the constitution did not prevent it though. Those central governments could've instituted a public investment-driven model with centralized planning and capacity building between 1947 and 1992 by finessing things. But in my opinion, it was rather natural that it did not happen, due to a couple of fundamental reasons I pointed out above.

Anyway, at this point, we cannot do public building of healthcare capacity fast-enough for the second option (that worked for say Sri Lanka), especially when the private sector already has built a lot of capacity in the last 25 years for the richer Indians. We may have no option but to follow the US route. And that is exactly what Manmohan started and Modi fine-tuned under Ayushman.

We have very much a federal-type government though many Indians seem to think it is unitary. What works in small countries do not work in large countries with a federal framework and no socialist central control. US is really the only model we can follow (China and Russia are unitary Governments). Just as US healthcare is sub-optimal, India's will be sub-optimal compared to many small European countries, whatever we do. But it will be much better than what we have now, which is basically NOTHING.

[prasen9]

Then why did Modi lie to the public promising a National Health Assurance Mission to get elected and then not do anything much about it?

While it may be constitutionally dubious, for the sake of argument, I doubt any court will declare it unconstitutional if say we have an AIIMS-style hospital in every district in India funded by the centre. My point is that the government could build clinics, etc. even though it is under state purview. Otherwise, we have to declare JIPMER unconstitutional.

Or the Centre could provide a 1:1 match for states to implement good public health infrastructure projects and/or policies to get things done. Maybe the Bihar/UPs will still not do much, but there can be a lot done.

We do not need to nationalize the private hospitals/clinics. We need to build a whole lot of public ones to supplement them and let them all compete. The government can negotiate rates across the clinics/hospitals and have some sort of a national health insurance program. The U.S. system with a single payer model. Or at least a single negotiator model where maybe the payment can be split 50-50 between the government and the patient (or some ratio therein).

Why do we have a Ministry of Health and Public Welfare or whatever it is called anyway?

All these are excuses. If there is a visionary who wants to do something about it, working around the existing roadblocks, they could do a lot.

[Atithee]

It would be best if we focus on the issue and not what Modi did or did not do. Not every Modi bashing/glorification needs to be masqueraded as a serious discussion topic. Thanks.

[prasen9]

It would be good if people read the substance of the posts and not blindly try to defend the PM. I have provided enough substance with pointers wrt Nepal and Bangladesh having higher life expectancy than us. I have also acknowledged that this has been a 70 year problem or more. It would be good if people engaged on the merits of the substance of the posts including the lack of public health and the lack of past and this government in doing anything about it instead of passing meta-comments trying to make Modi the focus.

That said, public health has to be lead by the government. For it to work, it has to be lead by the central government. And, this government is what we can talk about now. And, this government came into power promising a lot, which turned out to be just talk. That is fully germane to the discussion. Happy to talk about the past governments and their ills too, but they are gone and they cannot do anything to improve things.

And, for the government to lead, there has to be a visionary leader to lead it. I do not see anyway we improve unless this or any of our future PMs make it a focal area and takes the bull by its horns.

I have pointed out that Bangladesh made the move in 1990 and Nepal made it around 2003. Or a few years or a decade before that. Absolutely, the Congress governments were to blame for being asleep at the wheels for long. Good that they are out. But, we have moved from tweedle dee to tweedle dum and I am hoping that we move on from the tweedles altogether soon by either this guy stop being a tweedle or someone better coming on board.

I would be delighted if someone points out what Bangladesh and Nepal did to improve their citizens' lots and what we should be doing in the near future that our leaders past and present have not done. I do not have that knowledge.

[Atithee]

@Jay: On the topic—if health is a state responsibility, why is central Government responsible for oxygen supply, vaccines, and related meds like Remdesevir?

[jayakris]

@Jay: On the topic—if health is a state responsibility, why is central Government responsible for oxygen supply, vaccines, and related meds like Remdesevir?

Central Government is is NOT responsible for any of it, legally and constitutionally speaking. But the Central Government knows that people will die if that is all left to the states. More importantly, the Government won't be elected the next time, if they don't take responsibility. That is all

[jayakris]

Then why did Modi lie to the public promising a National Health Assurance Mission to get elected and then not do anything much about it?

Did I say that he didn't do anything about it? I only said that he didn't increase the spending in healthcare, and only kept it where all the previous PMs had kept it. Under 2 percent of GDP. As for what he did new, it was basically the modified insurance scheme built into Ayushman Bharat, and that had its roots in the insurance scheme that Manmohan started. So he did follow through on the National Health Assurance Mission he promised, right? [Not rhetorical question. I actually don't know, because I didn't follow his healthcare promises] What lie did you see there?

All these are excuses. If there is a visionary who wants to do something about it, working around the existing roadblocks, they could do a lot.

Stating the reality like i did, and saying that none of the PMs did anything, shouldn't be taken as making excuses for them. And would you stop being a dreamer, for a change? What I was saying above was what happened, and what can happen. Why do you go dreaming of visionaries?

Visionaries are not that common. What India has got so far is all the visionaries we should expect to get as PMs. In fact, we have been unusually fortunate in having people who really cared for India and pretty much none who worked against India's interests except by mistakes in thinking. Nehru, Indira, Rajeev, PVNR, Vajpayee, Manmohan and Modi. None of them were unpatriotic and none of them put themselves over the country (in my opinion). That is a good set of PMs, and I would make an argument that India had a much higher share of honest and well-intentioned PMs governing India than almost any country out there. Some of them even had some good vision to boot. If they could do something easy on the healthcare matter, they would have at least tried to do it.

India did achieve a lot in food security and even shelter security, military strength, space program, basic education etc and even in higher education, infrastructure and cleanliness. But public health is the biggest laggard. Why? I have to think there are some systemic reasons why we spend 1/5th of the world average fraction of GDP. If it was simply less than average, I could consider it lack of vision. But being 180th out of 195 is not due to lack of vision but more than that. That is my judgment.

You are correct that if they REALLY wanted to do it, they could have got it done. Could have spent twice or thrice as much on healthcare, by cutting for instance a portion of the humongous military budget. Sky might not have come down. I also mentioned above that the constitutional provisions would not have stopped it.

But it didn't happen for whatever reason... So we have to look ahead and see if there are signs of some systemic changes that could make it happen. I am optimistic that the system of private hospitals and the central government acting as insurer-payer and negotiator can make it happen. I think it will be more efficient and faster for the private sector to build additional capacity if there is payment coming from the Central Government for those who can't pay. The states will not complain, as long as they are not dictated to do X or Y with the money given to them.

And yes, it will be great if the central government starts building a lot more Government hospitals too. That won't be as easy as giving direct payment to people for healthcare and having private sector build the right kind of healthcare capacity to extract that money from them.

[Atithee]

Central Government is is NOT responsible for any of it, legally and constitutionally speaking. But the Central Government knows that people will die if that is all left to the states. More importantly, the Government won't be elected the next time, if they don't take responsibility. That is all

But the courts have been ordering the central government to supply oxygen and telling them to change the PSA ringtone because it cannot supply enough vaccines. And, why are chief ministers writing to PM to give them a bigger allocation of vaccines and oxygen? I thought it was quite clear that the central government bears this responsibility. I’m confused.

[Atithee]

In a way, the central government provides hospitals and basic care directly to millions of people. I grew up in what are called “colonies,” which are essentially full fledged towns built around major factories etc. These are like an army base here in the USA, with all services available. Hospital is one of such services. We never had to go to a public or private hospital until my parents grew old and their specialized needs needed a better equipped specialty hospital in nearby big cities. Also, the defense forces have their complete healthcare system. So, it’s not like it’s all on state government or needing private-payor relationship based services.

[jayakris]

Central Government is is NOT responsible for any of it, legally and constitutionally speaking. But the Central Government knows that people will die if that is all left to the states. More importantly, the Government won't be elected the next time, if they don't take responsibility. That is all

But the courts have been ordering the central government to supply oxygen and telling them to change the PSA ringtone because it cannot supply enough vaccines. And, why are chief ministers writing to PM to give them a bigger allocation of vaccines and oxygen? I thought it was quite clear that the central government bears this responsibility. I’m confused.

There is technically only one reason to make the Central Government responsible for something in the oxygen issue. That is the transport of the oxygen tankers on the trains - as they are under central control. The states are technically requesting the Centre to run trains for them. That's it. It was indeed the responsibility of the states to plan and order oxygen from where they needed it, early enough, to be brought on trucks that are slower than trains. States like Kerala and TN were talking to each other and managing oxygen supply, until at one point Kerala requested for a train from Odisha, and the Centre made it get there fast (actually they diverted a train meant for somewhere else to Kerala). Incompetent IITans like Khichdiwala didn't do anything by himself, it got late, and it had to go to the SC with an inflated quantity request for oxygen in Delhi.

Anyway, there is an argument that the states cannot manage some things under an emergency and plan all the logistics (and some CMs like Khichdiwala doesn't know what planning is; other than planning his next tearjerker drama). They often call the Centre and pass on the responsibility to them (and usually blame them later anyway).

The supreme court ordered the Centre to bring oxygen, because they knew that only the Centre was capable of orchestrating that on trains. Only they could set up green corridors for the oxygen expresses to move fast and even building a ramp at the Delhi station within 24 hours for roll-on and roll-off of tanker trucks bringing oxygen from Odisha. Of course, if the Centre had appealed saying it was not their responsibility, I am sure Justice Chadrachud would have a conundrum with him and will have to to agree. But he knew fully that the Centre wouldn't do that, fearing a public backlash, and so ordered them.

There is no law that the Centre cannot take responsibility on a state subject. They cannot pass laws for a state and dictate terms to the state, on a state-subject like healthcare; that's all. The Centre can certainly assume responsibility when the state asks, like in the case of a severe law and order situation needing military or CRPF intervention, even if policing and law-and-order is a state subject. The oxygen SOS from khichdiwal was like that. Chandrachud knew all this when he ordered the Centre. Once the SC order is there, the order gets its muscle from people who would want the Centre to carry it out promptly. So to avoid that criticism, the Centre would oblige. That also was known to Chandrachud. In other words, he knew the centre could assume responsibility and knew he could make them not get lazy on it. That is how it works in India.

[Atithee]

Lots of words to confuse me. Is the gist that there is no legal requirement but the center did it anyway? I don’t get why center is responsible for even transportation. This way, they will hardly ever be the good guy; they will almost always be the bad guy for poor planning for on states’ part.

What about supply of vaccines? Is that center’s responsibility? If not, why are foreign pharma refusing to deal directly with the state governments? And if yes, how can a state own Health care when the center controls pharma production and distribution?

If India’s healthcare has to be improved, I don’t see how this can remain a state’s responsibility? Just policy making and giving away funds to states for whatever they want to do will create haves and have nots. And, some dumb alternative medicine spending as you said earlier by some
states. And, how do you prevent people from one state going to others?