The Hardest Lesson

OUTSIDE A SMALL, TWO-ROOM structure just above the road in a village in Uttarakhand’s Kumaon region, about 50 people, mostly women above the age of 45, squat on the verandah. All are wearing masks, but some have let theirs slip below the nose or chin. A woman comes out of one of the rooms of the health sub-centre and calls out a name. Those who have registered online are given priority in the queue for vaccination against Covid-19. The others, some of whom have walked for over an hour through the mountainous terrain, wait, hoping their turn will come before it starts getting dark.

The sub-centre, which has two health workers and a volunteer, one of the around 1,800 such centres in the state, is the nearest healthcare facility for most in nearby villages. About four kilometres away by foot and 20 km by road, in another village, is the primary health centre, the first point of contact between the community and a medical officer. People with influenza-like symptoms, uncertain if it is Covid-19, are visiting the centre, which has a doctor, a nurse and a few other staff. Moderate to serious cases with coronavirus symptoms are advised to go to the already overcrowded hospitals in Haldwani in the plains, a three-hour drive. A pall of gloom has descended on the villages amid reports of deaths due to lack of oxygen and ICU beds in major Indian cities and the rising number of Covid cases in the state among those tested. There is disquiet among the symptomatic untested, a hush over any death and a fear of the unknown as the virus permeates the backwoods, leaving almost no place untouched in India’s second wave.

Two days after Prime Minister Narendra Modi said the pandemic is rapidly spreading in rural areas, the Union health ministry issued guidelines asking states to designate primary and community health centres, the seven-decade-old health infrastructure in the country’s hinterland, as Covid Care Centres (CCCs), each with 30 oxygen beds and a life support ambulance. Under the three-tier plan, these will handle moderate cases, where oxygen saturation level is between 90 to 94, while community halls, schools and panchayat buildings can be converted into makeshift 30-bed hospitals with two five-litre oxygen cylinders to take care of mild cases, under supervision of the health centres.

The CCCs will be mapped to one or more Dedicated Covid Health Centre (DCHC) to manage moderate cases and to at least one Dedicated Covid Hospital (DCH) for referral purposes in severe cases. To take testing facilities closer to the villagers, Rapid Antigen Test (RAT) kits will be made available at all public health facilities, including sub-centres, Health and Wellness Centres (HWCs) and primary health centres.

The move has come as a relief to the villagers, for whom the three-tier primary health infrastructure is the closest lifeline. It was a recommendation in a report by a committee headed by an Indian civil servant, Joseph William Bhore, in 1946 that had led to the creation of primary health centres in the 1950s across the country, each serving about 40,000 of the population. The Health Survey and Development Committee, set up by the British in 1943 under Bhore’s chairmanship, recommended that, in the long term, the primary health centres would have a 75-bed hospital for a population of 10,000 to 20,000, depending on density. The Bhore report went into every detail—20 beds for infectious diseases, 25 for medical problems, 10 for surgical, 10 for gynaecological, six for malaria and four for tuberculosis. Each hospital was to be served by six medical, surgical and obstetrical, and gynaecological specialists, 20 nurses, three hospital social workers, eight ward attendants, three compounders and other non-medical workers. This primary unit would be linked to the secondary unit, the Community Health Centre, with a 650-bed hospital having all the major specialities with 140 doctors, 180 nurses and 178 other staff, including 15 hospital social workers, 50 ward attendants and 25 compounders. Besides, every district centre was to have a 2,500-bed hospital providing largely tertiary care with 269 doctors, 625 nurses, 50 hospital social workers and 723 other workers. A large number of these district hospitals would have medical colleges attached to them, while each of the three levels would have functions related to medical education and training, including internship and refresher courses.

When the recommendations started getting implemented in the early 1950s, about 80 per cent of India’s population lived in rural areas. It was nearly three decades later that the Alma-Ata Declaration, adopted at an international conference at Almaty, identified primary healthcare as key to the attainment of the goal of Health for All. By then India had a network of primary health centres and sub-centres. Today, it is estimated that there are about 1.5 lakh sub-centres and nearly 25,000 primary health centres in the country’s rural areas, where almost 65 per cent of the people live. Even if half the primary health centres were designated as CCCs as per the Centre’s recent guidelines, there would be about 3.75 lakh additional oxygen beds across the country.

Health experts say that, despite national health policies and a National Rural Health Mission (NRHM) brought out by various regimes in the years after Independence laying emphasis on strengthening the primary healthcare infrastructure, there was inadequate focus on implementing them, leaving them neglected in most states. They attribute it to a lack of political will. The 1983 policy, under a Congress Government, focused on achieving health for all by 2000. In 2002, the Vajpayee Government came out with another policy, with objectives to achieve an acceptable standard of good health among the general population, increasing access to a decentralised public health system by establishing new infrastructure in existing institutions and ensuring a more equitable access to health services across the country. Its objectives included increasing utilisation of public health services from 20 per cent to 75 per cent by 2010 and raising health expenditure from 0.9 per cent to 2 per cent of GDP. The NRHM, launched by the Manmohan Singh Government in 2005, was aimed at providing accessible, affordable and quality healthcare to the rural population, especially vulnerable groups.

When the Modi Government came to power, it built further on the 2002 policy. The 2017 National Health Policy (NHP) aimed at universal health coverage, reinforcing trust in the public healthcare system and aligning the growth of the private healthcare sector with public health goals. Its health infrastructure goals were to ensure availability of paramedics and doctors as per public health standard norms in high-priority districts, increase community health volunteers to population ratio and establish primary and secondary care facilities as per norms in high-priority districts by 2025. It aimed to establish HWCs that would provide a package of 12 primary care services and make referrals for advanced care, by upgrading existing sub-health centres (serving up to 5,000 people) and primary health centres (serving up to 30,000 people) with more health workers, infrastructure, service packages, drugs and diagnostics. The policy envisaged spending 2.5 per cent of GDP on health by 2025. In the 2021 Budget, the Government increased spending on healthcare by 137 per cent.

“The Bhore Committee’s was a very robust plan. It was implemented and is still in place covering around 50 per cent of the population, but the progress was slow. We lost focus on the primary health system and it was neglected in the past seven decades. With more private investment in the health sector, the focus was on cities. The Modi Government did lay stress on primary health centres and sub-centres in its policy. But then the coronavirus came and nobody was prepared for it,” says Dr Vinay Aggarwal, former president of the Indian Medical Association (IMA). According to him, with the healthcare system administered by states, Kerala, and to some extent Tamil Nadu, Gujarat and Maharashtra had a strong primary healthcare system, but in the northern states like Uttar Pradesh and Bihar it was weak.

WHEN THE SECOND WAVE, WHICH BEGAN IN February, started spreading through cities, even the infrastructure in urban India was unprepared for the huge numbers which would have posed a challenge to any country. As per the Ministry of Health and Family Welfare statistics in April, as daily new cases touched three lakh, India needed 1,62,000 ICU beds, about double the number that existed.

In April last year, just as cases had started rising, a CDDEP (Center for Disease Dynamics, Economics & Policy)-Princeton University study on the existing hospital capacity of India’s public as well as private health sector estimated that there were approximately 19 lakh hospital beds (including seven lakh in public health facilities), 95,000 ICU beds and 48,000 ventilators. Most of the beds and ventilators were concentrated in seven states: Uttar Pradesh (14.8 per cent), Karnataka (13.8 per cent), Maharashtra (12.2 per cent), Tamil Nadu (8.1 per cent), West Bengal (5.9 per cent), Telangana (5.2 per cent) and Kerala (5.2 per cent).

Anticipating the challenge to the health infrastructure, the Government approved a Rs 15,000 crore Covid-19 emergency response and health system preparedness package. Both the Centre and state governments started looking at all options—railway coaches, stadia, large spaces—for installing isolation beds, ICU beds, oxygen beds and ventilators. According to official figures, by September 2020, when cases in India peaked, there were 2,47,972 oxygen beds from just 62,458 in April 2020, while ICU beds increased from 27,360 to 66,638 and ventilators from 13,158 to 33,024. By December 2020, 2,288 laboratories were conducting Covid testing across the country, from 235 government and 85 authorised ones in April 2020. As cases started ebbing, however, the numbers of these beds reportedly started falling in some states, particularly the bigger ones which had to enhance their infrastructure owing to higher numbers of cases.

As Delhi shuddered under a second wave, the Union health ministry announced in April-end that the number of beds for Covid-19 patients at Centre-run hospitals in the national capital had increased by more than four times and stood at 2,105 from 510 on March 1st. Of these, 1,875 were oxygen-supported beds and 230 ICU ones.

The first wave of Covid and then the second, more devastating one, which perforated even rural India, exposed the faultlines in the country’s health infrastructure, the fallout of decades of various governments’ approaches to it and their reluctance to spruce up spending on health infrastructure. There was no overnight solution to the crisis, as demand for oxygen and ICU beds rose to unprecedented levels. India has 0.5 public hospital beds per thousand people, but the figure varies for each state. According to CDDEP data from last year, the US had 2.77 beds per 1,000 people, Italy 3.17 beds per 1,000 and China 4.05 beds per 1,000 people. Of the nearly 19 lakh hospital beds in India, more than half were in cities. Various studies have estimated that an average 50,000 people have been dying in India of snake bites annually. As per the 2010 National Health Profile, there were 5,76,793 government hospital beds in the country, with each serving an average of 2,012. Of these, 3,99,195 beds were in urban areas.

After the All India Institute of Medical Sciences (AIIMS) was established in New Delhi in 1956, also along the lines of the Bhore committee’s recommendation for creating a major Central institute for postgraduate medical education and research, it had taken another five decades to announce more such institutions. In 2003, the Vajpayee Government, while launching the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY), announced six AIIMS-like medical institutes for Patna, Bhopal, Raipur, Bhubaneswar, Jodhpur and Rishikesh. Another one at Raebareli was added through a gazette notification in 2013, when the Manmohan Singh Government was in office. After the Modi Government came to power in 2014, 14 more AIIMS were announced for various states. While some are partially functional, the Government declared in 2019 that all would be fully functional by 2025.

The Covid-19 pandemic, laying bare the unpredictability of a virus and its calamitous consequences, has been a brutal eye-opener on the laxness towards health infrastructure over decades. The Bhore committee had said, “[I]f it were possible to evaluate the loss, which this country annually suffers through the avoidable waste of valuable human material and the lowering of human efficiency through malnutrition and preventable morbidity, we feel that the result would be so startling that the whole country would be aroused and would not rest until a radical change had been brought about.” If only these words had been kept in mind by every Union and state government since Independence.

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