Never before has the need for healthcare reforms that ensure universal access to affordable care for all been more apparent than this year

For the healthcare sector, 2020 was all about battling the Coronavirus. However, this year also taught us a lot of lessons as the pandemic brought into sharp focus the need for reforms that promote universal access to healthcare at an affordable price. The Indian healthcare sector faced incredible challenges this year and will continue to do so well into 2021.

Given the piecemeal way in which our healthcare system is governed and the way the citizens, particularly the poor pay for care, it was no surprise that the sector unravelled in this time of crisis. To begin with, the highest number of people insured under Government-sponsored health insurance schemes as well as under individual insurance plans, stood at a meagre 35 per cent in 2018. A very low percentage of Indians receive health coverage through their employers and, with a record number of people paying for treatment out of their pocket, millions found themselves without affordable and accessible healthcare in the midst of the largest pandemic in living memory. To address the panoply of issues brought into the spotlight by the outbreak this year, the Government should pass futuristic legislations in order to address the need for healthcare reforms in the country. There should be appropriate laws to provide critical assistance in clinical treatment, additional policies to ensure that people can access affordable care as the crisis continues.

Most of the health policy critiques and recommendations this year primarily targeted the Centre, even though as per the Constitution, State Governments are mainly responsible for healthcare delivery. However, as the management of the epidemic was delegated to the States, for the first time the State Governments took a leadership role in managing the healthcare sector, making this year a landmark one in that sense.

The responses of the Centre and States to the contagion exposed the fault lines in our public health governance system. The Disaster Management Act, under which most executive actions have been undertaken this year, is a central legislation though public health is a State subject. The exact delineation of responsibilities between the Centre and the States has always remained a work in progress and over the last few months that resulted in confusion (around quarantine rules, lockdown measures and so on) in the pandemic’s management. This is despite the fact that we have been independent for over seven decades and at the time of the framing of the Constitution, parliamentarian HV Kamath had expressed that health should be the top priority of all governments in Independent India.

 The loss of jobs, income and health insurance issues associated with the pandemic greatly exacerbate existing cost challenges for many. The out-of-pocket healthcare expenses incurred by people impacted their decision to seek care in the middle of an outbreak and will continue to do so as the pandemic rages on. Failure to go for testing and receive treatment because of the cost associated with it, harms not only the person concerned but society as a whole by prolonging the pandemic, increasing its morbidity and mortality and exacerbating its economic impact. We need to bear in mind that this is a collective fight and the whole of humanity is pitched against the novel microbe.

Except for a few States like Delhi, most of the other State Governments did not try to regulate hospital charges or treatment/procedure pricing in the private sector before the pandemic struck the nation. In India, the private sector is the care provider for the majority of the population. It accounts for 82 per cent of outpatient care, 58 per cent inpatient care and 40 per cent of institutional births. This year saw some historical changes taking place in the healthcare sector of the country. Many State Governments took strict measures to control private sector hospitals. Out of 28 States, 16 brought out regulations for capping COVID treatment charges and testing at private hospitals. Despite the Central Government promulgating health sector regulations, the onus of regulating private hospitals has always been on State Governments. However, this is a responsibility that many States had been evading, till the outbreak forced their hand this year.

In the past three months, West Bengal alone brought out 11 different rules to regulate the prices of COVID-19 treatment in private hospitals. Depending on the severity of the infection and type of facilities, private hospitals can charge between `8,000 to `18,000 per day in Delhi and Uttarakhand and `5,000 to `15,000 in Tamil Nadu. Similarly, COVID testing is capped at `1,500 in Nagaland and `3,000 in Tamil Nadu. However, the sad reality is that even now 80 per cent of families would be financially crippled if they had to pay the Covid treatment charges for even one family member.  According to the National Statistical Office’s household expenditure report (2017-18) in Delhi, the average per person monthly expenditure for 80 per cent of the population is around `5,000. In contrast, the lowest price of an isolation bed is around `80,000 for 10 days. To make matters worse, the capped cost for a Covid-19 ICU bed would still come to several lakhs as the treatment usually stretches over two to three weeks or more.

Continuing with their agenda of reforms in the private sector, many States issued strict directives for hospitals refusing COVID patients and many other actively punished violators of these regulations, which was never observed earlier. The present experience of price regulation in the private sector may provide impetus and experience for the regulation of other services important for public health, such as tuberculosis. In the current scenario, States are actively managing public hospitals, ensuring smooth functioning  of supply chains, coordinating as well as regulating the private sector. Recognition of the important role a State Government plays in steering the healthcare sector will lead to the reorientation of health policy research and capacity building in the coming years.

The outbreak has highlighted the role public hospitals play in times of a crisis, drawing the attention of policymakers and politicians. The epidemic has led States to create several middle managerial positions. These new roles, activities and processes will probably persist and strengthen the delivery of public health services in years to come.

The year has also drawn attention to healthcare planning, organisation and management of supply chains. It brought attention to the importance of coordination between public and private sector facilities like never before. Extensive coordination is being observed between the public and private sector hospitals for testing and  reporting of Corona cases, bed availability and treatment. Many States have established committees or appointed officers to facilitate this coordination.

Data sharing, too, increased significantly between the public and private sectors this year, which is a welcome change. Before the epidemic, apart from some basic data, there was little sharing of information and coordination between the public and private sector, which negatively affected health planning at the grass root level.  Never before has the interdependence of our health, finances and social fabric been so starkly visible. Never before has the need for healthcare reforms that ensure universal access to affordable care for all been more apparent than this year. Our policies on health and healthcare, both during this pandemic and in the future, should reflect this reality and we should not forget the lessons we learnt this year. We must use them to frame the healthcare policies and legislation of the future.

(The writer is an author and a doctor by profession. The views expressed are personal.)