The Oxfam Report, 2021: India’s Health Inequality & Covid-19

-Kakali Das |

According to a report by Oxfam India titled “India’s Inequality Report 2021: India’s Unequal Healthcare Story’ there are sharp inequalities that exist across different caste, religious, class and gender categories on various health indicators in the country. It provides a comprehensive analysis of the health outcomes across different socioeconomic groups to gauge the level of health inequality that persists in the country. The report indicates that the “general category is better off than the SCs and STs, Hindus are better off than Muslims, the rich are better off than the poor, men are better off than women, and the urban population is better off than the rural population” on most health determinants, interventions and indicators. It has been an already known fact that the people of means have access to good hospitals, doctors, treatments etc., unlike the poor. This report says that Covid-19 has further exacerbated the inequalities in the country. The findings are primarily based on secondary analysis from rounds 3 and 4 of the National Family Health Survey and various rounds of National Sample Survey.

Covid-19 was clearly an X-ray which highlighted, amplified the fissures and the failures of the country’s healthcare system. The first being the inadequacy of the health system, with the data confirming how enormously inadequate the healthcare system is to be able to serve this country. Secondly, with the growing inequality, there is a disproportionate impact of it in terms of health outcomes for the marginalised communities. During the pandemic, the people from the marginalised or rural backgrounds were not able to access the Covid-19 facilities as per their counterparts. Thirdly, with the government driving blind-folded amidst the massive earthquake in the form of Covid-19, we have still not woken up, and are on the same trajectory, towards collapse.

The Government, by its own admission, made ‘a large allocation’ (?) to healthcare in the last union budget amidst the pandemic. Upon scrutinising the Union budget in greater detail, a massive cut of 9.8% in the allocation for the Ministry of Health from the revised estimates of the previous year has been found. At the moment, our investments on healthcare is merely 1.25% of GDP, whereas, it should be 2% – 3% of GDP. It’s startling to witness Brazil allocating 9.2%, South Africa 8.1%, Russia 5.3%, China 5%, Bhutan 2.5%, and Sri Lanka 1.6% of its GDP on healthcare. In terms of the number of hospital beds, there are 0.5 beds for every thousand populations in this country. Whereas, according to WHO, not less than 5 beds per thousand patients is adequate, indicating to what extent India is way behind many countries. For instance, Mexico has nearly 1 bed, Bangladesh has 0.87 beds, and Chile has more than 2 beds per thousand patients. In a country where 70% of the population lives in the rural areas, merely 40% of the total hospital beds are available in these areas. This is the stock inequality which is alarming. The infrastructure, the way it’s distributed, ends up in terms of unequal access. That’s where the problem lies – if you aren’t willing to invest your resources, how will you set the system? The public health system in this country is orphaned politically, as well as in terms of any serious policy intent.

If in the middle of this crisis, the government cuts the budget of the healthcare sector, what is it that it is trying to achieve?

In addition to that, there is one allopathic doctor for every ten thousand three hundred patients. In terms of nurses, we have 1.7 nurses for every thousand patients, whereas, according to the WHO norm, it should be 3 nurses per thousand patients. That’s the level of inadequacy the country needs to deal with. Unless we address these inadequacies, I doubt, if we will be able to handle the crisis. The issue, primarily, is that the government isn’t willing to acknowledge the inadequacy of the healthcare system, and that insurance is not a response, privatisation of public health system is never a solution.

“During a survey post Covid-19 phase 1, we clearly saw that different communities have had difficulty in accessing the Covid-19 healthcare. For instance, the scheduled caste and scheduled tribes found accessing non-Covid-19 medical care extremely difficult during the Covid-19 times. Whereas, only 18% of population belonging to the general caste found it difficult. So, there are layers to difficulty and unequal access for different communities,” Amitabh Behar, Chief Executive Officer, Oxfam India said.

Interestingly, in 20^th July, there was a question that was raised in the Rajya Sabha, to the health ministry, by a Member of Parliament regarding the total number of doctors and nurses who have succumbed to Covid-19, to which the health minster responded that they didn’t have the data, and suggested that the ministry must keep a record going forward.

Is this perhaps a symptom of how poorly the country has dealt with this crisis, looked after its health care staff? If we aren’t even aware of the number of healthcare workers who have lost their lives in this pandemic, how are we maintaining the balance of patients to doctors in this country?

Celebrating the work of the doctors by banging plates, clapping from the lavish balconies, shedding crocodile tears or praising them on camera are nothing but empty rhetoric. It’s clear that the government doesn’t consider healthcare as a topmost priority even post Covid-19; it isn’t a political priority for the government, which is reflected in how it treats healthcare system in this country. In terms of the figure, the report by the government says that 4 lakh people died of Covid-19, which we now know is hugely underreported, with every study reporting that it is five to ten times more than the numbers officially announced in the country. If the data is flawed, then all the planning based on that data will also be flawed. Is this an inherited problem of recording flawed data in the country, or is the government trying to cover it up?

The union health ministry has recently put out a statement saying that India’s death registration system is very robust, and the odds of them missing deaths are completely unlikely, and hence, the reports stating that the deaths are under counted is extremely fallacious, and that no one died of the lack of Oxygen. To my experience, in the month of April and May, there were at least two to three people I knew of died of Covid-19 each day. Acquaintances, parents of many friends, teachers I knew of succumbed to the virus, and if the government, now, tells me that it’s merely 4 lakhs in a country of 130 crores of population who died of Covid-19, why will I accept this scam in the numbers? As a citizen, it’s not the numbers, but my experience which signals inadequacy and the underreporting of the data.

“Our healthcare system is completely overwhelmed and it isn’t ready for universal health coverage with the investments they have made so far,” the Chief Executive Officer further said.

On being asked if the Ayushman Bharat Scheme delivered during the pandemic, the CEO further said, “Till October 6, 2020, of all the people who have registered under the scheme and hospitalised, only 65% were able to receive their claims from the Ayushman Bharat. 35% people didn’t get their claims.” To the uninformed, Ayushman Bharat, according to the government of India, is a national health insurance scheme of the state that aims to provide free access to healthcare for low income earners in the country.

Moreover, the health inequality stems from the fact that the health is primarily a state subject, however, the state governments have far lower resources and streams of revenue to spend on them. But, in the court, we have had the centre and the various state governments kick the ball into each other’s courts in terms of the health responsibility. Whose responsibility is the healthcare sector in reality? Is it of the centre or the state?

In the midst of the pandemic, and the harrowing experiences that we have had, this isn’t a party political question, but an existential question of how to make ‘health’, the well-being and dignity of the citizens a critical issue. And hence, it’s certainly about coordinating between the union and the state government.

Besides, there are many Indian doctors on the U.S. television panels exhibiting their expertise on the virus and the pandemic in general. It’s a known fact that the brightest minds in the country choose to leave the country at a certain point and work overseas. Working in the public sector healthcare is made extremely unpleasant, and as a result, a lot of the time, the doctors who can help serve and change the system, choose not to. I think, fundamentally, based on the reports that Oxfam has put up, one of the lessons as citizens we must learn is to start voting based on healthcare and education – the foundation on which the lives of our families and children are built. Unfortunately, the Indian population doesn’t base its vote on the results of health care and education. We also believe that democracy is about democracy once in 5 years. No! We need to start holding government to account whether through reports, social audits on a daily basis. That’s how, I think, substantive democracy could be achieved.