The raging second wave of Covid-19 hasn’t just collapsed the Indian healthcare, it has devastatingly uncovered preexisting public health policy deficits and healthcare frailties.
In India, there is a need to revive a serious conversation around public health policy, along with upgrading healthcare. But wait, isn’t the term ‘public health’ interchangeable with healthcare? Actually, no. ‘Public health’ is the population-scale program concerned with prevention and not cure. In contrast, healthcare essentially involves a private good and not public good. Most public health experts point out, the weaker the healthcare system (such as in India), the greater the gains from implementing public health prevention strategies.
India focused its energies on preventing malaria by fighting mosquitoes in the 1970s and then regressed to treating patients who have malaria, dengue or Zika ineffectively. A developing public health policy got sidelined for a more visible, vote-grabbing, yet inadequate healthcare program. Why? Indian elites tend to transfer concepts and priorities, from the health policy debates of advanced economies, into Indian thinking about health policy without much thought. As a result, there is considerable confusion around terminologies. There is a need for a sharp delineation between: ‘public good,’ ‘public health’ and ‘healthcare.’ The phrase ‘public health’ is frequently misinterpreted to imply ‘healthcare.’ On the contrary, ‘healthcare’ is repeatedly assumed as a ‘public good.’ In official Indian directives, the phrase ‘public health expenditure’ is often applied for government expenditures on healthcare. It is confusing because it contains the term ‘public health,’ which is the antonym of ‘healthcare.’
Many of the advanced economies of today have been engaged in public health for a very long time. As an example, the UK began work on clean water in 1858 and on clean air in 1952. For over forty-five years the Clean Air Act in the U.S. has cut pollution as the economy has grown. Therefore, the elites in the UK and US can worry about the nuances of healthcare policy. On the other hand, the focus of health policy in India must be upon prevention, as it is not a solved problem. Problems such as air quality has become worse today in India. Can the Ministry of Health do something about it? Not much, because plenty of public health-related issues lie outside the administrative boundaries of the Ministry of Health. Air quality—that afflicts North India—lies in the Ministry of Environment and internal bureaucracy—“officials love the rule of officials”—deters the two departments from interacting and working out such problems productively. Economist Ajay Shah points out, Indian politicians who concern themselves with health policy take the path of least resistance—to use public money to buy insurance (frequently from private health insurance companies) for individuals who would obtain healthcare services from private healthcare providers. This is an inefficient path because a fragile public health policy bestows a high disease burden, which induces a market failure in the private healthcare industry, followed by a market failure in the health insurance industry.
In other words, Ajay Shah implies that the Indian public sector is not effective at translating expenditures into healthcare services. Privately produced healthcare is plagued with market failure. Health insurance companies suffer from poor financial regulation and from dealing with a malfunctioning healthcare system. No matter the amount of money one assigns into government healthcare facilities or health insurance companies, both these routes work poorly. As a consequence, increased welfare investment by the government on healthcare, under the present paradigm of the Indian healthcare, is likely to be under par.
The long-term lessons from the second wave of COVID-19 is that inter-departmental inefficiencies cannot be tolerated anymore. Public health considerations and economic progress need to shape future elections and the working of many Indian ministries in equal measure. India deserves improved intellectual capacity in shaping public health policy and upgrading healthcare to obtain a complete translation of higher GDP into improved health outcomes. This implies that health policy capabilities—data sets, researchers, think tanks, local government—will need to match the heterogeneity of Indian states. What applies to the state of Karnataka will not necessarily apply to the state of Bihar. The devastating second wave is not arguing for imposing more centralized uniformity in the working of healthcare and public health policy proposals across India, as it will inevitably reduce the quality of executing these proposals in its diverse states with various hurdles. Instead, Indian elites need to place ‘funds, functions and functionaries’ at the local level for better health outcomes. After all, large cities in India match the population of many countries. They deserve localized public health and healthcare policy proposals.
The need to address the foundations of public health and healthcare in India around the problems of market failure and low state capacity has never been greater.