Dr Manisha Bangar
(Round Table India has been hosting a series of online talks by activists and thinkers on issues of importance to the Bahujan. This is the transcript of Dr Manisha Bangar’s talk on July 25th, 2020)
Thank you so much for inviting me to give this very important talk, ‘COVID-19 and the failures of India’s healthcare system’.
It is a huge topic, and involves two topics, one is COVID-19, which in itself is a huge saga, which started in Feb 2020 and we have almost 4-5 months down the line. And we have seen how the healthcare system has unfolded itself, from the perspective of healthcare workers as well as from the consumers’ point of view, that is the citizens of the country. We have also seen how these two major stakeholders were treated by the governments, whether central or state government. In between, somewhere, are people like us, who are evaluating what we have undergone in all these months and what went wrong where.
And we are trying to make some sense of the whole thing. But this is not something new, this is something which was predictable. We knew all through that health policy and healthcare system as such has never been at the center of a national discourse in India despite the very worst performance of Indian healthcare ranking at the larger, international level. And we have always come across sporadic writings and reports, especially on social media, from people who follow healthcare activists and healthcare personnel. This has been my area for long.
I have been involved in the area of healthcare accessibility, not only as a person who has been a part of BAMCEF for a long time of almost two decades, where we took up all issues of representation like education, and other social issues, very vehemently at the national level. Apart from that, from my own professional commitment and background, which includes working in both private and government sectors for almost two decades and with training in the government sector at the central institutes of repute, like PGI-Chandigarh and JIPMER. I have a fairly good hang of how the healthcare institutions have worked, in private and public sectors. And also healthcare accessibility. Riding on top of this experience, and then thirdly, came my own involvement in promoting liver health as well as hepatitis awareness all over Andhra Pradesh and Telangana. There has been almost a period of almost 8 years, when I was involved with various state and non-state agencies, as well as non-profit organizations where we took up the issues of accessibility of healthcare and hepatitis related liver diseases. So, that is my background.
From that vantage point, I would say that there has hardly been a time in which the health system has ever been in the national discourse in the country. The government did not want to discuss such an important parameter, which is related to the well being, progress of the country and progress of each and every community. Apart from education, health was particularly kept on the backburner: the rulers of this country really want a weak and feeble population to come up? I don’t really want to get into the depth of it. But yes, it has never been in the center of the discussion.
We’ve also seen since 2000 onwards, a very relentless privatization of the healthcare sector. For people like me and you all, how do we reconcile this entirely privatized healthcare, sitting on top of the whole healthcare system? When I was given this particular topic, I felt I should rename it as ‘COVID sitting on top of a fragile healthcare system’. It’s like somebody’s back is already broken and then COVID happens: a huge monster sitting on such a healthcare system. So how do we reconcile these values of public-private partnership on one side, as well as liberalisation, privatization, globalization on the other side and then we have the values of equity, justice. So this is a totally discordant era we are living in.
Not only this, I remember, when I was just out of my MBBS and into my MD, then there was this huge fanfare, grandiloquent ideas, and entire newspapers and their business sections were replete with news, views, analysis, enthusiasm, a very gross jubilation about how the healthcare system is going to be privatized. And the only thing that seemed important to them was that the waiting period for patients is going to be less, performance of the system is going to be better, it’s going to be state of art and it’s going to be technology driven, and a lot of technology is going to come in.
So yes, ‘state of art’ and ‘technology driven’ became very hyped words and this kind of drove along for the last 20 years and today this is where we are. At a stage in which we have seen utter failure, in whatever sector, whether private-public partnerships or public sector or exclusively private sector we have seen that it has totally failed at not only at the policy making level but also policy execution level. Because the dominant model was essentially the public-private partnership or more slanted towards the private domain. It never really translated into better healthcare outcomes that we actually look for.
And that is the reason why India today stands at 147 in international rankings and does miserably compared to even Sri Lanka, Bangladesh and Nepal, these are the reasons. We need to take a hard look today, as to what we want, what this country wants, and what is the driving factor which will decide the model of healthcare in India. And I sincerely feel that a kind of top dressing approach will not help, and definitely not this piggy-back approach, which rides only on emulating the West … If they were to emulate the West I wouldn’t really mind, if it meant to emulate Scandinavian countries or Canada or something like the NHS to a certain degree, I would say yes, let’s emulate that. But the thing is that it inexorably goes towards emulating the US which is a very highly privatized, technology driven healthcare system, and we have seen how it has failed miserably. Today, US policy makers and academia are deliberating on whether there is something grossly wrong with their own policies, they are voicing their concerns, and they say that they are lagging behind and have fared much worse compared to even Japan and Korea. So, all this churning of thoughts is going on.
When I talk about the failures of the Indian healthcare system, when I say it has failed, how has it failed? It is a huge topic, but let me tell you two things. One would be to assess how highly privatized this sector is. What was the state of the public healthcare sector before the privatization? And also, these various models which came up in the public-private partnership, whether it was the Rashtriya Swasthya Bima Yojana or the Ayushman Bharat – National Health Protection Mission. So, how have these fared in delivering social equity and accessibility to healthcare? Because the majority of the benefits are out of the reach of almost 80-90 crore people. This finally dictates the health outcomes, and also finally dictates the ranking in various indices all over the world.
Let me give you a very simple example. Sri Lanka as a country, we know that it has a population of 2 crores, and we have a population of almost 135 crores. I am following Sri Lanka, Bangladesh and how these countries are doing in terms of COVID control. Sri Lanka has about 11 deaths due to COVID in the past 3-4 months, we have 22,000. If you multiply the number of deaths, if their population were to be 130 crores, it would amount to something like 660 deaths. Look at our deaths, which have already crossed 22,000. Some very rough parallels that we can draw, and when we compare with other countries, the situation is pretty bad.
That is one thing. So what has been different from Sri Lanka, which has not been thought over or taken care of in India? We have never really focused on equipping and empowering and strengthening the public healthcare system, that has been the only glaring factor we can see. I went to Sri Lanka about 2 years ago, and again later last year, in our interactions with the doctors there, because I am an executive council member of the South Asian Association for the Study of Liver Disease, that’s the reason I am closely engaged with healthcare professionals, policy makers, as well as activists, people who matter in the neighboring, South Asian countries. Almost throughout the discussion, the entire thrust of the Sri Lankan doctors was, they were talking about Public Healthcare Centers, they were talking about the medicines which are available in the PHCs. They were not talking about antibiotics, Monocef and all the other drugs that we actually get off the counter. They were talking about paracetamol, and very basic minimum medications, to which in India we have already developed resistances. There has been so much of overuse and so much of disregulatory mechanisms, because the regulatory mechanism in India is very fragile and feeble, and very dishonest and very unauthenticated.
What I mean to say is that the health of the people can be maintained and managed with a lot of focus on preventive healthcare, public healthcare system, as well as taking care of basics such as education, sanitation, and good quality, hygienic water. In a country like India we have not tackled these basics. The focus has been totally skewed and invariably it has been entangled with other parameters of development and accessibility. Whether it is accessibility to hygienic water, good sanitation, basic education.
In the example of COVID, when it started, our Prime Minister actually diverted the whole issue by giving ways and means to tackle COVID, either by banging a thali, lighting diyas, and then we already have a spate of babas and babis who are promoting various ways. So all this misinformation, myths, and disinformation — if it goes and sits in the minds of ignorant masses, then naturally, health takes a beating.
Even among well-to-do families and people, even the middle class, scientific attitude is so pathetic, so dismal that whatever comes up, you know, through the media agencies, or healthcare and welfare ministries, it is hardly taken up and grasped properly. These are the dynamics, these are the factors that underlie this crisis. That is what differentiates us from other countries which are ahead of us, whether it is Bangladesh or Sri Lanka. They have not taken health in isolation, they have taken it in totality, and that is what has been different.
I am trying to give you an overview of how things were before 2000, then 2000 to 2020, and then February 2020 onwards. When it comes to policies, we were lacking, before 2000 also, I will let you know how. Then medical education, the hospital infrastructure: what was lacking in hospital infrastructure was the inadequacy of equipment, inadequacy of facilities, staff, network of PHCs, all this was lacking. And the budgetary allocation itself was pathetic. For almost three decades there has always been a very cursory, very nominal and tokenistic talk on enhancing the budgetary allocation for health, which has not till date gone beyond 1% of GDP, which is horrible, absolutely terrible, we should be pretty ashamed of it. When we say we are a shining country, we are a developed country, or we are competing with the USA or whatever, that really doesn’t put us anywhere nearby.
I’ve talked to you about ancillary features and departments which should have been strengthened, and the lack of facilities and budgetary allocation and how they kept the public hospitals, whether they were government medical colleges or central institutes always in dire need of many things. And they were always lagging behind, as far as equipment, facilities, medicines, the pharmacy — and that kind of percolated down to the PHC level. We have heard and we know how deliveries are conducted. When I was a resident, gynaecology was not my subject but as a resident we had to study it, and we still dread the thought of the way we conducted deliveries. In the PHCs, the way the injections were given, I cannot revisit the thought, it’s unimaginable. The spurt in HIV cases and HCV cases was definitely because of the lack of equipment – no exclusive injections and vials were available for a very, very long time, that’s pretty gory actually. Despite that, the public healthcare was doing OK on two fronts. One was medical education, and the other was the faculty and degrees that were being given and allocated. That was a pretty fair system to a large extent which kind of dwindled after the private medical colleges came about.
Let me take you on this journey and then tell you about two very important policies, and you will come to know how the policies were made and how they were faulty. So yes, what happened between the year 2000 and 2020, how did it shape up? First, there was a lot of propaganda about how the privatized healthcare sector is going to be good. And there was a lot of machinery … this is something which I have not got through books or the Internet, but it is something I have seen, evaluated, and analyzed. I was finding out from people, and written and talked about all through. Then there came the entire thing of banks giving loans to hospitals. In Hyderabad we have the Medwin Hospital, the owner of Medwin knew the bank loaning guy in State Bank of Hyderabad — crores and crores of loans were given to this family, whose head Sambasiva Rao was in politics here, in Congress. I’m giving you the model, that’s how most of the private medical colleges and corporate hospitals have come up, and that nexus still remains. So they give a loan, they run the hospital and there is no regulatory mechanism on the charges. The fragile regulatory mechanism, as regards to the fees and tariffs, it is driven by the market, it is driven by the coterie in power in that particular city, of that particular state. All of them sit together and decide, this is the charge for this blood test, there might be a little deviation, but that’s about it. And then when they had actually earned their money, a lot of the money was put in other companies they owned that were building bridges and highways, they are suddenly bankrupt. And then, the government waives off the loans.
Then you see CDR, a very famous hospital — in 2008-2009, the hospital started closing. There were bad loans, they expressed their bankruptcy, it closed, and there was a whole journey of closing of the hospital. And then on top of it, new hospitals are coming up, with the same model of investment from people putting in their money, whether they were doctors, or investment bankers, or people from the dominant caste communities. This is the kind of roller coaster going on. This has been the private sector, this is how it has worked.
In between all this, what were the rights of the patients, what were the rights of the doctors themselves, who are the consultants and backbone of the hospital, nobody cares about that. There has been a national accreditation board, and there is a JCI (Joint Commission International) board, which is an international regulatory board and NABH (National Accreditation Board for Hospitals & Healthcare Providers) is a national board. These accreditation boards, they look into whether the facilities are available or not and they look into the logistics, whether the building is ok blah blah blah. And of course, because of the international standards, they have to implement certain good practices, specifically regarding certain diseases. Having established that, once the private or corporate hospital has shown that it has established that, thereafter there is only a review after 3 or 4 years, and in between the hospital is free to do what it wishes to do, on its own free will. There is no monitoring, hardly any surveillance, and if there is any, it is a pretty biased kind of regulatory mechanism. This has been another part.
And somehow or the other, these two things have reflected on both sides. It has reflected on the public side, in the way that many of the doctors were kept at a low pay, so they always had the lure of going into the private sector, because they were not earning enough, and then they also wanted to do private practice. On the other side, you have a private sector coming up, but which is lacking in research, which is lacking in ethics, which is lacking in good medical education, which is lacking in good training, and which is lacking in regulation. We have this entire spectrum, but the two ends of the spectrum are more prominent than anything else. We do not really have a good, robust middle arena where the best combination of the ends of the spectrum are alive and giving good health to the people. This is how it has been and these are the two forces which have been pulling each other apart.
I hope I have given an overview of what exactly went wrong and how things started dwindling in a way that we have now ended up in the very worst of the worst scenarios.
Let me tell you about policy making. My interest in policy making, the interest in the Harvard program was precisely for this reason, I saw how faulty the policies were. One arena is that people feel that certain policies have to made, ok fine, 1-2-3-4, and then a government order or leaflet has to be given to the IAS, IPS and so on to be executed. No, it should not be like that! Actually, the bureaucracy hardly comes into the picture where it matters, they only come very late in the course. Where the policies are made, the bureaucracy at that level matters, and of course, the people who are ruling, whether as a class, or as a caste, or ruling party, whichever way, it matters at that level. These issues and the policies have never taken center stage and that has been a major faultline in the healthcare system in our country.
You must be aware of this midday meal scheme, right? I’ll tell you how policy making matters. If it is faulty, if it is governed by biases, by traditional thinking, and a very casteist, iniquitous thinking, it really matters a lot. This particular thing came in and became a part of my project also, which I presented to the universities, not only this year but also five years ago, and also to the Hepatitis Alliance, through which I was awarded a kind of honor in the form of ‘Friend of Aliiance’. What was Dr. Manisha telling them, which others were not, that made them take cognisance? The only thing that I said was, I was working with Dr. Veena Shatrugna, who is superannuated now, and she was the head of the National Institute of Nutrition. We also had Dr. Arlappa also, who happens to be from the Bahujan class, and we were working together on a certain thing. So what were we looking at?
I had conducted a conference on nutrition, and what came across in my mind was that the differences in health in rural vs. urban India, in male vs. female, in various religious groups, and of course, the SC/ST vs. the others, this has been studied. It came to my notice that OBCs, or the Muslims, or the Sikhs were not studied. We don’t know what is happening to their health. How are the OBC women doing compared to general caste women? How are they doing compared to the Muslim women? Either we had SC/ST because of the affirmative action they get or we had the ‘others’. The entire middle population was totally forgotten. That intrigued me, and that was pretty shocking as well. Thankfully, Dr. Veena Shatrugna had a study in which she had graded and categorized people, and she showed that the weight of a person not only depended on male vs. female or urban vs. rural factors, but actually differed in gradation according to the caste/class hierarchy. This was quite revealing to me, and it is from there that I picked up the notion that caste as a determinant for accessibility has been studied very dismally, hardly studied, very few people are engaged in it, in this particular aspect, and this needs to be highlighted.
There was a precedent in the form of an article and studies that were done on the midday meal scheme. As we all know about the ration subsidies that people get in the public delivery system — what do we get? We get rice, wheat, atta and a few more things. The children, who are part of the midday meal scheme, what are they fed? They are fed the nutritional value, the food stuffs, which was decided by a body of people who were non-representative, in the sense that they entirely belonged to the upper castes. And the upper castes, out of their own notions and understanding, and their own politics and social standing, felt that the people in this country and in this scheme need to be fed with protein from vegetarian sources, and they picked up pulses as the main source of protein.
With the midday meal scheme, we were not only going to tackle the dropout rate of the children, we were going to enhance the educational participation of people, especially of the backward classes, enhance the participation of the students so as to increase and enhance their nutritional status. Because the Indian population has the highest death rate among toddlers in the world even today, and that was true in the 1960s also. When in 1960s, similar to the Kothari Commission, there was a Health Commission, in which they decided that protein has to come from pulses. Now pulses are the worst performer as far as protein content is concerned, it has got more of carbohydrates if at all, there is hardly any fiber, hardly any nutrients. And the entire thing was totally focused on such a poor source of protein. They could have very well have included milk, they could have very well have included eggs, but they did not. They went by their own whims and fancies. They kept the entire population malnourished for the entire span of about 6 decades. Isn’t that crazy? Isn’t that horrible? Isn’t that genocidal?
We have a totally malnourished population, and malnourished women giving birth to malnourished children. Then we have malnourished kids going to school, and a whole malnourished generation. When I was doing my degree and we were in our clinics, and I used to get so perturbed, it was quite disturbing, because 80% of the pediatric ward was filled with children who had Marasmus and … And at that time, it was shown as a disease, It is not a disease! It is just that they did not get enough to eat! They were supposed to get food to eat! The public distribution system in the remote areas, whether in the Adivasi areas, or Thane, or Melghat, or Nagpur, or Buldhana, or any other such place in Maharashtra (I did my MBBS and post-graduation from Nagpur). All these people were coming with gross malnutrition to the extent that they died, and there were kids, small kids, mothers clinging to their children, and they were not diseased, they just did not have food to eat. That was because a body of upper caste people in 1969 decided that they need to have pulses as protein and not milk and also have the honor of saying that ‘yes, we as a country are having a midday meal scheme’.
That is how policies can be faulty, and need to be rectified. A similar thing happened in the national TB program, in which a small hinge effect could be created by making an ambulance accessible to remote areas, and delivering the drug to those areas, that made the entire difference. But it wasn’t actually in place for almost a decade and a half.
This is where caste as a determinant, and social location as a determinant comes into play. That the majority of this country need to be in policy making positions, they need to draw and finetune policies, assess and examine the policies and get them rectified.
I also want to talk about two recently propagated schemes, with much fanfare. I will not talk too much, just give anecdotal examples. Rashtriya Swasthya Bima Yojana and the Ayushman Bharat – National Health Protection Mission. Why I wish to talk about them is that these two things determined the number of COVID cases tested, how we performed during COVID, whether equipment was there, whether ventilators were there; and the health ministry, how much it allocated to dissemination of information through the media, how much total amount of money it expended on dispensing information to the various sections of society: all this will tell us the story of why we are at a major faultline here.
Now, Ayushman scheme is insurance driven, which covers less than 50 crore of the population. If you see what are the drawbacks of this scheme, it is entirely skewed or slanted towards the private insurance bodies. It is something which has been given as a profitable thing for them. And even in the Arogya Shri Scheme, which is part of the Rashtriya Swasthya Bima Yojana, what happens is that the government says, ‘you admit the patients, and we’ll take care of the expenditure’ and only a few diseases are covered in it, not all of them. What has been seen in this scheme is that there were a lot of fraudulent cases, lots of fraud. So much so that they literally had to develop a lot of corrective mechanisms, and almost 200 hospitals were dis-empanelled. There were a lot of fake e-cards, a lot of manipulation to the extent that FIRs had to be lodged, there was a huge administrative structure and architecture which had to be developed, and technology database, all these things had to be done.
All the allocation for Ayushman Bharat scheme has resulted in diversion of all the funds towards privatized care, which is already fraudulent, and which has not performed well, which we have seen already. And this particular thing has not led to improved health outcomes, in terms of whether it was number of beds available, equipment etc. There was PPE shortage for almost a month and half, the beds are full, and on top of that the private hospitals had been totally excused from admitting patients for a long time, they were hardly allowed until a month ago, 25 days ago. They could not even recruit their private medical colleges, to which they had given subsidy in the form of a lot of land, lot of electricity subsidy, lot of aid in the name of public-private partnership. They could not recruit or bring them under the gamut of imparting COVID care. The minimal resources which are available in the country, in the face of a highly inadequate budgetary allocation, it was totally diverted towards maintaining the technology driven system and database which itself has seen a lot of flaws.
This has been the background on which COVID has evolved. That is the reason why we see that the number of tests done for COVID patients are less even today, and the charges are not under regulatory framework, they are still being debated. Except for Maharashtra, there is no other place which has allocated IAS officers to monitor hospitals, so that they are within the purview of the government and rules. It is totally arbitrary, it is pretty haphazard and haywire everywhere. The cost of the COVID treatment is very exorbitant. Not only that, the most important area where it has faltered is that: suppose a person suspected of having COVID goes to a private medical college or hospital. Why do they go there? Because the government hospitals are not adequately equipped, and they are falling short and the number of cases are increasing. And we knew it very well, for a population of almost 135 crores, we knew we would be landing in this situation.
Now, when the corporate hospitals have been opened up, when the patient goes there, they get tested even if it is a suspected case. This particular suspected case needs to be upgraded and updated into a unique identification number, which is in a government driven system database. It has been seen that at the behest of the patient themselves, or for whatever reason, these things are not updated. There is a whole lot of gap in tracking the patients. We now have 2 lakh patients or more (in the third week of April), who are possibly COVID positive and they are not in the tracking registry at all. So you can imagine the amount of COVID load which is already there and it is not being tracked, and not under any systematization. These are the faultlines which have started way back, and hence today we are not able to tackle the pandemic. Forget about tackling it, we are not even able to control it.
In the face of it, we have a political system which is totally diversionary, it is totally tactical, and which has created ways and means to divert, whether it is in the communal form, or in casteist form. However, what needs to be done is, we need to take a hard look at the insurance model. There can’t be an insurance model and a private model when you aim to ensure universal healthcare for all the people of India. They are totally discordant things, absolutely. There is a huge dichotomy there.
What has also been the basic faultline is that, without attending to the facilities, to basic, primary things, we have the habit of leaping onto bigger things, in the name of technology, in the name of state of the art, in the name of best in the world. This is a big vice actually, which is ailing the healthcare system. It is intricately related to the disease, the malaise which is there in the education system and which is there in the social hierarchical system that we are in.
I will end my talk by saying that in all health indices, in which India ranks very low, caste is a determinant, and it is still the backward classes who are faring very badly. We have to see that in the COVID scenario, right from the time of the migrants, who were relegated to the background, to the time that most of the population in India, including females, all the vulnerable groups, the religious vulnerable groups, and the backward classes, are out of the purview of good quality healthcare in India. So that’s how, COVID is sitting on top of a very fragile healthcare system.
Dr Manisha Bangar is a leading organizer of Mulniwasi Bahujans of India (the Indigenous majority population). Currently serving as National Vice President of BAMCEF (Backward and Minority Communities Employees Federation), she is former National Vice President of Mulniwasi Sangh and National President of Mulniwasi Mahila Sangh the mass based offshoot wings of BAMCEF.
A good orator, freelance writer and poetess she has continued to speak for more than a decade at Universities, Civil/Human Rights and Phule Ambedkarite Organizations, both Nationally and Internationally (USA, UK, Europe and Middle East) including the United Nations on issues of Caste, Gender Equality, Health and Education rights, Comparative Religious thought and Phuley Periyaar Ambedkar Ideology. She is also a super specialised, practising Hepatologist in Hyderabad, Telangana, India.
This talk was reanscribed by Sundeep Pattem.