India's Public Health Care Delivery: Policies for Universal Health Care

By Sanjeev Kelkar

This book describes the present awful state of India’s Public Health Care Delivery, its dismal planning and implementation. It argues that it can be remedied comprehensively and effectively, using its ‘own already present’ resources. A radical re-evaluation of some sacrosanct ideas and discarding many of these, especially in Primary Care and its structure is required. It can be done without disadvantage to the last man served. 

This book starts with the sea change India has undergone and emphasizes new ways of managing health. High quality work force creation and its deployment, an unsolved problem is effectively given a solution. The bulk of the book discusses the entire public health care structure and function and how it can be newly laid out with proper work force allocation, hitherto grossly inadequate, including professionals from other training backgrounds. It is total solution that will help India to achieve the goal of Universal Health Care.

• Language: English
• Publisher: Palgrave Macmillan
• Release date: Mar 5, 2021
• ISBN: 9789813341807

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© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021

S. KelkarIndia's Public Health Care Deliveryhttps://doi.org/10.1007/978-981-33-4180-7_1

1. Introduction

Sanjeev Kelkar¹  

(1)

Pune, Maharashtra, India

Public health care has been deteriorating over decades now. In all these years the totality of the scenario in its history, development and unbiased critique in a single volume was not available. It was divided into different segments of the health literature and policy documents. Each dealt with a specific vertical. The thought process about what can or should be done was also limited to each vertical. Some aspects received much more attention and many others were treated almost cursorily. This book is written to provide a totality of the picture of public health care delivery and what can be done to make it better. New ideas are at times considered not feasible, especially when they draw people out of their comfort zones. Sometimes these are considered absurd. However, the more absurd an idea may seem, the more it is possible that it could have a kernel of truth to it that will have future substantial possibilities.

The idea of and policies needed for universal health care were to be the backdrop of this volume when it was submitted in mid-February 2020, for prepublication processes. Then all of a sudden the Covid-19 pandemic started and shook the whole world health wise, and devastated it economically and psychologically. We considered it essential to provide a brief overview of the Covid-19 situation and assess the role, contribution and relevance of public health care delivery in India vis a vis this disease. The same consideration was extended in my volume India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021), published in January, 2021. For me it was a lifetime opportunity to test the many elements, observations, shortcomings, other injurious effects and contribution of the public health care sector I have discussed in this volume during the fight against Covid-19. It was also a lifetime opportunity for me to weigh the measures suggested by me with respect to the public health sector about its suitability and effectivity today against this new background. In my 49 years in medicine I have never found the health system of any country prior to 2020 in such great difficulties.

Covid-19 as a disease, its pathology, the controversies surrounding it, its future course, mutability and vaccines, the world scenario of health care, both public health and private health care delivery methods, their shortcomings, attitudes and effectiveness vis a vis Covid-19 are discussed in the volume India’s Private Health Care Delivery: Critique and Remedies (Kelkar, ibid). The volume also covers the contributions, attitudes, deficiencies and shortcomings of the Indian private health sector vis a vis Covid-19. This volume will therefore exclude these topics.

Formal Public Health Care Structure and the Pandemic

In the main this covers the largest sector of public health care delivery—the sub-centers, the primary health centers, the community health centers and the sub-divisional or the taluka-level hospitals with the largest health armies. Before going further into the discussion it must be stated that Indian public health care delivery as it stands is expected to be effective in pandemics and epidemics. The large national programs are a surrogate for testing to see if this has worked or not. It has not worked this time. As reported in this volume, it is not even geared to handle small localized or state-level recurring endemics. Hence there is little point in examining or emphasizing the public health care failures in the Covid-19 situation. The attention of the reader is directed to all the structural changes described in many of the chapters here which will perform better in such situations. From the district hospitals to medical colleges the utilization of public health care facilities seems to be better during Covid 19.

Where Lies the Deficiency?

The cry of neglecting the public health care sector on various counts, raised for the last 60 years of low budgetary provisions and its failure during Covid-19, has gone up as expected. However, I believe that this is a gross simplification of the matter and that low health expenditure is irrelevant to the present pandemic conditions. As has been repeatedly emphasized in this volume, it is structural faults like duplication, redundancy, undue emphasis on primary care, the work time ratios at all levels and the enormous wastage of money in faulty schemes, as well as many other aspects that have been outlined in the Covid-19 period. Those who are shouting about the public health care inadequacies of funding have never even remotely considered understanding or offering solutions to these aspects, which are where the fault lies (see below).

The real need during Covid 19 pandemic was for simple isolation facilities, which are not difficult to obtain. India conducts elections involving 1.3 billion people. Procuring these facilities is a simpler matter. This was not handled well by many state governments. The challenge was in establishing higher care centers for which the facilities under both central and state governments were inadequate. The point is that the situation could have been substantially improved but has not been in several states. However, many states have still done their job well. A rational understanding of these numbers is required for action, rather than worry.

The Health Care Activities of Non-Covid-19 Nature

In general, non-Covid-19 acute care was left to function in all the private sector entities as well as in the district hospitals in the public sector. The routine activities were shut down to prevent unnecessary contact among people and to create bed capacity for Covid-19 patients. India’s growing number of non-communicable diseases have added their own burden to infectious diseases, which had been on the decline for many years. To this a pandemic was added with extremely rapid spread, high mortality rates among the susceptible and those with co-morbidities such as diabetes and heart ailments. The public health infrastructure in most parts of the country has been far from adequate to meet these challenges and was overwhelmed early in the pandemic. The poor states have had to struggle the most during serious outbreaks. There have been other yearly recurring contagions of menacing proportions, like the encephalitis epidemic in the summer of 2019, which have somehow not troubled the system as much as expected. Later migrant labor was another issue that put stress on the system.

In the primary health care domain something similar seems to be happening. The postponement of case-finding campaigns for tuberculosis (TB) and other related activities and routine immunization-related activities took a hit that resulted in at least 5 million children missing out on being vaccinated. The lockdown has compromised the Ayushman Bharat , Pradhan Mantri Jan Arogya Yojana’s (PMJAY) ability to reach out to critically ill people living below the poverty line, including those afflicted with cancer (Express News Service, May 7, 2020).

The scores and scores of measures to cope with these situations discussed over six chapters here can be seen as relevant to answering these questions. Covid-19 has created one more vertical in the care profile as a temporary battle but long-lasting new national program. The inadequacy of structural planning and work function time mismatches that have caused this situation have been discussed extensively in this volume.

The Inept Handling of Public Health Resources

The inept handling of available public health care resources is another serious aspect. Fifty-one days after the announcement of lock down, the largest Hindu Rao Public Hospital of the Municipal Corporation of Delhi North had not taken off for its conversion to Covid-19 facilities. It is a 980-bed hospital, with a staff of 600 doctors, 350 nurses and 300 allied workers. There was a lack of various elementary necessities such as PPE equipment, adequate security; timely staff salaries were not paid for up to three months. Poor maintenance of simple things like temperature guns show the everpresent apathy (Rajput Abhinav, June 16, 2020) which has also been depicted in this volume. It is obvious that the AAP government did not use the lockdown properly. The lack of coordination visible in Maharashtra also indicates this apathy and inept handling.

On 14 June 2020 Home Minister Amit Shah had to step in and announce several measures to address Delhi’s worsening Covid-19 crisis. It took AAP nearly 50 days to ask the center for help with 500 railway coaches or 8000 isolation beds to Delhi to make up for the shortage. When testing all over the country had been ramped up to 100,000 tests, adding three more types of tests for mass application, AAP was sleeping for 50 days until the center stepped in, doubling the testing in the next two days and tripling it in six. The Delhi government did nothing to enlist the cooperation of the private sector, which has a large bed capacity. Their issues should have been discussed in these 50 days and a solution determined much earlier. With high number of testing Delhi recorded positive cases in continuously rising high numbers after 14th June, daily and hospitals filled to capacity and patients suffering greatly.

Inept Handling in Maharashtra

This has added to the woes of public health care. It is difficult to know about the interaction between the bureaucrats and their political bosses. Neither seemed to have a correct appraisal of the situation. The orders finally issued reflected this. One thing is obvious though: the bureaucracy became the decision makers, those very people who do not have as good an understanding of health care as do practicing doctors. The final outcomes in the form of circulars and advisories have often been conflicting and therefore confusing to an average doctor or a small nursing-home owner. This was a salient feature from March and will overflow in to the next year.

However, one of the most sinister factors is the complete indifference for weeks on end after the lockdown for the suffering patients and unwillingness to do anything substantial for them by ramping up the public health facilities in Maharashtra. No importance was given to the provision of simple observational isolation facilities that could be easily housed in schools and colleges and such other large structures and preparation for those needing more observation. Instead jumbo facilities were created. Intensive care in the absence of any planning suffered terribly, and experiences in this regard at Sassoon General Hospital in Pune or Sion and KEM in Mumbai were horrible.

Of the 18 large public sector hospitals in Mumbai only four were built in independent India. This can be viewed as a scenario of long-term neglect. But when the class four staff disappeared from KEM Hospital in Mumbai and refused to work, no action was taken. This class has repeatedly disrupted Municipal hospital functioning in Mumbai in the past four decades despite being the recipients of all kinds of perks. The Maharashtra Essential Services Maintenance (MESMA) Act 2011 has been invoked but not put into action to date (https://​www.​facebook.​com/​107242304256980/​posts/​142804354034108).

The lack of sensible management of caseloads by balancing the evolving situation of Covid 19 protocols was obvious. The laws and procedures existing in non-pandemic times were not adapted to deal with the ground realities, another glaring failure, noticed in the disposal of dead bodies in Mumbai. It is impossible to understand why this could not be managed efficiently when the Epidemic Disease Act was applied, invoked and used for threatening private practitioners. The delays in coordinating with and seeking cooperation from the private sector are detailed in my volume India’s Private Health Care Delivery (Kelkar, 2021).

The next was both the inaction and the cynicism for not implementing the only weapon we had-detect, isolate and treat as much as one can under equitable terms in anticipatory action was complete. The protocols were ready quite early. There was an enormous amount of data available on how things would worsen in terms of numbers and complexity, how these should be managed and how things would improve. The public health capacities ran out because this information was not translated into action.

There were four stages among those isolated:

(a)

Symptomatic but tested negative: Initially their quarantine was to end after the second and third tests were negative. Later it was found that one negative test is enough for discharge (Gangakhedkar RR, May 18, 2020). Home quarantine for 14 days where possible in an effective manner as a sound option surfaced to keep more beds free but it was not used effectively, thereby increasing the shortages.

(b)

Symptomatic and tested positive: These were the cases that needed the Covid Centers most. These could worsen in some cases but most patients would be able to go home.

(c)

Tested positive and condition worsened and needed Covid Hospitals with oxygen-supported beds only: It is much easier to construct or procure these beds and reduce the congestion in ICUs. Over the weeks the medical community learnt that beds with oxygen support and various non-invasive methods of supplying oxygen were needed in much larger numbers, and were more effective than treatment with a ventilator as found later.

(d)

Critically ill: These patients went on ventilators with much lower numbers surviving than those in the earlier three stages. Those who survived were not moved back to a less intensive setup as quickly as should have been done, thereby reducing the number of ICU or High Dependency Unit (HDU) beds available. For a long time there was no dashboard in Mumbai to indicate to people where the beds were available, in contrast to Haryana and Kerala where this was well managed (see below). The back and forth movement in these four stages was not managed efficiently, nor was the availability translated to the dashboard, adding to people’s plight.

Health Care Infrastructure at the Periphery and Covid-19

Oxygen-supported beds are also manageable in public health care delivery in more remote places. Hypothetically, if migrants cause a much larger number of fresh cases to develop that require active hospital management, how many such oxygen-supported beds do we have at the sub-district, sub-taluka level? Practically, it will be insignificant or nil because these are the places where no work goes on. It would be a miracle if the 25,000 primary health centers had full and finctioning 500 such beds. The 5300 community health centers also placed in remoter locales do not have ICUs or HDUs. It would similarly be a wonder if these centers even had oxygen-supported beds. Covid-19 may not necessitate these arrangements but local endemics often do. For this the structural modifications given in great detail in this volume will give astonishing results, one more validation of the changes prescribed.

If all such things were occurring in Mumbai, the prime Indian city, things might be expected to be worse elsewhere but this does not seem to be the case. Looking at this situation, it would not be considered farfetched given the antecedents of those governing Maharashtra state for one to draw the conclusion that the people manning the ministries had no interest in discharging this responsibility because there was no ‘gain’ for them. Another reasonable conclusion is that the ministers may not understand what to do, but indeed the bureaucracy may not either. Alternatively, however, all that the bureaucracy does or did was to manipulate their bosses, or make fools of them, and remain unbothered about what happens to citizens. This is generally the character of the IAS-type bureaucrats in independent India, and hence this is not at all surprising.

When the Governments Function Well and People Cooperate

In contrast to this scenario, the Haryana Covid-19 record of 21 deaths as of 6 June and 2083 till December 20 in 2020 is a model in pandemic management. As expected, the Kerala model was praised but Haryana’s was ignored. Kerala, however, saw a second resurgence but this was also managed well. The success of both of these states is based on the same reasons. Both states

1.

Conducted a large number of tests approximately 5167 tests per million population, substantially higher than the India average of 3831 tests per million.

2.

Undertook early testing of those entering the state from Indonesia, Nepal, Thailand, Bangladesh and the Maldives, among others and their efficient contacts tracing.

3.

Excellent use of the three-layer health infrastructure Covid care centres (CCCs) for patients with mild or very mild symptoms, Covid health centres for patients with moderate clinical symptoms and Covid hospitals for treating patients with a severe or critical manifestation of the disease preferably in medical colleges.

4.

A clear pathway for the back and forward movement of Covid-19 patients through various categories of Covid health facilities, streamlining the management of resources, initiate efficient and timely treatment.

5.

Strong monitoring mechanisms at the state and district levels with a dashboard providing a comprehensive, district-level overview of the latest status of Covid-19 cases.

6.

Emphasis on the management of containment and buffer zones, restricting the entry and exit through the effective deployment of the police, frontline health workers like ASHAs and auxiliary nurse midwives.

7.

Testing all patients for Covid-19 who contact health system for unrelated surgeries and screening their high-risk contacts of patients, with TrueNat test, to save time and reduce the burden on the state laboratory.

8.

Extensive use of print and electronic media the community radio for creating awareness and dispelling myths and misconceptions and stigma about Covid 19. (Urvashi Prasad, June 8, 2020, 11:25 am, blog site Swarajya)

Kerala’s success lies in its extraordinary alertness in preparing for the pandemic in minute detail early in January and being aware that Malayalis would be coming back from Wuhan and would potentially be bringing the virus with them. The health system in Kerala has always been a cut above the rest of India. The public and private sectors have many reputable institutes and when it comes to health, all appear to cooperate. Ready lists of such institutes and medical and human resources seem to be their specialty. Even though the numbers returning to the state were high, as were the death rates, they were alert for second and third waves as people continued to enter the state. Kerala has undertaken the standard Covid-19 drill so thoroughly and sincerely. It received full-page stories in major newspapers and media whereas Haryana did not (The Indian Express, Saturday, June 13, 2020). There was a substantial resurgence in Kerala after initial containment but the state government cannot be blamed for insincerity and insensitivity like Maharashtra’s can.

Inept Handling of Data

There are indications that the AAP government initially underreported deaths; there were accusations of the crematorium and burial ground data being grossly in excess of the reported cases. Now AAP is projecting 5.5 million people likely to test positive and 80,000 required beds required. Both of these claims are ridiculous. Even then in the five worst affected states—Delhi, Tamil Nadu, Gujarat, Maharashtra and Uttar Pradesh—the first will fall seriously short of ICUs and other facilities. Who is the AAP government trying to fool? Are they trying to cover up their incompetence with these figures? Their much touted Mohalla Clinics simply have not worked—another indication that public health delivery in cities is inappropriate for the urban poor as well as non-poor.

Three states appear to be guilty of this inept handling: Maharashtra, Delhi and West Bengal. On June 6, 2020, 428 unreported deaths surfaced in Maharashtra outside Mumbai. Mumbai’s Covid-19 death toll surged by more than 900, and Maharashtra’s tally surged by 1409 with only 81 of the deaths reported as of June 2, taking its total toll to 5537, following a data reconciliation process. Many other examples have been quoted in this report (Barnagarwala Tabassum & Shaikh Zeeshan, June 16, 2020).

West Bengal claimed a 9.75% mortality rate when the center’s figure for the state stood at 13.2%. It set up the first death audit committee, which was accused of being set up for the purpose of underreporting and incorrectly reporting Covid-19 deaths through semantics of labeling the cause of death. West Bengal blamed the center for not providing kits, which was challenged from within Bengal. The inter-ministerial group was blocked from visiting Bengal for assessment to avoid incompetence surfacing (Bhattachrya Ravik and Mitra Atri, May 10, 2020).

The Challenge of Urban Prevalence

One glaring aspect of this pandemic is urban prevalence in large congregations of people living in hutments and slums like Dharavi in Mumbai, which initially gave rise to high numbers of people affected. The numbers were still growing even while a report, unconfirmed by any other agency, states that Dharavi’s cases have now been contained (Sanjana Bhalerao May 21, 2020). This has been challenged by the reality that 75% of Dharavi’s population fled from Mumbai, making the situation more manageable. At least three voluntary agencies and public-spirited doctors have played a major role, which has been suppressed, and the Maharashtra government has attempted to take the credit. Another reason stated for lower numbers being reported from Muslim-dominant communities is on account of the reluctance and fear of the inhabitants regarding getting tested.

The high numbers even otherwise are seen also because it is easier for the testing machinery to reach them as compared to the remote villages; city dwellers, even if they are poor, are more alert and there is more communication in cities. Clearly the urban public health care delivery system is unfit to handle this challenge. This will be discussed in the appendix on the urban poor.

The Illegitimate Scare of Rising Covid-19 Numbers

The pandemic initially alarmed everyone, as the death tolls in Italy, Spain, the USA and later the UK and then Brazil and Russia started rising extremely quickly. Over the next two months the Indian figures rose substantially to increase the scare, resulting in a great deal of action. As we completed the third month of the lockdown on June 25 many more observations surfaced and certainly quite a few of these were reassuring. Unfortunately, in the interest of TRPs, the media, with the honorable exception of DD India, has managed to increase the fear factor. This may have helped to make people behave a little more sensibly, but as on June 15, 2020 the media was not positive in its coverage of newer information. Some examples of this are given in the volume India’s Private Health Care Delivery and this will be discussed below and in other places in this volume as well.

As on June 19 the total number of people infected who have tested positive was 2, 54,708, of which 1, 94, 324 were discharged. The total deaths so far were 12,237 (mygov.app, COVID-19 Dashboard, as on: June 18, 2020, 08:00 IST (GMT+5:30). As on December 20, 2020 the total number of Corona positive cases has crossed 10 millions. The percentage of those who died was at 4.8%, and has been consistently low compared to many Western nations where it was 10% or higher. It stands at 1.4% on December 20, 2020. The proportion of those who were laboratory tested for symptoms and found positive was a mere 6.8%. Since the third week of May the number of tests has increased to 100,000 per day or at least 75,000 for a cautious estimate. As more tests are performed the numbers will rise. This is common in medicine. But what do the numbers consist of? The recovery rate has already touched 95% as predicted by Dr. Randeep Guleria of AIIMS (Guleria Dr. Randeep, May 18, 2020). This means that of the 10 cases 5.2 will need or will not go beyond isolation facilities, and if home quarantine is feasible for a patient the risks of cross infections will be reduced along with the numbers. In that case 4.8% will require advanced care and may die, assuming that there are no recoveries. With over 900,000 tests per day since August 18, 2020, totaling over 150 millions on December 20, 2020 the positivity rate is still low—5.8 to 6.1%.

Another way of looking at the statistics is through extrapolation. Ten years ago a similar scare was noted about the infection mortality rate and with regard to swine flu. The actual number of deaths was comparatively low, at 0.02% of all those infected as reported by WHO. The actual number of Covid-infected patients is much greater than the 400,000 and counting; rather it is approximately 10 million, extrapolated from a survey of 70 districts and 28,000 specimens. Of these, only 0.73% have been detected as positive. If the deaths reported are divided by this number the actual mortality is just 0.1% of all those infected. This means that 99.9% of those infected will not only be cured but also become immune to the disease, constituting a major part of herd immunity. The quoted survey will continue and should reveal even more encouraging statistics (Phadke Anant, June 21, 2020, Loksatta Daily, Mumbai).

The Good Statistics

1.

The statistics can be understood simply in percentages. If 100 cases are detected in a day with or without symptoms, 50% will not even know that they have been infected (Phadke Anant, June 21, 2020, Loksatta Daily, Mumbai).

2.

Eighty percent will recover without any active treatment in 14 days. Dr. Randeep Guleria, Director AIIMS, also stated that ultimately the recovery rate will be more than 90%. (Guleria, May 18, 2020). Of the remaining patients, 3 to 4% will die and 17% will have serious enough symptoms to require hospital care and will eventually recover. Instead of bringing this encouraging statistics out, the focus remained on rising numbers actually detected, which as shown does not pose great problems in majority (Phadke Anant, June 21, 2020, Loksatta Daily, Mumbai).

3.

In medicine, sensationalism always wins at least temporarily over science, hands down.

4.

Another interesting statistic presented by Dr. Gangakhedkar was about the ability to infect another contact. It is 1.5 persons for Covid-19 and 13 in measles. But there was no positive reporting about this reassuring news either, from other media channels (Gangakhedkar RR, May 18, 2020).

5.

The scaremongering continued and had at least one major effect on migrants (more about this as a health issue is discussed below).

The Covid-19 and Public Health Measures

As mentioned above, the formal system of public health care from sub-centers to sub-divisional hospitals has not been used to cover the bulk of the rural population. The measures taken outside this system, however, have done a good job (see below). This is partly so because the bulk of the cases were found in the dense population pockets in the cities and not in rural areas.

6.

From the district hospitals to governmentmedical colleges, due to the admissions for isolation and treatment of more severe cases of Covid-19, the capacity was exhausted, leaving a great deal of urban misery unanswered. The governments have done a poor job of enlisting the cooperation of the private sector, shown in detail in the volume India’s Private Health Care Delivery (Kelkar, 2021). Despite all this, however, the Covid-19 statistics and the data that kept surfacing over in Ocotber to December 2020 have many positives, described below.

7.

The initial rapid doubling rate of a few days which by June 14 had increased to about 14 days despite high rising numbers of Covid-19 cases is something of a miracle.

8.

Without doubt, the rapid decrease in the doubling rates is due to the closure of airlines and railways, the largely observed lockdown, and the system of red, orange and green zones later converted to containment and non-containment zones. These measures were outside the health measures cutting at the root of the problem. The police and other forces actually are not health agencies but have done a remarkable job in maintaining containment zones, which has also led to reduction of these, if not to their disappearance.

9.

Most red zones and later containment zones have been Muslim communities due to their initial refusal to obey the rules about social distancing and congregations. Assaults on police and the meeting of the Tablighi Jamaat that occurred right under the nose of the Central government escalated the problem.

10.

This situation has resulted in distrust between the police, the government and the Muslim communities, leading to lower rates of testing and refusal of symptomatic people to seek treatment through the regular channels. Despite this, the number of cases detected in these red zones was much higher than in the general population (Ghosh Sohini, Sharma Ritu, May 10, 2020).

11.

Such issues are not only community related. These are the differentials which teach lessons for public health management.

12.

A big thank you must be extended to the Muslim religious leaders for emphasizing the importance of this in a straightforward and authoritarian manner to make these communities compliant. Muslim Trusts such as the Haj House in Ahmadabad offered isolation facilities. The Muslim community also needs to be saluted for this more than it has been so far.

Migrant Workers as a Health Issue

This will be dealt with at some length vis a vis the public health care of the states. In simple terms it means carrying the Covid-19 virus from high-prevalence areas to low-prevalence areas with much less dense population segments. I did not think that there would be high infection rates in villages, that it was likely to remain low. The reason was that those who were allowed to migrate had not been shown to have any symptoms, not even temperature rise at the railway stations before they boarded the trains. Even if this was elementary testing, it was remarkable in detecting those residing in high-incidence cities. There is some evidence that the habit (or scare) of social distancing, isolation and so on has permeated to the village level, which would result in much lower than expected fresh incidences. Three or four weeks after migration started, data on new incidences at the district level surfaced, which has vindicated my judgment.

How Serious Was the Spread After Migration?

By June 22, 2020, 5,12,000 migrants had already returned to Jharkhand. On May 31, 610 was the number of positives which grew to 2140 over one month, which is meager. Of the migrants, 1325 became positive but only 205 among the locals (Saran Bedanti, June 24, 2020, Hindustan Times Ranchi). As on December 2020, a total of 1,12,606 cases were reported out of a population of 40 million with 1008 deaths. The state had a capacity of fewer than 2000 tests daily. One write-up has projected this as a serious scenario and raised a futile alarm (Abhishek Angad, May 21, 2020).

By June end Covid-19 hit 174 out of 300 districts which had no cases, mostly in Bihar and Uttar Pradesh, with an average of 23 cases in each district. One hundred and fifty districts with 10–50 cases on April 22 had an average of 100 cases. The 30 districts that had between 50 and 100 cases had an average of 220 cases. The migrant load, it was logically concluded, had spread over many more districts compared to high numbers in few districts in severely hit states. This migration was being termed the ‘first phase of the pandemic’ for the states (Mehrotra Karishma May 21, 2020). It is an incorrect and unnecessarily alarmist statement. An average district has a population of 1 million in these provinces. An average of 23 is too low even if it spreads because those infected are few. The migrant distribution is over a large number of villages. Hence this will not represent a second wave or the first phase of a village pandemic. This is a health issue which can be contained.

Migrant Labor—Whose Failure Is It?

The migrant issue, however, has been taken up for criticism as a failure of the Central government. At the least, it is unfortunate. The migration started at least four weeks after the lockdown. The center had appealed to the migrants to stay where they were and they did. It was elementary for them to see that going back was not an answer, and it proved to be so, shortly after, as the reverse exodus began within 15 days. The center had seen to it that some money supply to crores of people was efficiently managed, another non-health measure. An appeal not to cut wages or ask for rent had gone out. The cities, and the police force in particular, the voluntary agencies and the public distribution system were helping them in every way to sustain themselves fairly well—miraculously almost without corruption. All these were non-health measures too.

Failure of Employers and House Owners

Employers with short-sighted selfishness denied people wages and house owners asked for rents. The center had seen to it that money stayed in the hands of all the people, including employers, for at least three months in their first announcement. This was of no significance to those who deal with money and employ people for long periods. The same employers are now wooing them back at higher salaries.

Was It Failure of the Central Government?

Another accusation leveled at the Central government is that the Shramik trains should have been started earlier. This is pure nonsense. When the migration finally started the Indian railways did a magnificent job of ferrying workers back to their homes. The dismal coordination of arranging migration in the state, particularly in Mumbai, is not criticized by those who comment. Another nonsensical criticism is that time should have been provided to send them home before the lockdown; this was never the idea. Moreover, lockdown would then never have effectively happened, making it a health issue of mammoth, unmanageable and serious dimensions. Assisted migration in itself is a foolish idea as has now been proven with reverse migration.

Engineered Migrations

For some reason several instances took place at the New Delhi, Noida and Ghaziabad borders where migrants were collected as a result of instigation or rumors. Was this an attempt to get rid of them as soon as possible, defying all logic, or was it done with a clear idea of disrupting the lockdown and bringing discredit to the states and Center. It was reversed for some time, efficiently managed by Uttar Pradesh and badly by Maharashtra, as seen in the Bandra area first in rumors and later as lack of coordination in Mumbai. But the idea had spread and the physically tough laborers started walking back. One major reason for this is also the herd mentality without any forethought. It may seem harsh but it is true.

Every media channel reported that lakhs of laborers were walking back, which was highly suspicious reporting. Continuous screening of the media images in those early days of migration reveals that a few and the same pictures were being shown for days on end. Obviously the media persons had not gone farther than the first couple of kilometers and still reported millions walking back. The numbers are therefore likely to be not as high as reported. Thus, even before this became a big issue the Indian Railways responded speedily only to face refusals to allow trains back, lack of coordination and accusations, as in Bengal and for some days in Bihar. The railways have not stated officially how much it has spent so far on these services, but officials have indicated that the national transporter spent around Rs 80 lakh per service (PTI, May 06, 2020).

Deaths During Migration

The second falsity was about migrant deaths on their way back. In all, four or five road and railway accidents were reported. The people in villages staying along the highways seem to have taken care of these migrant workers as they walked back. A large number of local voluntary agencies did their part in a heroic manner. This is not unusual; villagers do this often. In 1990, 800,000 agitators coming from all over the country were thus cared for, sheltered and sneaked to their destination by these poor villagers in Uttar Pradesh. On May 25, 2020, I traveled by road for 800 kilometers from Nagpur to Pune with special permission without seeing a single villager going back, but provisions made by people for those who might be walking back were in place at different points. (See below also.)

There are many ‘heart rending’ tales reported in popular media, including prestigious newspapers. One such article distorted the concept of herd immunity by stating that the poor get infected to develop herd immunity. The rich acquire it without being infected, thereby making a mockery of lockdown when imposed and when lifted. Herd immunity is discussed below for better undersgtanding. People sitting at Harvard and high-class Delhi individuals wrote these spiteful stories with the purpose of maligning the achievements made (Ashok, Indian Express, June 12, 2020, Delhi Edition). These are not worth responding to but need to be condemned. Every issue discussed here has health aspects and logistical considerations yet it is a job well done overall.

Uttar Pradesh and Madhya Pradesh have employed 700,000 and 1125, 893 people under Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA). One hundred and sixteen other districts with the help of Garib Kalyan Yojana (Welfare Scheme for the Poor) and MNREGA had employed 1,985,166 by the end of April, many getting employment every day in the states (https://​economictimes.​indiatimes.​com/​https://​economictimes.​indiatimes.​com/​news/​politics-and-nation/​state-govts-prepare-job-opportunities/​articleshow/​75585654.​cms?​utm_​source=​contentofinteres​t&​utm_​medium=​text&​utm_​campaign=​cppst).

Herd Immunity

Herd immunity is an old but valid biological concept even today, and has many aspects. Covid-19 belongs to the SARS family, to which the world has already been exposed. As such, the versatility of the human immune system can cross-react and produce immunity to Covid-19 in many people, even in India (see above also). Had this been not so, detection of 6.8% of all those with symptoms tested, a predicted 90% recovery rate, low mortality and detection across all strata of the society cannot be explained without a rapidly developing immunity among hundreds of thousands of people. Every major pandemic including the Mumbai and Pune plagues in the early twentieth century killed not all but a significant proportion of the population. Every pandemic then peters out, with or without care. No pandemic has recurred or recurs. This is because herd immunity continues to increase.

The only exceptions to an epidemic recurring were cholera coming to Bengal and India in the 1960s yearly from East Pakistan, or the limited endemics of leptospirosis and jaundice in Mumbai in the 1980s. The first of these ended long ago. In widespread infections herd immunity develops itself; one cannot create or gift herd immunity. Hence when the migrants go back or come back, people are discharged from hospitals and others are asymptomatically affected, and lockdown is relaxed with people mixing freely, herd immunity will develop as a natural phenomenon. The lockdowns are said to have pushed the second wave spread by 74 days. Over this time the infectivity or virulence of an agent also goes down. Hence the fear concerning rising numbers can be said to be baseless and firm action should continue.

A Good Measure to Meet the High Covid-19 Patient Load

One good step was the development of a three-stage structure of fever or Covid Clinics where elementary testing for fever, symptoms and swabbing for the samples was undertaken. The second was to isolate symptomatic patients until the report came back negative and then discharge, and isolate them if the report came back positive at the Covid Care Centers for 14 days. If the patients came with severe symptoms they were to be shifted to Covid Care Hospitals. This measure incidentally did not use the existing public health care structures within urban areas or these structures could not be utilized for some reason or the other, once again underlining the penchant for duplication, or confirming the ill-conceived formats of the urban public outfits. These aspects will be discussed in the chapter on urban poor and health care delivery in this volume.

Non-Health Care Decisions and Actions

China informed WHO about the virus on December 31, 2019, and WHO declared Covid-19 a global emergency on February 1, 2020. India undertook the first airlift of its citizens from China on February 2, 2020. India also started to test, screen and quarantine those returning from abroad, reaching 1.97 lakh screenings by February 11, 2020. On the global level 46 countries stopped air services to China. As those affected by Covid-19-like symptoms started appearing in the general population, the most major, most difficult and most daring as well as unprecedented decision of stopping both domestic and international air services was taken, with railways and public transport shut down. The next most astonishing feat was to convert 5000 railway coaches into isolation beds to be stationed at 215 stations near power house facilities, which the states could ask for.

The most welcome and somewhat astonishing aspect was the huge support people gave to the lockdown despite the initial disrespect for it in many quarters, which was dealt with using a strong hand. Fear was not the only key. Credibility of a person leading the battle from the highest position was working. Social distancing and sanitization became norms and translated into people’s behavior. Successive lockdowns started from March 25, 2020 and lasted until May 31 and June 8 saw some easing of the same. Essential supplies were transported all over the country. Ration cards were made portable, with the Public Distribution system responding gallantly with hardly any corruption during this time. Crores of rupees were transferred in crores of Jan Dhan accounts and many simultaneous announcements were made to the effect that whatever money people had would stay with them for three months to follow. There is no need to go into the pedantic discussions over the five-day marathon addresses by the Finance Minister—the sum and substance of these is mentioned above.

The Heroes of the Struggle

From the beginning the heroes were the police, the medical and paramedical services and the cleaning services. Without doubt, the voluntary agencies have played a yeoman’s part in feeding people and caring for them. People rising to the occasion have no longer remained a rarity lately. Two recent examples are the devastating floods in Kolhapur in Maharashtra and Belagavi in Karnataka in 2019, which were responded to by actions more by people than by the government, and this has been repeated during Covid-19 times. Digitization has also helped greatly in the development of apps to disseminate information. The early appreciation they received helped people to behave properly and carry out the lockdown.

Pertaining to this volume, the role played by the junior and resident doctors as well as the nurses is the most important. They have worked throughout public health care at all levels beginning from the large institutes and medical colleges to public hospitals, and wherever else they were summoned. Their greatest requirement was in critical care. The senior doctors seem to have stayed out of this. Sassoon, the largest public hospital in Pune, had none. A group of private anesthetists volunteered on a one-week assignment. The greatest of their astonishing findings was a terrible lack of elementary as well as higher-level gadgetry. The care without any formal system was dismal to say the least. The junior residents worked but had no training and no guidance. But they stuck to it. When the system was built they responded to it and care improved. These doctors faced all the ordeals of Personal Protection Equipment for hours on end in a day and for days on end to the limit of exhaustion but they did not complain.

Down Side of Dealing with Doctors and Paramedics

From various quarters what surfaced was that many medics and paramedics were not paid their salaries for three months. As is well known, their living conditions are far below ordinary expectations. The pandemic has once again underlined the need for better treatment and emoluments of these doctors (and nurses also), the need for better training and so on. The emoluments, living conditions and lack of effective training have all come under discussion in this volume. The first two have been chronically attributable to low funding for health care as a whole. The third is attributable to the structural havoc in medical colleges. The severe paucity of doctors and consultants across the public health care structure is another factor. No government seems to have any answers as to how these matters can be improved. There are scores and scores of measures I have suggested in this volume about how to improve all these conditions as well as the quality of health care without any strain on the budgets. I hope a note is taken and action initiated by those in power.

The AYUSH Ministry Contribution

The AYUSH Ministry issued a long advisory on which drugs would be useful from among Ayurveda, Unani, Homeopathy and Siddha in prevention and treatment with a long list of references attached. From Ayurveda there was a recommendation of two drugs, Siddha one, Unani one which mixed two ingredients and five from Homeopathy, each with details of consumption and in a few preparation of the medicine as well. The effects claimed were antioxidant, immuno-modulatory, anti-allergic, smooth muscle relaxation and anti-influenza activity for the Unani preparation. The research base expounded surpassed all expectations. Arsenicum album 30 was credited with affecting the HT 29 cells and human macrophages, showed NF-KB hyperactivity, reduced expression of reporter gene GFP in transfected HT29 cells, and showed TNF-alpha release in macrophages. It is a common prescription for respiratory infections in day-to-day practice (Secretary, Ministry of Ayurveda, Unani, Siddha, Sowa-Rigpa and Homeopathy, March 16, 2020).

The AYUSH Ministry supported the use of these medicines quoting WHO. During the Ebola outbreak in 2014 an expert group of WHO had recommended that it is ethical to offer unproven interventions with as yet unknown efficacy and adverse effects, as potential treatment or prevention, keeping in view no vaccine or antivirals were available (Secretary, Ministry of Ayurveda, Unani, Siddha, Sowa-Rigpa and Homeopathy, March 16, 2020). The most remarkable and laudable part of this exercise was the way these medicines were studied carefully and in detail while reporting the findings in the modern language of allopathy.

In this volume an appendix is dedicated to the controversies surrounding the AYUSH system of medicine. In the volume on India’s private care the last chapter is on integration of medical systems. This advisory has brought about many discussions and these two chapters will provide an understanding in great detail and with strong relevance to these discussions, making both the volumes pertinent in this unusual Covid-19 time.

Before I return to the original Introduction of the volume a few small points need to be answered. In the wake of Covid-19 some voices called for nationalization of all hospitals, more by habit I suppose, without even realizing the utterly irrelevant nature of such suggestions. This is another form of Universal Basic Services for which there are always some proponents. Suffice it to say here that these are dangerous suggestions which will fatally harm the economic strength India has built over years, and hence should be cremated on the altar of rationality.

A small observation on the disaster management capabilities of India shows how well these have developed, admirably and greatly in the last six or seven years. The Ministry of Health and related functionaries could take a leaf from their book in handling pandemics and responding more effectively. Kerala has set an example this time.

Now I will go back to the original volume.

Irrespective of whether it is the private or public health field, it is the government that is central. It plans, sanctions, restricts or frees the system, gives legal backing, and is finally responsible for the outcomes. Every word of this volume is primarily and finally to help the governments to think about what happened with earlier policies and what policies need to be adopted.

It is written mainly for the ministers and public policy maker bureaucracy in Ministries of Health and Family Welfare, high-level officers from Departments of Health Services and Medical Education, chief officers of their numerous directorates, in the state and union territory governments, and the officers of the NITI Ayog and National Institute of Public Finance Policy, Health Activists, Health Organizations and Health Economists. The Deans and Heads of Departments of the 260-odd government medical colleges are addressed to facilitate a relook in their respective domains and for them to think about action for betterment.

This requires fresh, bold thinking, in new paradigms backed by political will, bringing all the stakeholders on board for consensus. This is an area where all the responsible and experienced persons mentioned above have to come together to understand, analyze, and ponder the merits of the idea, the feasibility of implementing it or better ways of doing the same. A new policy solution can then be found. Health care professionals working in any of the health sectors–preventive-primary, curative governmental-private-voluntary sectors, those in non-clinical fields, administrators, policy makers, regulatory professionals and those working in industry–are also important contributors. The more professionals from diverse fields ponder these issues, the better the models presented can be made.

Half of the book is devoted to policies needed in manpower production and its deployment in the public health care delivery system. This is an as yet unsolved problem. More or less an equally substantial part deals with the structure and function of primary health care.

The real and perceived health needs over vast tracts of land, the varying and changing economic state of people located in more than half a million settlements with varying densities, their ways of prioritizing health issues, and socio-cultural beliefs and practices is one set of variables. The other is the perception of those who are finally responsible for providing health care and the structures and functions in which it is provided. These two could be at variance, even in conflict with each other. The third set of variables is the way modern medicine is expanding and changing, the complexities that have been introduced in health care delivery, and the effects and changes these may cause in the thinking of the population across the board. In the globalized world, countries are also bound by the fourth factor of transnational world body agreements and compulsions. It is ‘wisdom forced upon’ which cannot always be ignored.

On the other hand, in the early 1980s, a radical thought process emerged from the left of center and the Christian groups which had their own ideological basis for thinking about health care and poor people. It remained confined mainly to primary care. It led these scholars to consider only those ideas, instruments and the structure as the far more effective solution, a panacea for better health care especially among the deprived classes of rural Indian society. The issues were discussed in in-depth scholarship, thought over and tested by experimentation, as was every idea/model/agency that was on offer over decades from the policy makers on primary care. The statistics were there, as was the description of the rather lamentable situation of the health sector. These were undoubtedly worthy efforts.

However, these groups did not think of newer or different models for health outside the primary care skeleton that proliferated in the public health realm. The primacy and emphasis on primary care created discernible limits to the solutions these groups tried to provide. The need for quality curative services was forgotten.

I will discuss four more ideas indicating why this could have happened. These concepts became Conventional Wisdom, leading to Observance of Etiquette, to being Politically Correct and using Statistics as the proof of all one wants to prove. These are always a safe haven, if you are speaking the same language. The criticism will lose its edge. One can carefully continue to prescribe more quasi-conventional ideas that may look newer. More often than not, these four elements have served as an able deterrent to break out and chalk out different paths and think differently.

These four elements are also a part of a code, simultaneously making it an evaluation instrument. If one is outside any one of the four, then one’s ideas are not acceptable. They will be judged by the above code, to prove that the proposers of the new ideas are guilty. This is a verdict they should accept, disowning their thinking. Those who play this game do some disservice by preventing people from seeing the shortcoming of the existing situation in full measure. The travel to truth becomes confusing or misleading. These players are engaged with subtlety in a game that perpetuates the problems rather than solving them. But it makes them indispensable to the debates. In simple terms, there is a planned obstructionism to realistic solutions.

The goal here is to reach the truth and heart of the matter to improve the health situation. All that matters to me is the functional ability of an existing structure to solve the problem in the local situation and the country as a whole, the way it needs to be solved. If it is unable to do so an alternative must be sought. The arguments, facts, propositions and objections argued for the older ideas will be respectfully considered in great detail here. The volume is reflective and compares the ground realities, analyzed with my views on what should be done, in a reasoned manner. This will help in revealing a clear picture, replete with operational details.

This will place the remedies I have suggested, the reasons behind them and the feasibility of employing these ideas under further scrutiny. Only then will a fair, detailed and productive debate ensue. Such a debate is needed. Each area requires scrutiny to discover how to harness its potential and weed out what is unrealistic and/or counterproductive for the welfare of those who need it. I do not dwell ad nauseam on problems: more than half of the book talks about solutions. The final test of all endeavors here is justice for all people. There is no use shying away from the failures of planning, and displaying a blithe complacency with an undertone that matters are well thought out and everything is working should be cast aside.

I have been studying health literature and policy documents for decades now. The thinking in the health literature has a dual nature. One is the theoretical or cerebral understanding and the second is the quality and duration of, or the lack of, actual field experience among the pundits and activists over many years. In the absence of this, instead of a total, a fragmented and differentially weighted view presents itself. A certain dogmatism develops, which halts the cross-fertilization of ideas.

There are five primary considerations with regard to health care: accessibility, affordability, quality, equity and justice. Accessibility was partial and differential. Affordability in the free system was marred by corruption. Quality was not reached in public health care delivery due to the lack of competent professionals. The first three having failed, the question of equity and justice for the population was never achieved. This pushed the people, even the disadvantaged, to increasingly resort to the private health sector. What affordability people had turned into a huge and inevitable debt trap. The exploitative nature of the private sector marred the fruits of the quality that people encountered. And justice was the first casualty everywhere.

This book is about government or public health care delivery in India. I hope to present a new workable and efficient policy framework to restructure it, for it to deliver much better results.

In the latter half of the 1990s Indian society started changing significantly. Unfortunately, the contemporary and futuristic appraisal of those changes