 World Bank data reveal that India had 85.7 physicians per 1,00,000 people in 2017 (in contrast to 98 in Pakistan, 58 in Bangladesh, 100 in Sri Lanka and 241 in Japan), 53 beds per 1,00,000 people (in contrast to 63 in Pakistan, 79.5 in Bangladesh, 415 in Sri Lanka and 1,298 in Japan), and 172.7 nurses and midwives per 1,00,000 people (in contrast to 220 in Sri Lanka, 40 in Bangladesh, 70 in Pakistan, and 1,220 in Japan).

 This situation is a direct result of the appallingly low public health expenditure.
 The latest data narrative from the Centre for Economic Data and Analysis (CEDA), shows that this has been stagnant for years: 1% of GDP 2013-14 and 1.28% in 2017-18 (including expenditure by the Centre, all States and Union Territories)
 Health is a State subject in India and State spending constitutes 68.6% of all the government health expenditure.
 However, the Centre ends up being the key player in public health management because the main bodies with technical expertise are under central control.
 The States lack corresponding expert bodies such as the National Centre for Disease Control or the Indian Council of Medical Research.
 States also differ a great deal in terms of the fiscal space to deal with the novel coronavirus pandemic because of the wide variation in per capita health expenditure.

 Bihar, Jharkhand and Uttar Pradesh, States that have been consistently towards the bottom of the ranking in all years, are struggling to cope with the pandemic, as a result of a deadly combination of dismal health infrastructure as well as myopic policy disregarding scientific evidence and expert advice.
 Odisha is noteworthy as it had the same per capita health expenditure as Uttar Pradesh in 2010, but now has more than double that of Uttar Pradesh. This is reflected in its relatively good COVID-19 management.
 Given the dreadfully low levels of public health provision, India has among the highest out-ofpocket (OOP) expenditures of all countries in the world, i.e. money that people spend on their own at the time they receive health care.
 The World Health Organization estimates that 62% of the total health expenditure in India is OOP, among the highest in the world.
 CEDA’s analysis shows that some of the poorest States (Uttar Pradesh, Bihar, Madhya Pradesh, Jharkhand and Odisha) have a high ratio of OOP expenditures in total health expenditure.
 This regressive nature of OOP health expenditure has been highlighted in the past. Essentially, this means that the poor in the poorest States, the most vulnerable sections, are the worst victims of a health emergency.

 The inter-State variation in health expenditure highlights the need for a coordinated national plan at the central level to fight the pandemic.
 The Centre already tightly controls major decisions, including additional resources raised specifically for pandemic relief, e.g. the Prime Minister’s Citizen Assistance and Relief in Emergency Situations (PM CARES) Fund.

 CEDA came out with a policy brief, where among other measures, it recommended the creation of a “Pandemic Preparedness Unit” (PPU) by the central government, which would streamline disease surveillance and reporting systems; coordinate public health management and policy responses across all levels of government; formulate policies to mitigate economic and social costs, and communicate effectively about the health crisis.
 Indians were already “one illness away” from falling into poverty. Families devastated by the loss of lives and livelihoods as a result of this pandemic will feel the distress for decades to come.
 The central government needs to deploy all available resources to support the health and livelihood expenses of COVID-19-ravaged families immediately.

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