Stressed even in normal times, Indian health care held up in a crisis year

As anti-virus vaccines become the biggest productivity leap of the 21st century, India could possibly emerge as the destination of choice for products against a larger number of viral diseases

In a matter of 21 days, Indian states have ramped up their pace of vaccination by close to 500 per cent. As percentages go, it is difficult to wrap one’s head around such numbers. As on March 1, the number of shots were 427,072. They had risen to 2,540,449 last Sunday and crossed three million one day in between. Effectively, in each minute of the working day in March, close to 2,000 shots are being administered. Experts are obviously asking for further scaling up the numbers. 

For the fragmented Indian medical services, this is an achievement. There are bizarre data from the states. Union health ministry numbers show that in states like Bihar, Odisha and Haryana for instance, there are supposedly 15 per cent more doctors in positions in district hospitals than their sanctioned strength. Yet, at the all-India level, there is a vacancy of 25 per cent among nursing staff in urban areas. Covid is even now an urban disease.  

A year after the lockdown, with cases rising again and states like Punjab ominously showing case fatality ratios above the global average, it is a good time to check, despite these infirmities, how the Indian health system has fared. 

Former union health secretary C K Mishra ascribes the relative success to the targeted approach to tackle the disease that India took early on. “We recognised that testing has to focus on the vulnerable population, and that reduces mortality,” he said, adding that the same targeted approach is evident in the current pace of vaccination too and has helped to ration load on scarce medical resources. 

Between the Centre, states and municipalities, India runs one of the most fractured medical systems. Ministry of health data shows the doctor-to-population ratio as of June 2020 was 1:1,343 against the WHO norm of one doctor per 1,000 people. That of nurses (all categories) to the population is one per 1,658 people. Again, at the start of the pandemic, most of the beds and ventilators in India were concentrated in seven states-–Uttar Pradesh (14.8 per cent), Karnataka (13.8 per cent), Maharashtra (12.2 per cent), Tamil Nadu (8.1 per cent), West Bengal (5.9 per cent), Telangana (5.2 per cent) and Kerala (5.2 per cent).

Table: Doctors in district hospitals

State	Sanctioned	In position
Andhra Pradesh	551	406
Bihar	888	1,301
Haryana	821	1,049
Jharkhand	984	671
Maharashtra	1,292	875
Punjab	917	761
Tamil Nadu	1,884	1,522
Odisha	1,243	1,331

Source: Parliament reply; Data on March 2019

The poor numbers are only partially overlapped in certain segments by the private sector, but with its own share of problems, offering satisfaction to very few who have to deal with it. The complaints about shoddy performance, particularly of the under-financed government medical system, have been consistent over the years. Till last March, it was therefore a fair estimate to say the expectations of doom because of Covid were not far off the mark.

Last year at this time, the health ministry was fighting a grim battle of perception. There were red faces in the government in April when the ministry of external affairs reported the nation had averted 820,000 cases through the lockdown. It quoted an alleged Indian Council of Medical Research (ICMR) report to buttress its point. The very same day, the health ministry at its daily briefing said, “There is no such report.” Meanwhile, as an Indian Express report noted, a nurse who died of the disease had possibly contracted infection because she was made to wear reused personal protective equipment. To make matters worse, soon as the lockdown happened ICMR became an accused in a corruption charge over the import of antibody test kits. Testing was essential to halt the spread of the disease and kits were in short supply globally. 

It was also alleged that the national research organisation, which was thrust into a sort of quasi regulatory position, had contracted to import a Chinese company-made testing kit at a higher price. The Delhi High Court responded to a public interest litigation that the kits from Guangzhou Wondfo Biotech Co. should be sold to ICMR at Rs 400, about 33 per cent lower than what NRO had signed on for. To raise tempers in a horrible summer, the kits malfunctioned and ICMR had to issue advisory to the states to suspend their use. The government had to issue a statement on the higher price paid for the kits: “It needs to be also remembered that this was the first ever effort by any Indian agency to procure such kits and the rate quoted by the bidders was the only reference point.”

Researchers at Washington DC-based Center For Disease Dynamics, Economics & Policy, led by Ramanan Laxminarayan, estimated India with just 95,000 ICU beds and 48,000 ventilators, was on course to record deaths of close to 2.5 million. The team connected the toll to the evident shortage of healthcare facilities in the country. 

The number of both infection and mortality undershot the estimates massively. The level of treatment and the consequent death toll have remained moderate by global standards. Mishra says without the targeted approach, the calamity could not have been averted. His position is supported by World Health Organisation’s chief scientist Soumya Swaminathan. ”Overall, India has been a positive story—-whether you take diagnostics or the vaccine, the industry has stepped up to fill in the gaps," she remarked at an event this month held by the department of biotechnology. 

Till the middle of 2020, few however could be reasonably sure India would be part of the improvement. Yet, not only has the change in pace held up, it is now reasonably certain that it will continue at least for this year to reach 300 million, the approximate number the union health ministry reckons will be needed to make herd immunity from Covid a reality for India. The beleaguered system has surprisingly managed to hold up in the first wave. 

At no stage did any state get overwhelmed with patients, and that allowed them to shift gear, as is happening now every week with the pace of administration of vaccines. While the vaccine story is not the first of the positive changes to have occurred, it is by far the most noted. 

India, though, is not an outlier on the pace of vaccination. Across the world, the time needed to cover 75 per cent of the global population with the required two doses has improved from five years to 3.3 within the past month as most countries ramp up the pace of shots, notes a study by Kriti Kapur and Oommen C Kurian at Observer Research Foundation.

Also before March is over India would have exported over 65 million doses of Covishield vaccines to 70 countries. Of these, more than ten million doses will have been gifted to over 37 countries and another 20 million would be delivered under the WHO’s COVAX initiative.

Of course, the vaccine story is somewhat different from the ramp up of health care facilities. India had for years been the largest producer of vaccines, so it was expected that once the pharmaceutical companies were ready with their products, mass production would be led by India. It is quite possible that as anti-virus vaccines become the biggest productivity leap of the 21st century, eclipsing other technologies like renewable energy storage batteries or genomics, India could seal its place as the destination of choice for products against a larger number of viral diseases. 

Table: Health workers in PHC Urban areas

State

ANM  Doctors   Nursing staff In position  Vacant In position Vacant In position Vacant Andhra Pradesh 751 33 375 9 97 6 Bihar 95 NA 95 NA 155 NA Haryana 808 23 85 6 93 17 Jharkhand 202 109 39 6 89 71 Maharashtra 1,092 269 171 219 884 # Punjab 80 # 45 # 44 1

Tamil Nadu

2,087 161 282 181 1,275 144 Odisha 200 # 109 # 123 #

# Surplus; NA Not available; Source: Parliament reply Data on March 2019