While the horrible images of tens of thousands of immigrant workers reaching bus terminals and borders to go back home, and the stories of many dying while marching for miles on an empty stomach will always remain with us, instances of true valour and bravery also stand out. The most obvious one is of the doctors, nurses, and other paramedic staff who have braved all odds—often without even basic protective gear—and tended to those who needed caring; indeed, as terrible episodes with not just the Tablighis showed, doctors and nurses were even beaten up for doing their job. The police, all over the country, has battled tremendous odds to maintain the lockdown, the incidents of excessive use of force notwithstanding.
And, even as the big boys of India Inc have chipped in to make ventilators, India’s startup community is—as it did at the time of demonetisation, led by the government-owned NPCI—delivering some truly outstanding solutions (bit.ly/2RcKXV1), having come up with innovative methods for rapid testing for corona (go.nature.com/3aKMeKK), including pooled testing for community spread (bit.ly/2JBlGQm). Several state governments, too, have shown great resolve in tackling the situation, including looking after the homeless and hungry—way beyond what would have been expected given India’s state capacity and level of development.
But, if India is somehow able to get away relatively lightly, it will primarily be due to the lockdown, since it is clear the country’s creaking health infrastructure simply can’t take the load of the present crisis. Indeed, as Dr Laxminarayan of CDDEP showed (bit.ly/34bty4i), even in a scenario where 1% of Indians got infected, with a much smaller share of these needing hospitalisation, and India were to get rid of all other patients, the country still simply doesn’t have the hospital beds to take care of them. And, as India will find out when it gets the lakhs of ventilators it might need if the crisis gets as bad as is imagined, it doesn’t have the required number of doctors, or intensivists to operate them!
There are some obvious short-term solutions, such as allowing 4th-year MBBS students to practice during this emergency to augment the pool of qualified medical personnel, as Dr Devi Shetty of Narayana Hrudalaya has proposed. Over the long-term, however, India has no option but to completely transform its healthcare system—one doctor per thousand patients is hardly enough, and where it matters most, this is a mere one functioning primary healthcare centre (PHC) for every 64,800 people, and one PHC doctor for every 38,000. Throwing money at the problem won’t fix everything, but 1-1.5% of GDP as annual health-spend is clearly too little. India has 50,000 gynaecologists/paediatricians vs a need for 200,000 each, 10,500 radiologists vs the 150,000 needed, and 65,000 surgical specialists vs 600,000 needed. Moreover, while we have a shortage of 2.5 million nurses, it is not easy to start nursing colleges.
If the government needs to borrow several lakh crore every year for a decade to fix this, it must; borrowing abroad, from bilateral and multilateral agencies at concessional rates, will also help keep the impact on interest rates to a minimum. As the prime minister has recognised with the Ayushman Bharat scheme, getting India’s health system on track is critical.
But, it is not just money, India needs to completely rethink its medical system (bit.ly/349mTYF). Leading health practioners like Devi Shetty and Srinath Reddy (of Public Health Foundation of India) argue, India’s bigger problem is ‘over-medicalisation’. Nurses in India, for instance, spend the most time looking after patients, but aren’t even allowed to prescribe painkillers whereas, as Shetty puts it, “even in litigation-happy US, 67% of anaesthesia is given by nurses, not doctors”. Reddy emphasises the need to train nurses to become ‘nurse practioners’ and ‘nurse anaesthetists’.
Part of the reason for the short supply is the high cost of setting up a medical college. There are, Shetty says, 35 medical colleges in Cuba training doctors for the US in just 50,000 square feet of space. The over-engineered medical colleges in India, by contrast, require 140 teachers to train 100 students! In a report for the Planning Commission in 2011, Reddy had recommended setting up of nursing schools in under-served states, and linking medical colleges to district hospitals to dramatically lower costs of medical colleges, and ensure greater supply of doctors in rural areas.
Other critical parts of getting India future-ready, like the huge shortage of police and judges, too, need to be addressed. As in the case of doctors, part of this needs to be addressed by reimagining the system, but there can be little doubt that the budget constraint is a binding one. Borrowing more is always a solution, but this is where all political parties need to come together and eliminate wasteful subsidies. Do we, for instance, need to give two-thirds of Indians a 90% subsidy on food each year? Indeed, as Icrier professor Ashok Gulati keeps pointing out, reducing the scope of the FCI-based physical ration system—this involves government not artificially fixing prices for wheat, rice, sugarcane, etc—will also reduce India’s need for water. In 2018, Niti Aayog spoke of 20 cities, including Delhi and Bengaluru, running out of groundwater by 2020, and 26 of 29 states are reporting increased desertification. As Gulati points out, 78% of India’s total freshwater resources are consumed by agriculture, and within this, rice and sugarcane consume more than 60% of the country’s irrigation water while accounting for just 24% of its cultivated area (bit.ly/3bV4kK6).
Indeed, one of India’s biggest constraints in all sectors is the inability to get the policy framework right. We’ve discussed health and agriculture here, but the same applies to education, manufacturing, infrastructure (the right policies on airports and ports allowed us to ramp up supply dramatically, but the wrong one in the power sector ensured it is a mess). Given how corona has made fixing the healthcare sector a top priority, Modi needs to start there first.