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Public Health in India: Lessons of a Pandemic

Public Health in India: Lessons of a Pandemic
 Christophe Jaffrelot
Senior Fellow - India, Democracy and Populism
 Vihang Jumle
Data Analyst and IT Engineer

The Covid-19 crisis has tested the resilience of India's health system. Shortage of personnel and underfunded infrastructure are amongst the symptoms of India's ill public health system. In the first article of this new series on health issues in India, Christophe Jaffrelot, Senior Research Fellow at CERI-SciencesPo/CNRS and Vihang Jumle, Data Analyst and IT Engineer, provide an analysis of the effects of the pandemic on the national as well as the state level. This article underlines India’s significant regional disparities and assesses the impact of the virus across the country.

As of October 30 2020, India has recorded the second biggest number of Covid-19 cases (8 million), next only to the US (9.2 million). India is third on the number of deaths (121,144), behind Brazil (159,033) and the US (234,222). It is currently third on the number of active cases (595,074), after the US (3 million) and France (1.1 million), and second on the number of critical cases (8,944 in India, and 16,931 in the US). These figures may reflect a certain underestimation, as India ranks low on "tests per million" (at 77,813), while the US ranks near 19th (at 427,446). Moreover, test positivity for India is 7.5%, while for the US it is 6.5%.

8 million cases when evenly distributed over 1.3 billion (for India) would of course paint a rosier picture than distributing 9.2 million cases over 331 million (for the US). But cases in India are not evenly distributed: they are clustered in major cities and select states with varying fatality ratios. For instance, cases per million in New Delhi stands at 18,964 with a fatality ratio of 1.7% (out of 100 people), Andhra Pradesh stands at 15,658 cases with a fatality ratio of 0.8%, and Maharashtra stands at 13,644 cases per million with a fatality ratio of 2.6%. On the contrary, some states like Rajasthan only have 2,503 cases per million and a fatality ratio of 1% and some exceptional states like Gujarat have only 2,531 cases per million but a high fatality ratio of 2.2%. This regional disparity, therefore, calls for a deeper investigation at the state level to better assess the impact of Covid-19 in India. Before that, we will analyse the effect of the pandemic at the national level in the context of a chronically underfunded public health system.

Why is the Indian Public Health System Lagging Behind?

The pandemic has brought to the forefront the shortage in medical staff and infrastructure in India. As of September 2019, India had 1 medical doctor for every 1,404 people and 1.7 nurses per 1,000 people, lower than the WHO recommended 1 medical doctor and 3 nurses for 1,000 people. In comparison, in 2017, the US had 26.12 doctors per 10,000 people, Brazil had 21.6, China had 19.7 and India had only 7.7. For nurses per 10,000 in the same year, the US stood at 145.48, Brazil stood at 97.37 (this increased to 101.19 in 2018), China stood at 26.6 and India stood at only 21 (this reduced to 17.27 in 2018).

In 2017, the US had 26.12 doctors per 10,000 people, Brazil had 21.6, China had 19.7 and India had only 7.7.

And things are not improving. Several reports underline that after the early signs of the pandemic, caution and fear pushed healthcare workers to return home in March, April 2020. Since August 2020, government and private hospitals have faced difficulties in recruiting additional healthcare workers to care for rising Covid-19 patients. Staff was also cut down due to the abrupt lockdown and the fact that less people were willing to apply for jobs due to short-term contracts and incommensurate wages.

For instance, in June, Ahmedabad Civil Hospital - the city’s largest Covid-19 facility - offered only INR 13,400 a month (EUR 155.8) to nurses. This was protested by the All Gujarat Nurses Union and the hospital later provided additional incentives in line with the state guidelines. Southern states too offered a similar pay - INR 23,000 (EUR 267.4) for nurses, INR 21,000 (EUR 244) for pharmacists, and INR 17,000 (EUR 197) for lab technicians, monthly.

The financial situation of India’s public hospitals is dire. Many (all?) are in such a bad shape that many healthcare workers in India, to this date, have not been paid salaries for the past months and continue to suffer social stigma because people fear being infected by them. There is also significant shortage in personal-protective equipment, including masks. As a result, locals were also being hired to work as "helpers", to be trained from scratch and look after Covid-19 patients.

Besides available staff, India also falls short of health infrastructure. In 2017, India had 5.3 beds for 10,000 people, the US had 28.7, Brazil had 20.9 and China had 43.1. The condition remains similar for Critical Care Units beds (the US at 34.7, China at 3.6, India at 2.3 per 100,000 people), ventilators (the US at 160,000, India at 48,000 in total) and other advanced medical equipment and services.

Public health has never been a priority of the State. Current Health Expenditure ("CHE") as percentage of GDP in 2017 was only 3.5% for India, whereas for the US it was 17.1%, Brazil, 9.5% and China, 5.2%. In the past, India’s highest health expenditure was 4.3%, in 2001. India CHE per capita in PPP (against USD) in 2017 (253.3) was comparable to Kyrgyzstan (241.2) and Timor-Leste (263.8) and was lower than several of India’s neighbours. The USA, Switzerland, Norway, Germany, and France stood above 5,000.

Consequently, India is amongst the top 15 nations with highest out-of-pocket expenditure when measured as percentage of CHE ("OOP"), simply because there is no social security system worth that name. Households in India spent 62.4% of India’s CHE directly from their pockets in 2017, although this has come down from +70% a decade ago. France, Germany, the US, Ireland, Norway, UK, and Japan had it below 20%.

Regional contrasts

Better understanding of India's health system requires a look at the state-level data as well, and the pandemic has served as an acid test to determine their resilience. Different states perform differently: many managed to control the virus quite early, some took to rigorous testing, some were majorly hit and took to testing late, whereas some states neither controlled nor tested enough.

Better understanding of India's health system requires a look at the state-level data as well, and the pandemic has served as an acid test to determine their resilience.

Some states like Bihar were even spared of much spread - which may change now, as people have compromised safety to participate in massive election rallies for its upcoming state election, whereas some states choose to not report data regularly keeping everyone in an oblivion state. There is still not enough clarity on if many states even have enough infrastructure, protective equipment or the number of critical patients, simply because there is no granular data reported (or even collected) on it.

The assessment here is for four categories: state with a good performance, states with low testing, state with stressed infrastructure, and the worst hit.

People per bed in each Indian State

Sources: Healthcare Infrastructure estimates are available at: COVID-19 in India: State-wise estimates of current hospital beds, intensive care unit (ICU) beds and ventilators, 20 April 2020


Amongst all, Kerala was looked up to for effectively controlling the curb with its "Kerala model". It took the centre stage way early in effectively handling the pandemic. Kerala has until now registered 418,485 cases and its tests per million stands at 130,535. Only 1,458 have died until now, which is better when compared with other states where the virus has spread rampantly. It also appeared for a while that the active cases in Kerala were stalling and slowly reducing. While the state has a significantly low recovery ratio (77.7%), it does have a very low fatality rate of 0.3%, amongst the lowest in the country. Why? Kerala has 359 people per bed, 7,196 people per ICU and 14,389 people per ventilator (people per infrastructure were derived by dividing the state-level population estimates for 2020 by state-level infrastructure estimates). These comparatively good performances reflect the state’s policy regarding public health. Many personalities even endorsed the way Kerala government took to handling the virus and it was amongst the first to acknowledge "community transmission". Not only does this sector benefit from an old tradition of decentralization, but it has also received more investments. It was estimated to spend INR 2,200 (EUR 25.58 / 1 EUR = 86 INR, Morningstar, 14 October 2020) per person in 2020 on health. As a result, Kerala has one of the highest ratios of beds per 1000 people: 2.77 (Maharashtra stands at 1.88). Things however started reversing July onwards - a media website also called its unfortunate rise in infections a "setback". Kerala now has the second highest number of active cases and a mid-paced growth rate of 1.8%. Kerala therefore needs to recalibrate efforts to control the spread of the pandemic.

West Bengal on the other hand, with a population 2.8 times that of Kerala but a near comparable cases per million and a percent low test positivity, has amongst the lowest testing rate in India at only 46,563 tests per million (Kerala tests 2.8 times more). West Bengal also lags behind with 877 people per bed, 17,546 people per ICU and 35,098 people per ventilator. Its 2020 health expenditure per person was estimated to be INR 1,132 (EUR 13.16). Not just West Bengal, many similar populous and infrastructure stressed states like Uttar Pradesh and Rajasthan, can do a much better job at testing and being proactive despite a comparably low test positivity rate, to better assess their resilience should the spread increase.

But the most infrastructure-stressed state is Bihar, with 4,044 people per bed, 80,881 people per ICU, 161,868 people per ventilator and an expenditure of only INR 849 per person in 2020. Bihar fortunately has amongst the lowest test positives at only 1.99%. However, if Covid-19 were to rampantly spread in Bihar, it is likely that it may witness an overwhelming number of fatalities and hence, such states need to take extreme precautions in controlling the spread.

India is now steering its "Unlock-5.0" phase - reopening theatres and entertainment parks with some restrictions - in a bid to restart non-essential services that were abruptly shut down 7 months ago as part of a national lockdown.

Maharashtra (second largest state in India) clearly remains the most Covid-19 hit state with 1.6 million positive cases, high case fatality ratio of 2.6, 43,710 deaths and test positivity at 18.7%. It is comparably a low testing state with only 72,915 thousand tests per million (Delhi on the other hand has it at 233,994 tests per million). Maharashtra’s recovery ratio at 90.1% also stands comparably decent however the state is now seeing a mid-paced average growth rate of 1.3%. The state has 531 people per bed, 10,627 people per ICU and 21,257 people per ventilator and government’s health expenditure per person in 2020 was estimated to be INR 1,403. Maharashtra clearly needs to do way more: on testing and on controlling the spread!

In this context, India is now steering its "Unlock-5.0" phase - reopening theatres and entertainment parks with some restrictions - in a bid to restart non-essential services that were abruptly shut down 7 months ago as part of a national lockdown. These are certainly not relaxation measures, but desperate measures, rather, to drain away people’s resentment towards the administration’s mismanagement of the pandemic. More importantly, these measures aim at containing the resulting economic crisis. In 2020, according to the IMF, India should register a historic low (negative) GDP growth at -10%, and its per capita GDP is already below Bangladesh’s this year.

Unfortunately, this economic crisis will make it difficult for the government to invest more in public health. The gap between the rich and the poor (whose number is increasing very quickly this year) will widen and while the former have access to private hospitals, the latter will not be able to spend enough money for their health.


Copyright: Money SHARMA / AFP

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