Gandhi's talisman is best guiding light to reform public health

Dr Sandeep Pandey, Shobha Shukla, Bobby Ramakant *

Mahatma Gandhi's talisman is perhaps the best guiding light to reform the public health system in the wake of coronavirus disease (COVID-19) pandemic:
"I will give you a talisman.
Whenever you are in doubt, or when the self becomes too much with you,
apply the following test-
"Recall the face of the poorest and the weakest man [woman] whom you may have seen,
and ask yourself, if the step you contemplate is going to be of any use to him [her].
Will he [she] gain anything by it?
Will it restore him [her] to a control over his [her] own life and destiny?
In other words, will it lead to swaraj [freedom] for the hungry and spiritually starving millions?
Then you will find your doubts and your self melt away."

Our health system must meet the needs of the poorest of the poor and weakest of the weak. And the same quality of service which goes to this person should be a benchmark for everyone else.

COVID-19 pandemic has some blessings-in-disguise too. For example, it is evident that there is no role of private sector when we are confronted with a public health emergency. Only public services, no matter how weak they may be, are to be relied upon. Nationalization of private health sector is one of the most important political decisions that a government can take in the wake of this public health calamity.

This step will immediately increase the public health infrastructure, trained and skilled healthcare workers, and will also curtail the unbridled damage privatisation has brought to the public health sector over the years in myriad ways.

But the manner in which we invest and foster a sense of national pride in our military and army, is it the same way we treat our public health service workers and others who are risking their lives in this grave time of crisis (such as, farmers and vegetable sellers, grocery shop workers, police, community kitchen workers, social workers, journalists, and others)? Can we survive if farmers stop working?

Should not our national pride recognize these primary essential workers too?

India's health spending has drawn global concern since years as it stands around 1.25% of our GDP. Our National Health Policy 2017 is aiming to double the health budget to 2.5% of GDP by 2025. We take pride in being 'third largest military spending after US and China' but on health spending, are we aspiring to be the world's top spenders which guarantees health for all in letter and spirit, where 'no one is left behind'?

China spends about US$ 847 billion every year on health. India's health spending for financial year 2020 is US$ 34 billion (₹2.6 trillion, or 1.29% of GDP). If we combine public and private spending on health in India, then it stands at 3.53%.

If we look at data from the World Bank of total health expenditure (public and private spending on health) as part of GDP, then India ranks 24th in the world from the bottom.

Only the following 23 countries spend less than India: Venezuela, Monaco, Bangladesh, Brunei Darussalam, Papua New Guinea, Lao PDR, Qatar, Gabon, Angola, Eritrea, Pakistan, Republic of Congo, Indonesia, Equatorial Guinea, Kazakhstan, Bhutan, Ghana, Gambia, Djibouti, Vanuatu, United Arab Emirates, Fiji and Ethiopia.

Countries that have weaker economies than India are spending more on health (such as Afghanistan 11.78%, Cambodia 5.92%, Democratic Republic of Congo 3.98%, Cuba 11.71%, Kenya 4.80%, Libya 6.05%, Maldives 9.03%, Myanmar 4.66%, Nepal 5.55%, Philippines 4.45%, Rwanda 6.57%, South Africa 8.11%, Sri Lanka 3.81%, Sudan 6.34%, Thailand 3.75%, Uganda 6.19%, Vietnam 5.53%, Yemen 4.23% of their GDPs).

Richer nations are spending many times more than India on health (North America 16.56%, China 5.5%, Canada 10.57%, Australia 9.21%, Finland 9.21%, France 11.31%, Germany 11.25%, Japan 10.94%, South Korea 7.60%, Norway 10.45%, Sweden 11.02%, Switzerland 12.35% of their GDPs).

On an average, high income nations spend 12.53% of their GDP on health, low and middle income countries (India is part of this group) spend 5.39%, and low income countries are also spending more than us on an average 5.25% of their GDP.

If we take pride in being the third biggest spender on military then how should we feel with being among the lowest spenders on health? If the real 'enemy' is health problem, then how ill-prepared are we to tide over this pandemic, with as less as possible human suffering and untimely deaths!

Just an increase in health spending is not enough. Ensuring that we 'fight the real enemy' is also important. Perhaps the real 'enemy' is not the virus or bacteria, but inequality of different kinds and at different levels.

Rich and poor alike, all are at risk of infectious diseases like COVID-19. But diseases that do not affect the rich and mighty the same way that make the poor suffer and die, do not make us take such radical steps to curtail it. Pneumonia which is preventable, and curable, continues to be the biggest killer of children under five in India.

Over 70% of deaths happen because of non-communicable diseases (heart diseases and stroke, cancers, diabetes, chronic respiratory diseases, etc), but a significant number of this disease burden is preventable and untimely deaths could have been averted.

Tuberculosis (TB) is world's biggest killer infectious disease, but the slogan of our national TB elimination programme of government has been 'Pakki Jaanch Pakka ilaaj' (accurate TB diagnosis is possible and TB is curable).

As TB is preventable, and curable, then why did 26.9 lakhs of people in India suffered through active TB disease, and 4.49 lakhs of people died because of active TB disease in one year (as per latest WHO Global TB Report).

India has the highest burden of TB in the world. So let us also recognize the inequalities that put people more at risk of TB. Malnutrition is the biggest risk factor for TB. No prizes for guessing who will be suffering more from TB.

"TB anywhere is TB everywhere" is an old slogan. But COVID-19 has driven this message home. What ails one, ails us all. We probably undestand that everyone, rich or poor alike, have to be free from coronavirus infection. "My health security depends on everyone else's health security".

So rich or poor alike should adhere to public health best practices for infection control (such as, hand washing, hygiene, physical distancing, masks etc). So we also have to make it realistic for everyone to stay healthy, otherwise how will the privileged few ensure their health security unless everyone else is able to do so too?

Same goes for other public services who should use Gandhi's talisman to evaluate their programmes. Health for all depends on food security for all, social security for all, and a range of other social determinants.