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A sustainable healthcare system plays such a pivotal role in building the backbone of an economy that it can not be avoided at any cost, especially in a country like that of India where the population is 1.36 billion. To curb the widespread of the Coronavirus, both prevention and treatment become indispensable. Though plenty of preventive measures were adopted numerous loopholes were highlighted in the former part. India is not the only country grappling through this adverse situation but includes several other countries across the world. The healthcare system is on the verge of collapse and the issue needs to be addressed as soon as possible to avoid any more death. This article aims at calling attention to the serious concern of “insufficiency of healthcare facilities”. To get a deep insight into the same, various aspects of the topic have been discussed and finally, a few feasible suggestions have been laid down.
Unfortunately, the importance of medical services has been lately by most countries while combating a series of widespread fatal diseases. There is a huge gap between the demand and supply of medical professionals and the amenities, where the latter falls short and subsequently, the masses have to suffer.
Healthcare is mainly classified into 3 categories:
- Primary healthcare-This essential healthcare is the foremost level of contact between an individual, family & community, and the health system.
- Secondary healthcare-It is the intermediate healthcare level where more severe ailments are dealt with, at district hospitals and community centers.
- Tertiary healthcare-This level comprises highly specialized health professionals where the services are provided at regional or central level institutions.
This legal article covers the problems revolving around the secondary and tertiary healthcare infrastructure in India.
The Existing Healthcare Capacity
acute shortage of trained nurses is drastic when it comes to the nurse-to-population ratio of 1:670 against the WHO norm of 1:300 as reported by the 15th Finance Commission as one of the important reasons, as to why the Covid-19 pandemic got out of control. Other observations in the report included the poor doctors-to-population ratio in Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Maharashtra, and Uttar Pradesh, shortage of various medical professionals in the states of Tamil Nadu, Kerala, Andhra Pradesh, Telangana, Karnataka, Maharashtra, and Gujarat which comprise of two-third of India’s medical seats, and the low hospital bed densities in Bihar, Odisha, Chhattisgarh, the erstwhile state of Jammu and Kashmir, Jharkhand, Manipur, Madhya Pradesh, and Assam. 1154686 registered doctors in India specialize in modern medicine and presently, one Government Allopathic Doctor cater services to the needs of 10926 patients. Govt. has set up 25743 Primary Health Centers, 158417 Sub Centers, and 5624 Community Health Centers to provide medical services in the rural areas, comprising of 60% India’s population.
Challenges faced by the health sector
- An extreme shortage of medical supplies and lengthy waiting period-Medical institutions are not able to keep up with the growing testing demands of the Covid-19 patients due to lack of testing kits and other resources. Besides, shortage of required materials, the patients also have to wait for an average of 7 days to get their results at hand, which further exerts pressure on the supplies of personal protective equipment, bed availability, and staffing.
- Need for paramedical and other supporting staffs-To tackle Covid-19, the Govt. has appointed nearly 265,000 health professionals on a contractual basis in the states, including 11,921 general physicians, 3,789 specialists, 73,619 nurses, 81,978 auxiliary nurse midwives, and 44,314 paramedics.The unanticipated surge of patients has triggered the need for a larger number of specialized healthcare staff and also worsens the situation by burdening the existing staff with overwork.
- Inconsistent guidance-Sometimes, conflicting Centers for Disease and Control and Prevention (CDC) guidelines such as including criteria for testing, determining which elective procedures to delay, use of PPE, and getting supplies from the national stockpile, from the local and medical authority pose a huge challenge to the hospitals and public. This results in the over-burdening of the health workers.
- Difficulty in expanding hospital facilities-The capacity of hospitals to accommodate patients has surpassed the limit. The patients require special rooms, beds, and post-acute-care facilities to treat the infection but the subsisting framework does not permit the needed treatment.
- Affordability of healthcare-It is one of the major concerns faced by the public in combating the deadly virus. Almost 75% of the healthcare expenditure is spent by the households and also serves as a huge factor in making them poorer. The private sector is given much more priority than the public sector since the latter is considered unreliable and therefore, no one opts for it in the first place when private healthcare is affordable.
- Rural-urban divide- Though villages have been provided with hospitals and other health-related institutions but still, healthcare in rural areas remains a matter of concern. Most of the rural people are illiterate and lack health awareness. In addition to this, most of the facilities do not meet up the laid down benchmarks for healthcare. As per the NSO data, the richest 40% of the population used government health programs more than the poorest 40%.
Impact of Covid-19 on the Indian Health Sector
The Covid-19 outbreak took a toll on the healthcare systems across the globe, and India was no exception. Both the govt. sector and the private sector tried to work at their fullest capacity. However, the private medical institutions outshone the govt. ones by catering to almost all the needs of the latter by providing facilities such as testing, isolation beds for treatment, medical staff, and equipment at hospitals and home healthcare.
The private sector accounted for approximately 60% of the patient care and most of the players responded to the challenge of inadequate healthcare infrastructure through investment in facilities such as quarantine centers and treatment, medical equipment, and an additional workforce. Another major challenge faced by the hospitals was a sharp decline in the revenue by almost 40%.
Apart from the conventional methods, the Indian Govt. incorporated technology in the medical sector, and developed various applications at central and state levels to detect cases. Arogya Setu App was such a development that assisted in syndromic mapping, contact tracing, and self-assessment, and was widely used throughout the country. Technology also played an important role in healthcare management which included delivery of essential items in containment zones, teleconsultations with patients, bed management, and real-time monitoring and review by the authorities. They undertook a robust response plan wherein various isolation centers, technology enabled mapping of resources .and Covid-19 hospitals were set up.
Relevant statutes concerning healthcare
- International Covenant on Economic, Social, and Cultural Rights- According to this Covenant, everyone has the right to “the highest attainable standard of physical and mental health.” Also, the government of different countries is obligated to take effective steps for the “prevention, treatment and control of epidemic, endemic, occupational and other diseases.”
- The United Nations Committee on Economic, Social, and Cultural Rights- Gives a detailed description of the right to health. It states:” The right to health is closely related to and dependent upon the realization of other human rights, as contained in the International Bill of Rights, including the rights to food, housing, work, education, human dignity, life, non-discrimination, equality, the prohibition against torture, privacy, access to information, and the freedoms of association, assembly, and movement. These and other rights and freedoms address integral components of the right to health.”
This right should also comply with some standards-
a)Availability inadequate quantity;
b)Accessible to everyone, and affordable for all sections, including marginalized group;
c)Acceptable, i.e. respectful of medical ethics and culturally appropriate, and;
d)Appropriate in terms of scientific and medical quality.
- Article 21- The Constitution of India has not explicitly stated the right to health as a fundamental right but the judiciary has laid down several precedents wherein it has been declared as a fundamental right guaranteed under Article 21, and has also given reference to the State’s role in providing healthcare services to the public. In Bandhua Mukti Morcha vs. Union of India & Ors, it was held that the right to life under Article 21 also ensures the right to health. InState of Punjab & Ors v Mohinder Singh Chawla, the apex court reaffirmed that the right to health is fundamental to the right to life and should be put on record that the government had a constitutional obligation to provide health services.
- Directive Principles of State Policy- Part IV of the Indian Constitution covers DPSPs which impose certain obligations on the state, among which the state’s role in ensuring better healthcare services is also included. Some of these are:
a) Article 38 (1)- The State shall endeavor to promote the well-being of the people by guaranteeing and protecting as effectively as possible the social order, in which justice, society, the economy, and politics will provide information to all institutions of the nation. life.
b) Article 39 (e)-The health and physical strength of workers, men, and women, and the childhood of children will not be abused, and citizens will not be forced to carry out occupations that are not suitable for his age or strength without financial need.
c) Article 41- In certain circumstances, the State, within the scope of its economic capacity and development, will effectively guarantee the right to work, education and public assistance, unemployment, old age, illness, and the right to receive public assistance. Disability and other undue deprivation.
d) Article 42-The State that provides just and humane working conditions and maternity relief shall take provisions to guarantee humane and fair working conditions and maternity relief.
e) Article 47 -The obligation of the State to improve nutrition, living standards, and public health is one of its main responsibilities. In particular, the State will endeavor to prohibit the consumption of intoxicating beverages and drugs that are harmful to health, except for medicinal purposes.
Judiciary’s role in strengthening the healthcare system
- Ganta Jai Kumar vs. State of Telangana and Ors.
In the present case, a writ petition was filed as a PIL by a resident of Hyderabad, to declare the action of the State of Telangana and other respondents as illegal, arbitrary and without power, wherein they were not permitting the “private hospitals” and “diagnostic centers” who were equipped with the adequate equipment and personnel, and willing to conduct Covid-19 test along with allowing such patients to be admitted for isolation and treatment.
It was held by the High Court of Telangana that limiting test centers arbitrarily jeopardizes the health of serious non-COVID patients and exponentially increases risks of spread of disease in COVID positive cases that remain undetected for prolonged periods. Therefore, it is imperative to reduce the burden on the health care system and ensure that COVID-19 cases get detected and treated. It was further observed that neither legal nor logical in totally excluding private sector participation in testing/treatment/ isolation of suspects/confirmed COVID-19 patients -and hence, the petition was allowed.
- Re: The Proper Treatment of Covid 19 Patients and Dignified Handling of Dead Bodies in the Hospitals and Ors.
This Suo Moto writ petition was filed with an object to note deficiencies, shortcomings, and lapses in patient care of Covid-19 in different hospitals in NCT of Delhi and other states. Subsequently, it intended to take remedial action to solve the plights of the patients in need of medical care. However, the court had held the following while disposing of the petition:
“The necessary guidelines on all aspects of patients’ care, hospital management, testing, infrastructure were in place. The main concern was the faithful and strict implementation of the said guidelines which could be only ensured by constant supervision, monitoring, and taking remedial steps about the improvement of infrastructure, staff, facilities, etc. The most important aspect was continuous supervision and monitoring of Government hospitals in the Government of NCT of Delhi and other States. Directions accordingly issued with the object of continuous supervision and monitoring of government hospitals, Covid dedicated hospitals and other hospitals taking care of Covid management”.
- Paschim Banga Khet Mazdoor Samity and Ors. vs. State of West Bengal and Ors.
The given case revolved around the question as to whether the non-availability of medical facilities in Govt. hospitals, to the people who sustained injuries, led to the infringement of the fundamental right guaranteed under Article 21. It was observed, “It is no doubt true that financial resources are needed for providing these facilities. But at the same time, it cannot be ignored that it is the Constitutional obligation of the State to provide adequate medical services to the people. Whatever is necessary for this purpose has to be done.” The court pointed out the failure on part of the Government hospital for not providing timely medical assistance to the needy and further, stated that the state can not avoid its responsibility.
4. Ashutosh Gupta vs. State of H.P. and Ors.
In this case, the HC of Himachal Pradesh reiterated that the right to health, including access to basic medical infrastructure, is a facet of Article 21 of the Constitution of India, which the State is duty-bound to provide. It also emphasized the affordability of these services. It directed as follows:
(i) Increase the number of authorized laboratories/clinics/hospitals which can carry on the testing for a larger percentage of the population.
(ii) Increase the number of testing being done in the bigger towns of the State. The State Government should consider the use of other kits, besides the Rapid Antigen Kit, or the RT PCR tests, for increasing the tests being carried out on daily basis.
(iii) To increase the testing facilities in the hill districts of the State, the State Government should consider sending ‘mobile vans which are fully equipped for carrying out the testing of COVID-19 virus.
(iv) The State should increase the number of dedicated COVID-19 Hospitals. For, merely having few dedicated COVID-19 hospitals, is too little to tackle the menace, especially when the pandemic is likely to spread and increase throughout the State in the coming months.
(v) The State is also directed to consider the feasibility of establishing temporary hospitals with the help of any other Central agency.
(vi) The State is directed to increase the number of beds available in the hospitals. It shall ensure that the majority of the beds are equipped with the Oxygen tank and sufficient numbers of the bed are equipped with ventilators. If necessary, the number of ICUs in the hospitals should be increased. This is essential as it is claimed that the second strain directly affects the lungs of the patient. Therefore, the patient needs to be given intensive care and may require to be put on a ventilator immediately.
(vii) The State Government is directed to ensure that the PPE kits and other protective gears, such as gloves, masks, and sanitizer are provided to all the medical staff, especially to the Doctors, Nurses, Ward boys to look after the COVID-19 patients. Until and unless our front-line worriers are protected from the COVID-19 virus, it will be impossible for us to win the battle against the COVID-19 virus.
(viii) The State Government is directed to publish the names and locations of the testing centers, and the names and locations of Hospitals/Dedicated COVID-19 Health Care Centres in the media bulletin daily. The media bulletin should indicate the total number of beds available in each hospital/Dedicated COVID-19 Health Care Centres, and the number of vacant beds available in each hospital. It should also indicate the class of the beds i.e. the number of beds attached with ventilators, number of beds attached with Oxygen cylinders, and the number of beds without any Oxygen tank/Cylinder.
ix) We make it clear that in case the private hospitals refuse to cooperate or reluctant to provide Covid test and covid facilities, then the State Government shall forthwith resort to coercive steps as provided under the Disaster Management Act and also Essential Services Maintenance Act. In addition thereto, wherever private hospitals have been granted incentives like plots on concessional rates etc. etc. The State Government shall be free to withdraw the incentive/recover the amounts etc. Lastly, the State may proceed to take any other coercive or punitive step as may be warranted and otherwise permissible under the law.
x) The State should also consider the purchasing of additional CT Scan Machines in the State as it is learnt that this machine is essential to detect the presence of the second strain of Covid-19 virus.”
How different countries tackled Covid-19?
- The United Kingdom- National Health System is the healthcare system that covers the whole UK population, whose one-fifth part is financed by national insurance, 79% is paid through taxes, and the remaining 1% is adjusted through private payments and copayments. Although the country was ranked among the top nations by the Global Health Security Index it decided against imposing lockdown unlike in other EU nations. Amidst the Covid-19, the UK set up 7 temporary hospitals to curb its spread. The former health workers were trained to provide aid in the crisis and specialists in other fields were redeployed. There was a lack of ventilators, following which they had to be imported and required the companies to produce more.
- Italy- The increasing no. of Covid-19 patients overran the efficient and effective healthcare system in the country. Initially, it was one of those countries which were affected very badly by the pandemic besides China, the EU .and the USA. The emergency services catered by the medical sector helped to tackle the situation to a great extent. It emphasized more on the containment zones through rapid tests and providing medical aid to the infected people. The availability of the beds was made accordingly by vacating the ICU beds, transferring the regular patients to non-containment zones to make the beds available in the affected areas , and changes were made in the delivery of services.
- China- China adopted a series of strategies to curb the infection. Planning at an early stage and conception of different healthcare strategies helped in containing the virus in the initial phase of the outbreak. Public health interventions such as early case detection, contact tracing, population behavioral change, and the establishment of hospitals, and the use of existing primary care centers specifically for the treatment of COVID-19 have contributed to contain the epidemic effectively. Drones, Machine Learning, and Artificial Intelligence were utilized effectively to trace and diagnose the cases.
- The United States- This developed nation also witnessed a no. of weaknesses in the US health care system. The claims surpassed the health insurance coverage, and as a result, hospitals could not respond efficiently to the masses showing up in this regard. Financial constraints in hospitals and other medical institutions led to layoffs of doctors, nurses, and other health care workers, and also shutdowns of service delivery apart from COVID-19 treatments. Temporary facilities were set up for the infected people, and the US govt. also introduced a reimbursement program for the services charging fees but its implementation was not executed properly, and thus resulted in failure. Apart from these, it also faced a shortage of supplies like personal protective equipment(PPE), respirators, etc.
- South Korea- The pandemic situation in South Korea was managed in a far better way than in other nations. 4 main factors contributing towards the effective response to Covid-19 included active compliance of the citizens with the govt. policies, systematic functioning of intensive care hospitals, the dedication of the medical personnel, and the intense and proactive management of the pandemic by the Korea Centers for Disease Control and Prevention (KCDC).What distinguished this country from other countries was its strategy to demarcate the treatment and follow-ups of serious and non-serious cases, which further lowered the bed occupancy for non-severe patients and made the same available for the serious ones. Tertiary care hospitals used telehealth tools to evaluate the situation.
1.During the last decade, only 2% of India’s GDP was invested in healthcare which is very less than what is needed. On the advent of the pandemic, priority must be given to the healthcare system and more funds must be allocated to the states from the Centre.
2.Lack of hospitals to accommodate patients call for higher investment in medical care such as research centers, equipment, institutions, etc.
3.Though the Indian Govt. has tried to utilize technology in tracking the deadly virus but the applications have not turned out to be that efficient. Therefore, it is suggested to use AI at its best capacity.
4.Affordability of medical services poses a major challenge in Indian society where a majority of the Indian population is below the poverty line, and can barely spend on their basic amenities. So, assurance as to the lowest cost of treatment possible is required to be granted by the Govt.
5. Rural areas need more focus than urban areas as the disease is much more in the former parts of India than in the latter parts. They need more awareness programs related to medical health, better medical services, and also a higher no. of medical professionals.
The foremost thing which everyone wants is the termination of Covid-19, and no one desires to witness more deaths. This condition can be curtailed by the active participation of the government as well as the private sector. Our healthcare system is on the verge of collapse and we can not risk exerting much pressure on the same as it would only make the situation worse. Though speedy changes can not be brought in the infrastructure still other necessaries can be made available in the short run. It is an eye-opener for all of us to emphasize more on healthcare expenditure than in other immaterial areas.
 Slideshare, available at: https://www.slideshare.net/tusharkedar2/levels-of-health-care-ppt(Visited on June 16, 2021)
 The Print, available at: https://theprint.in/health/1-doctor-for-1511-people-1-nurse-for-670-covid-exposes-indias-healthcare-fault-lines/602784/(Visited on June 16, 2021).
 Singh A, Deedwania P, Vinay K, Chowdhury AR, Khanna P (2020) Is India’s Health Care Infrastructure Sufficient for Handling COVID 19 Pandemic?. Int Arch Public Health Community Med 4:041. doi.org/10.23937/2643-4512/1710041.
 India Today, available at: https://www.indiatoday.in/magazine/cover-story/story/20210517-india-s-covid-collapse-part-2-how-shortage-of-trained-medical-staff-crippled-india-s-fight-against-the-disease-1800987-2021-05-10(Visited on June 17, 2021).
 Scroll. in, available at: https://scroll.in/article/945907/lack-of-health-insurance-is-deepening-the-poor-rich-divide-shows-survey(Visited on June 20, 2021).
 KPMG, available at: https://home.kpmg/in/en/home/insights/2021/02/india-healthcare-sector-transformation-in-the-post-covid-19-era.html(Visited on June 20, 2021).
 International Covenant on Economic, Social, and Cultural Rights,1976.
 The Committee on Economic, Social, and Cultural Rights,1985.
 The Constitution of India, 1950.
 Re: The Proper Treatment of Covid 19 Patients and Dignified Handling of Dead Bodies in the Hospitals and Ors. ((2020) 7 SCC 145).
 Paschim Banga Khet Mazdoor Samity and Ors. vs. State of West Bengal and Ors. (AIR 1996 SC 2426).
 Ashutosh Gupta vs. State of H.P. and Ors. (MANU/HP/0243/2021).
 Alanezi F, Aljahdali A, Alyousef SM, Alrashed H, Mushcab H, Al-Thani B, Alghamedy F, Alotaibi H, Saadah A, Alanis T. A Comparative Study on the Strategies Adopted by the United Kingdom, India, China, Italy, and Saudi Arabia to Contain the Spread of the COVID-19 Pandemic. J Healthc Leadersh. 2020;12:117-131 https://doi.org/10.2147/JHL.S266491.
 HealthcareITNews, available at: https://www.healthcareitnews.com/news/apac/covid-19-pandemic-south-korea-and-its-implications-future-telehealth(Visited on June 26, 2021).
Author: Sini Varghese, New Law College, Bharati Vidyapeeth Deemed University
Editor: Kanishka Vaish, Senior Editor, LexLife India.