COVID sitting on top of a fragile healthcare system :Dr Manisha Bangar

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Dr Manisha Bangar , National Vice President of BAMCEF , during webinar on Round Table India said that when COVID started our Prime Minister actually diverted the whole issue by giving ways and means to tackle COVID, either by banging a thali, lighting diyas, and then we already have a spate of babas and babis who are promoting various ways. So all this misinformation, myths, and disinformation — if it goes and sits in the minds of ignorant masses, then naturally, health takes a beating.

COVID-19, which in itself is a huge saga, which started in Feb 2020 and we have almost 4-5 months down the line. And we have seen how the healthcare system has unfolded itself, from the perspective of healthcare workers as well as from the consumers’ point of view, that is the citizens of the country. We have also seen how these two major stakeholders were treated by the governments, whether central or state government. In between, somewhere, are people like us, who are evaluating what we have undergone in all these months and what went wrong where,” Dr Manisha Bangar said.

She said that health policy and healthcare system as such has never been at the center of a national discourse in India despite the very worst performance of Indian healthcare ranking at the larger, international level.

I have been involved in the area of healthcare accessibility, not only as a person who has been a part of BAMCEF for a long time of almost two decades, where we took up all issues of representation like education, and other social issues, very vehemently at the national level. Apart from that, from my own professional commitment and background, which includes working in both private and government sectors for almost two decades and with training in the government sector at the central institutes of repute, like PGI-Chandigarh and JIPMER. I have a fairly good hang of how the healthcare institutions have worked, in private and public sectors. And also healthcare accessibility. Riding on top of this experience, and then thirdly, came my own involvement in promoting liver health as well as hepatitis awareness all over Andhra Pradesh and Telangana. There has been almost a period of almost 8 years, when I was involved with various state and non-state agencies, as well as non-profit organizations where we took up the issues of accessibility of healthcare and hepatitis related liver diseases. So, that is my background,” Dr Manisha Bangar added.

Dr. Manisha Banger while talking on Fragile health care system said that COVID sitting on top of a fragile healthcare system.

“We’ve also seen since 2000 onwards, a very relentless privatization of the healthcare sector. For people like me and you all, how do we reconcile this entirely privatized healthcare, sitting on top of the whole healthcare system? When I was given this particular topic, I felt I should rename it as ‘COVID sitting on top of a fragile healthcare system’. It’s like somebody’s back is already broken and then COVID happens: a huge monster sitting on such a healthcare system. So how do we reconcile these values of public-private partnership on one side, as well as liberalization, privatization, globalization on the other side and then we have the values of equity, justice. So this is a totally discordant era we are living in,” she added further.

She said that ‘state of art’ and ‘technology driven’ became very hyped words and this kind of drove along for the last 20 years and today this is where we are.

At a stage in which we have seen utter failure, in whatever sector, whether private-public partnerships or public sector or exclusively private sector we have seen that it has totally failed at not only at the policy making level but also policy execution level. Because the dominant model was essentially the public-private partnership or more slanted towards the private domain. It never really translated into better healthcare outcomes that we actually look for,” Dr Manisha Bangar added.

She said that kind of top dressing approach will not help, and definitely not this piggy-back approach, which rides only on emulating the West.

If they were to emulate the West I wouldn’t really mind, if it meant to emulate Scandinavian countries or Canada or something like the NHS to a certain degree, I would say yes, let’s emulate that. But the thing is that it inexorably goes towards emulating the US which is a very highly privatized, technology driven healthcare system, and we have seen how it has failed miserably. Today, US policy makers and academia are deliberating on whether there is something grossly wrong with their own policies, they are voicing their concerns, and they say that they are lagging behind and have fared much worse compared to even Japan and Korea. So, all this churning of thoughts is going on, she added further.

Dr Manisha Bangar added that the models which came up in the public-private partnership, whether it was the Rashtriya Swasthya Bima Yojana or the Ayushman Bharat – National Health Protection Mission.These all model very fared in delivering social equity and accessibility to healthcare, because the majority of the benefits are out of the reach of almost 80-90 crore people. This finally dictates the health outcomes, and also finally dictates the ranking in various indices all over the world.

She elaborate the failure of system by giving examples of Sri Lanka and she draw very rough parallels while comparing with other countries : Sri Lanka as a country, it has a population of 2 crores, and India has a population of almost 135 crores. Sri Lanka has about 11 deaths due to COVID in the past 3-4 months, India has 22,000. If you multiply the number of deaths, if their population were to be 130 crores, it would amount to something like 660 deaths.

While elaborating failure of public health care system, She added that India never really focused on equipping and empowering and strengthening the public healthcare system, that has been the only glaring factor we can see.As an executive council member of the South Asian Association for the Study of Liver Disease, she closely engaged with healthcare professionals, policy makers, as well as activists, people who matter in the neighboring, South Asian countries.

“What I mean to say is that the health of the people can be maintained and managed with a lot of focus on preventive healthcare, public healthcare system, as well as taking care of basics such as education, sanitation, and good quality, hygienic water. In a country like India we have not tackled these basics. The focus has been totally skewed and invariably it has been entangled with other parameters of development and accessibility. Whether it is accessibility to hygienic water, good sanitation, basic education.In the example of COVID, when it started, our Prime Minister actually diverted the whole issue by giving ways and means to tackle COVID, either by banging a thali, lighting diyas, and then we already have a spate of babas and babis who are promoting various ways. So all this misinformation, myths, and disinformation — if it goes and sits in the minds of ignorant masses, then naturally, health takes a beating ,” Dr Manisha Bangar said.

She said that the budgetary allocation of Public healthcare system itself very pathetic till now.

For almost three decades there has always been a very cursory, very nominal and tokenistic talk on enhancing the budgetary allocation for health, which has not till date gone beyond 1% of GDP, which is horrible, absolutely terrible, we should be pretty ashamed of it. When we say we are a shining country, we are a developed country, or we are competing with the USA or whatever, that really doesn’t put us anywhere nearby.

I’ve talked to you about ancillary features and departments which should have been strengthened, and the lack of facilities and budgetary allocation and how they kept the public hospitals, whether they were government medical colleges or central institutes always in dire need of many things. And they were always lagging behind, as far as equipment, facilities, medicines, the pharmacy — and that kind of percolated down to the PHC level.

Talking about what happened and how did health care system shape up between the year 2000 and 2020, there was a lot of propaganda about how the privatized healthcare sector is going to be good.

There there came the entire thing of banks giving loans to hospitals. In Hyderabad we have the Medwin Hospital, the owner of Medwin knew the bank loaning guy in State Bank of Hyderabad — crores and crores of loans were given to this family, whose head Sambasiva Rao  was in politics here, in Congress. I’m giving you the model, that’s how most of the private medical colleges and corporate hospitals have come up, and that nexus still remains. So they give a loan, they run the hospital and there is no regulatory mechanism on the charges. The fragile regulatory mechanism, as regards to the fees and tariffs, it is driven by the market, it is driven by the coterie in power in that particular city, of that particular state. All of them sit together and decide, this is the charge for this blood test, there might be a little deviation, but that’s about it. And then when they had actually earned their money, a lot of the money was put in other companies they owned that were building bridges and highways, they are suddenly bankrupt. And then, the government waives off the loans.

Then you see CDR, a very famous hospital — in 2008-2009, the hospital started closing. There were bad loans, they expressed their bankruptcy, it closed, and there was a whole journey of closing of the hospital. And then on top of it, new hospitals are coming up, with the same model of investment from people putting in their money, whether they were doctors, or investment bankers, or people from the dominant caste communities. This is the kind of roller coaster going on. This has been the private sector, this is how it has worked.

There is a JCI (Joint Commission International) board, which is an international regulatory board and NABH (National Accreditation Board for Hospitals & Healthcare Providers) is a national board. These accreditation boards, they look into whether the facilities are available or not and they look into the logistics, whether the building is ok.And of course, because of the international standards, they have to implement certain good practices, specifically regarding certain diseases. Having established that, once the private or corporate hospital has shown that it has established that, thereafter there is only a review after 3 or 4 years, and in between the hospital is free to do what it wishes to do, on its own free will. There is no monitoring, hardly any surveillance, and if there is any, it is a pretty biased kind of regulatory mechanism. This has been another part.

Dr Manisha Bangar while talking about policy making says ,

With the midday meal scheme, we were not only going to tackle the dropout rate of the children, we were going to enhance the educational participation of people, especially of the backward classes, enhance the participation of the students so as to increase and enhance their nutritional status. Because the Indian population has the highest death rate among toddlers in the world even today, and that was true in the 1960s also. When in 1960s, similar to the Kothari Commission, there was a Health Commission, in which they decided that protein has to come from pulses. Now pulses are the worst performer as far as protein content is concerned, it has got more of carbohydrates if at all, there is hardly any fiber, hardly any nutrients. And the entire thing was totally focused on such a poor source of protein. They could have very well have included milk, they could have very well have included eggs, but they did not. They went by their own whims and fancies. They kept the entire population malnourished for the entire span of about 6 decades. Isn’t that crazy? Isn’t that horrible? Isn’t that genocidal?

We have a totally malnourished population, and malnourished women giving birth to malnourished children. Then we have malnourished kids going to school, and a whole malnourished generation. When I was doing my degree and we were in our clinics, and I used to get so perturbed, it was quite disturbing, because 80% of the pediatric ward was filled with children who had Marasmus and … And at that time, it was shown as a disease, It is not a disease! It is just that they did not get enough to eat! They were supposed to get food to eat! The public distribution system in the remote areas, whether in the Adivasi areas, or Thane, or Melghat, or Nagpur, or Buldhana, or any other such place in Maharashtra (I did my MBBS and post-graduation from Nagpur). All these people were coming with gross malnutrition to the extent that they died, and there were kids, small kids, mothers clinging to their children, and they were not diseased, they just did not have food to eat. That was because a body of upper caste people in 1969 decided that they need to have pulses as protein and not milk and also have the honor of saying that ‘yes, we as a country are having a midday meal scheme’.

Dr Manisha Bangar while talking about Ayushman Bharat Scheme says,

Now, Ayushman scheme is insurance driven, which covers less than 50 crore of the population. If you see what are the drawbacks of this scheme, it is entirely skewed or slanted towards the private insurance bodies. It is something which has been given as a profitable thing for them. And even in the Arogya Shri Scheme, which is part of the Rashtriya Swasthya Bima Yojana, what happens is that the government says, ‘you admit the patients, and we’ll take care of the expenditure’ and only a few diseases are covered in it, not all of them. What has been seen in this scheme is that there were a lot of fraudulent cases, lots of fraud. So much so that they literally had to develop a lot of corrective mechanisms, and almost 200 hospitals were dis-empanelled. There were a lot of fake e-cards, a lot of manipulation to the extent that FIRs had to be lodged, there was a huge administrative structure and architecture which had to be developed, and technology database, all these things had to be done.

All the allocation for Ayushman Bharat scheme has resulted in diversion of all the funds towards privatized care, which is already fraudulent, and which has not performed well, which we have seen already. And this particular thing has not led to improved health outcomes, in terms of whether it was number of beds available, equipment etc. There was PPE shortage for almost a month and half, the beds are full, and on top of that the private hospitals had been totally excused from admitting patients for a long time, they were hardly allowed until a month ago, 25 days ago. They could not even recruit their private medical colleges, to which they had given subsidy in the form of a lot of land, lot of electricity subsidy, lot of aid in the name of public-private partnership. They could not recruit or bring them under the gamut of imparting COVID care. The minimal resources which are available in the country, in the face of a highly inadequate budgetary allocation, it was totally diverted towards maintaining the technology driven system and database which itself has seen a lot of flaws.

Dr Manisha Bangar said that this has been the background on which COVID has evolved ,

That is the reason why we see that the number of tests done for COVID patients are less even today, and the charges are not under regulatory framework, they are still being debated. Except for Maharashtra, there is no other place which has allocated IAS officers to monitor hospitals, so that they are within the purview of the government and rules. It is totally arbitrary, it is pretty haphazard and haywire everywhere. The cost of the COVID treatment is very exorbitant. Not only that, the most important area where it has faltered is that: suppose a person suspected of having COVID goes to a private medical college or hospital. Why do they go there? Because the government hospitals are not adequately equipped, and they are falling short and the number of cases are increasing. And we knew it very well, for a population of almost 135 crores, we knew we would be landing in this situation.

Now, when the corporate hospitals have been opened up, when the patient goes there, they get tested even if it is a suspected case. This particular suspected case needs to be upgraded and updated into a unique identification number, which is in a government driven system database. It has been seen that at the behest of the patient themselves, or for whatever reason, these things are not updated. There is a whole lot of gap in tracking the patients. We now have 2 lakh patients or more (in the third week of April), who are possibly COVID positive and they are not in the tracking registry at all. So you can imagine the amount of COVID load which is already there and it is not being tracked, and not under any systematization. These are the faultiness which have started way back, and hence today we are not able to tackle the pandemic. Forget about tackling it, we are not even able to control it.

“In the face of it, we have a political system which is totally diversionary, it is totally tactical, and which has created ways and means to divert, whether it is in the communal form, or in casteist form. However, what needs to be done is, we need to take a hard look at the insurance model. There can’t be an insurance model and a private model when you aim to ensure universal healthcare for all the people of India. They are totally discordant things, absolutely. There is a huge dichotomy there,” she added.

Dr Manisha Bangar is a leading organizer of Mulniwasi Bahujans of India (the Indigenous majority population). Currently serving as National Vice President of BAMCEF (Backward and Minority Communities Employees Federation).

Disclaimer : TOR captured and edited content of Dr Manisha Bangar’s talk held on Round Table India . Full  transcript of Dr Manisha Bangar’s talk available on Round Table India.

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