The gaping hollow in India’s obligations as a welfare state

By: Shivani Raheja

Health security as a responsibility of the State


Good health is “both essential and instrumental to human survival, livelihood and dignity.” The World Health Organisation defines health security as “activities required to minimise the danger and impact of acute public health events that endanger the collective health of populations living across geographical regions and international boundaries.”  


welfare state is a country that, in its paternalistic capacity, provides basic economic and social security to its citizens in order to protect them at their most vulnerable state. Citizens are considered most vulnerable when they are old, unemployed or sick. Therefore, in systems of socialist, welfare countries, the onus lies on the government to protect their citizens.


India’s obligations as a welfare state


India, in its Constitution, boasts of being a “Sovereign, Socialist, Secular, Democratic, Republic.” The Directive Principles of State Policy signify that the drafters of the Constitution meant for India to evolve into a welfare state – one where citizens live a comfortable life. Hence, it is the responsibility of the Indian government to ensure that citizens have material provisions which can constitute a good life. These provisions allow for citizens to have basic human rights and dignity in their existence.


It is commonly known that social inequalities cause health inequities. Some social factors that cause health inequities can be societal class, economic class or wealth, influence, power and access to material resources. However, proper policies, if implemented as directed, can ensure that the gap in health inequities are bridged. Article 47 of the Indian Constitution guarantees the Right to Health to all citizens and the Supreme Court has, throughout history, expanded Article 21to include the Right to Health under the Right to Life and Liberty. However, India has continually failed to ensure the provision of good health infrastructure to all its citizens. Out of the two integrants of social welfare – basic public goods (and services) and social protection, India has focused on the social protection policies in contrast to clean water, sanitation, primary education and public health.


Challenges to health security 


The Indian health infrastructure currently faces multiple problems. The biggest issue is that private players are continuously entering the healthcare sector at the cost of the public players. Private hospitals attract skilled doctors and allow for privileged sections of society to consult them and get treated if they can afford the adroit medical professionals. This leaves less-skilled doctors in the public hospitals and allows for discrimination of citizens on a social and economic basis. It is a constant struggle between high costs and low quality of care for people in India seeking medical help. Government healthcare infrastructure is spread thin due to lack of budget, poor allocation of resources and a lack of regulation and monitoring. India has 1 bed per 1000 people whereas the global average is 2.9 beds.


Besides the physical infrastructure, the human health resources i.e. Medical professionals, in India, also fall short of the recommended WHO guidelines. The WHO recommends that nations have a doctor to patient ratio of 1:1000 and anurse to patient ratio of 1:300. In India, one (allopathic) doctor caters to approximately 1511 patients and one nurse tends to around 670 people.

Some other issues in the provision of healthcare facilities include the lack of awareness among Indian citizens regarding their own health and their tendency to distrust medical professionals. Most women in rural India also lack the autonomy to make medical decisions which obstructs them from getting timely intervention regarding their health.


The rural and urban divide too, is a major contributing factor to the poor health security in India and physical access to healthcare facilities is also a barrier to public health security.


A country home to approximately 138 crore people, India spends less than 2% of its GDP on healthcare for its citizens — this is among the lowest in the world. Out of that 2%, most of the finances are spent paying for the employees on the state’s payroll. Very few state finances actually go towards health programs that allow the government to pay for medical procedures undertaken by the citizens. The out of pocket expenditure (OOPE) for healthcare in India amounts to 62.6% of the total health expenditure. This is one of the highest in the world and places India just below Sudan in OOPE.


India may be on the right path 


In 2021, the budget for the healthcare infrastructure was increased; however, in light of the pandemic, experts say that it is too little too late. The government also promised to boost the primary healthcare infrastructure and add 1.5 lakh health and wellness centres by 2022.


However, the progress on these promises remains to be seen. Multiple health care schemes under the Ayushman Bharat programme were also released like the Rashtriya Swasthya Bima Yojana (RSBY) which is aimed at providing insurance for secondary and tertiary healthcare and the Senior Citizen Health Insurance Scheme and while the Economic Survey 2020-21 stated that these schemes enhanced insurance coverage, India needs to implement more policies to ensure that the strain of health expenditures on the citizens pocket is reduced.

The COVID-19 pandemic not only drew back the curtain on the existing disparities in the healthcare infrastructure but also exacerbated the societal wedge in access to healthcare. The second wave overwhelmed the medical staff and took the lives of many skilled medical workers. On the other hand, citizens were left gasping for breath amid a shortage of oxygen cylinders and hospital beds. Economic power allowed people to buy oxygen cylinders and safety gear at the most ridiculous prices and in some cases, evensocial power did not help people to procure a bed in a hospital.


The fact that Indian citizens had to pay one of the highest prices for the COVID-19 vaccine in private hospitals when even Capitalist countries like the United Kingdom were offering the vaccine free of cost shows how far India is from its Constitutional Principle of welfarism.


Recommendations for the way forward 


India, in order to truly become a welfare state, like the Constituent Assembly dreamed it would, must drastically alter its healthcare policies. The second wave of the pandemic collapsed the medical infrastructure of the country. Now India must invest heavily in the healthcare sector. A huge chunk of the GDP should be invested into public health insurance schemes in order to prepare the country for a third wave or other unseen epidemics/pandemics. Additionally, government expenditure in health would lessen the economic strain hospital bills are putting on families, which are in turn dragging them to poverty.


India can take inspiration from countries like Canada and follow steps to start universal health coverage programmes like Medicare or implement the PMJAY scheme in a rapid yet scheduled manner. The country also needs to create a streamlined process to decentralise health schemes and policies in order to provide states with funding from the budget in accordance with their current population and number, condition of healthcare facilities.


India should involve NGOs and ASHA workers to spread awareness about the need for precautionary medicine and establish a relationship of trust between citizens and doctors. Reaching the goal of health security in India will be a multi-dimensional process and steps must be taken to educate citizens about the need to access healthcare facilities and also to make people, especially women, aware of their rights – especially to their own bodies and its medical decisions.


The government should, additionally, take steps to reduce the urban-rural divide and prevent brain drain to private healthcare providers by mandating government service for skilled professionals and also paying them for their skills. Lastly, India should increase the medical education institutions and take steps to ensure a diverse intake while also mandating a socially diverse curriculum so that the country’s upcoming doctors do not have societal biases and cater to all sections of society equally.

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