Context: As epidemiologists tend to consider that the peak of the COVID-19 epidemic may not come before July, in this scenario the question of the resilience of the Indian health system becomes even more pressing.

Limitations of India’s health care system


  • Lack of infrastructure
    • India’s public hospitals have only 7,13,986 beds, including 35,699 in intensive care units and 17,850 ventilators.
    • Hospital beds per 1,000 people:
      • As per the OECD data available for 2017, India reportedly has only 0.53 beds available per 1,000 people
        • These figures are 0.87 in Bangladesh, 2.11 in Chile, 1.38 in Mexico, 4.34 in China, and 8.05 in Russia.
      • Also, The numbers have not changed in the last four years of available data, this shows India’s stagnant allocation to the public health care budget.
  • Low public health spending in percentage of the country’s GDP
    • The general perception behind the inadequate provision and availability of healthcare services is attributed to the country’s developing nation status. 
    • However, India even lags behind its BRICS peers on the health and quality index (HAQ index).
    • As per the National Health Profile 2018, India’s public health spending is less than 1 percent of the country’s GDP. 
      • These figures are lower than some of its neighbors, countries such as Bhutan (2.5 percent), Sri Lanka (1.6 percent), and Nepal (1.1 percent).
    • India finishes second from the bottom amongst the 10 countries of its region for its percentage spending of GDP on public health. 
      • Maldives spends 9.4 percent of its GDP to claim the top spot in the list, followed by Thailand (2.9 percent).
  • Subnational differences in India
    • Differences in Health and Quality Index (HAQ index) 
      • While the best performing states, Kerala and Goa, scored more than 60 points, the worst-performing states of Uttar Pradesh and Assam scored less than 40 points. 
      • Also, the gap between these highest and lowest scores increased from a 23.4 point difference in 1990 to a 30.8 point difference in 2016. 
    • Availability of beds
      • Kerala with a population of only 3.5 crore (2018) has over 22,300 available beds in public hospitals/government medical colleges. 
      • However, bigger states like Gujarat and Maharashtra with populations of over 6.82 crore and 12.22 crore (2018) respectively, have only 16,375 and 6,970 beds respectively. 
    • These differences across states also speak for the differing capacities to contain the virus at a subnational level wherein Kerala has emerged as a successful model.
  • Non-significant role of Private sector during the pandemic
    • The CDDEP/Princeton study shows that the private hospitals have 11,85,242 beds, 59,262 ICU beds, and 29,631 ventilators. 
    • However, currently in India, most of the COVID-19 treatment is being done in public facilities but as the epidemic progresses, it will be critical to expand the outreach of healthcare services by involving the private sector as an equal partner and stakeholder. 
    • Despite private hospitals accounting for 62 percent of the total hospital beds as well as ICU beds and almost 56 percent of the ventilators, they are handling only around 10 percent of the workload and are reportedly denying treatments to the poor. 
      • This is witnessed in Bihar, which has seen an almost complete withdrawal of the private health sector and has nearly twice the bed capacity of public facilities. 

Recent steps taken by the government to effectively utilize private health care infrastructure 

  • In states where private hospitals have not opened their doors to the poor to enhance and supplement the governments’ efforts to ensure public health, the governments in question have taken control of some of them. 
  • The central government has invoked the National Disaster Management Act of 2005,
    • Through this authorities are empowered to take over the management of private institutions.
  • Case study of Maharashtra
    • Maharashtra has taken control of 80 percent of all private hospitals’ beds in the state till August 31. 
    • Capping of rates: For the patients, rates have been capped at Rs 4,000 in the case of simple ward and isolation beds, Rs 7,500 per day for ICU beds without a ventilator, and Rs 9,000 for those with a ventilator. 
  •  The Delhi government has asked 117 private hospitals to allocate 20 percent of beds for COVID-19 patients.
  • Recent ruling of the SC
    • The recent ruling issued that private labs should conduct free testing.
    • However, later it was modified to fix the rate of one of the most dependable tests at Rs 4,500.
      • However, The cost associated is still costlier than in Bangladesh, and which allows private labs to make some important profits.

Suggestions while utilizing private infrastructure

  • The question remains how will the private hospitals be compensated after taking over their control. 
    • The governments (Union and state), would be to pay crores of dues they owe to private hospitals for treating patients under the Central Government Health Scheme (CGHS) and the Ex-servicemen Contributory Health Scheme (ECHS).
  • In conducting tests
    • Similar policies should apply to testing, a key priority, as India continues to test less than it should in a post-lockdown scenario where testing is one of the most obvious ways to flatten the curve. 
    • Instead of need of SC to issue order, this should be the part of crisis management by the state.


  • The state is staging a comeback everywhere in the world in the context of the coronavirus crisis. In India, one of the domains where it has to step in is public health. 
  • Does not necessarily mean more centralization
    • A debate on the lack of investments in public health is bound to take place in the country after the crisis. 
    • But the return of the state does not necessarily mean more centralization. 
    • Some state governments are also doing a better job than the Centre today and the most effective ones are the most decentralized ones such as Kerala.
  • Role of the civil society
    • Civil society also needs to play a proactive role in such crisis situations.
    • The situation would be much worse if NGOs and private foundations (using CSR money sometimes) did not play such a huge part at the grassroots level. 
    • But the most effective interventions seem to take place when there is a high degree of coordination with the state apparatus.

About Health and quality index (HAQ index)

  • The index is released as part of the Global Burden of Disease study released by Lancet
  • The Index encompasses 32 causes of death considered to be avoidable provided that quality healthcare is available. 
  • It assigns a 0-100 score to each of the 195 countries and territories assessed
  • India has improved its ranking on a global healthcare access and quality (HAQ) index from 153 in 1990 to 145 in 2016, yet ranks lower than neighboring Bangladesh and even sub-Saharan Sudan and Equatorial Guinea.


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