May , 2021
India’s healthcare system collapses under deadly second wave
14:15 pm

Tushar K. Mahanti


India reported over 4 lakh daily coronavirus infections for four days between May 6 and May 9. It reported 4,03,738 fresh Covid-19 cases on May 9 - taking the total number of Covid-19 cases in the country to 2,22,96,414. As many as 4,092 patients died due to complications linked to coronavirus infections on May 9. The country's death toll reached a huge 2,38,270 as the devastating surge of new infections tears through dense cities and rural areas alike and overwhelms healthcare systems. With the new infections, the number of active Covid-19 cases in the country increased to 37,36,648.


India had earlier thought that it had weathered the worst of the pandemic but the virus is now racing through its population and systems are beginning to collapse. Hospitalisations and deaths have reached record highs putting pressure on healthcare workers. Patients are suffocating because hospitals' oxygen supplies have run out. Desperate family members are sending messages on social media, hoping someone would help them to find oxygen cylinders, empty hospital beds and critical drugs for their loved ones. 


With its health care system sinking fast, India is now looking at other nations to pull it out of the record surge. Many of them are promising help but in reality, they have left India to deal with its own cesspool of misery and disease.




What did India do after the Covid-19 struck in 2020?


With the Covid-19 pandemic testing even the more developed healthcare systems globally, the foundations of India’s healthcare system have naturally also been shaken. The overall response to the pandemic witnessed both the private and government sector working in tandem. The private Indian healthcare players rose to the occasion and have been providing all the support that the government needs, such as testing, isolation beds for treatment, medical staff and equipment at government Covid-19 hospitals and home healthcare.


The healthcare industry, along with the central and state governments, undertook a robust response plan to tackle the pandemic by setting up dedicated Covid-19 hospitals, isolation centres and tech-enabled mapping of resources. In order to effectively manage the outbreak, the Indian government also leveraged technology and developed various applications both at the central and state-levels. 


India did well to manage the spread of Covid-19 pandemic in 2020. But the country was caught unaware in 2021 when the second wave of the disease broke out. The government, the healthcare system all turned clueless against the ferocity of the second wave. Scientists across the world had cautioned of a second wave of the pandemic and alerted that it would be more severe than the first wave. 


The question is: What did our government do to tackle the second wave? “Health Care Takes Centre Stage, Finally” was the title of a chapter in the Economic Survey 2020-21, released before the 2021-22 Budget amid the continuing pandemic. The 2021 Economic Survey set out the importance of increasing public health spending and also discusses in detail market failures in health. It showed that an increase in public health expenditure from the current levels in India to 3% of the GDP can reduce out-of-pocket expenses (OoPE) from 60% currently to about 30%. As is well known, the OoPE on health burdens not just the poor but also the middle class of this country.


The Economic Survey therefore makes a case for increasing public spending on health from 1% to 2.5-3% of GDP, as the National Health Policy (NHP) 2017 states. This is necessary to improve India’s poor standings on various indicators of health, such as share of OoPE, equitable and good quality access to healthcare, availability of infrastructure and human resources for health. For example, India currently ranks 145 out of 180 countries on quality of and access to healthcare, and 179 of 189 countries in prioritisation of health in government budgets.


Against this backdrop, the Union Budget was expected to take the first step towards giving the public health sector the attention it deserves by stepping up the resources available. Nirmala Sitharaman in her Budget speech had also emphasised on a “holistic approach to health” that focuses on “strengthening three areas: prevention, curative and well-being.”


But as one looks into the details of the budget figures, that does not seem to be the case, despite all the talk. The Union budget has clearly failed to put its money where it was most needed.


Overall, the health budget has increased from `67,484 crore (BE 2020-2021) to `73,931.77 (2021-2022). While this is an increase of about 10%, the allocation for this year is in fact less than the revised estimates of 2020-2021(`85,089 crore).


But this has been the story for years. The government ritually promises to step up expenditure on healthcare but does little in reality. And if achieving a target of spending 2.5% of GDP on health, set by the government seems difficult, the actual spending of less than one per cent of GDP is baffling. This is clearly seen in the small and falling share of health in the budget allocation. 




 Budget expenditure on health (Rs crore)






























% Share in Budget exp
















Source: Various Budget documents - GOI




Since health is in the concurrent list of the Constitution, Indian states too are equally responsible in strengthening the health infrastructure. With limited resources, states seem to have allocated a larger share of their budgetary expenditure on health over the years compared to that of the Centre.




States' expenditure on health


As % of


As % of




total exp








































Source: State Finances – RBI




But if the government is unable to provide enough healthcare facilities to its people, the people themselves are compelled to spend on medical treatments from their own pockets. This is amply evident in the mushrooming of private hospitals and nursing homes across the country.




Pvt final cons exp on health (Rs crore)


% Share in






total PFCE






































Source: MOSPI, GOI




With ever increasing cost of healthcare, the expenditure on healthcare has become an important item in households’ consumption expenditure. The aggregate private final expenditure on healthcare at 2011-12 constant prices has increased by nearly 53% in five years between 2014-15 and 2019-20. The share of healthcare in total final consumption expenditure has gone up by about 0.36 percentage points during this period - from 4.18% to 4.54%.


Admittedly, the emergence of Covid-19 in 2020 was a sudden phenomenon and the government as well as the country’s healthcare system was caught unaware. But when the world at large was talking of a second wave, higher allocation in the health sector would have given us a better platform to face the second wave.


Understandably, nothing big could be achieved in a single year; building new hospitals or training doctors need more time. But then a year was a good enough time to train healthcare assistants, nurses and to build make-shift Covid assistance health zones. 


The government turned complacent and got busy elsewhere as the intensity of the pandemic slowed down towards the end of last year. As such, the health sector has been neglected year after year and the basic health infrastructure such as number of doctors, number of nurses and other health workers, number of hospitals and hospital beds have remained far too inadequate to meet the country’s regular needs let alone a pandemic of Covid-19 proportion.


Indeed, the Indian healthcare system is not equipped to handle the Covid-19 crisis. A good measure of our preparedness against the coronavirus is the proportion of doctors to the 1.35 billion people.


As per the reply by the minister of state for health in Rajya Sabha on July 2, 2019, in India, there was one doctor for every 1,457 people, which was far lower than the World Health Organisation norm of 1:1000.


A little over 11.57 lakh allopathic doctors were registered with the state medical councils and the Medical Council of India as on January 31, 2019 and assuming 80% availability, it is estimated that around 9.26 lakh doctors may be actually available for active service.


As per Indian Nursing Council (INC) records, there were around 30.4 lakh nursing personnel registered in the country as on December 31, 2018. Assuming 60% availability in the case of registered nurses and registered midwives and 80% availability in the case of auxiliary nurse midwives or lady health visitors, it is estimated that around 20 lakh nursing personnel are available for active services, which gives a nurse-population ratio of about 1:675 against WHO norms 3:1000 (population taken as 135 crores).


If one looks at the availability of government hospital beds for major states, the situation is shocking. According to National Health Profile 2019 data there are 7,13,986 total government hospital beds available in India. This amounts to 0.55 beds per 1000 population.


Given this appalling healthcare infrastructure, it is expected that the healthcare system will break down against such devastating medical emergency.




Vaccination debacle


But if India fails to improve its health infrastructure, shouldn’t it have taken measures to prevent the spread of the pandemic. Today when Israel, UAE, USA, UK are all witnessing a dramatic reduction in death count and in new cases on account of vaccine drives, India is struggling with ever increasing supply demand gap of vaccines.


India’s very own Serum Institute of India (SII), the world's largest vaccine maker, was meant to supply most of the vaccines as the country headed towards an ambitious target - covering 250 million people by July. But three months on, Covid cases and deaths are spiking across the country. Only about 26 million people have been fully vaccinated out of a population of 1.4 billion and about 124 million have received a single dose. Worse, vaccine stocks in the country have nearly dried up, and no-one is sure when more will arrive.


And this could have been avoided had India chased the vaccine instead of waiting for SII to deliver it. Two of the biggest vaccine makers in the world today, BioNTech and Moderna, started development way back in January 2020. A Chinese pharmaceutical company immediately invested in equity in BioNTech to fund development, and get rights to use the vaccine later. BioNTech also received funds from European Commission and Germany. China, Europe, USA – all partnered up. India was nowhere and is now crying for help.


Until now, India's federal government had been the sole purchaser of the two approved vaccines - Covishield, developed by AstraZeneca with Oxford University and manufactured by SII; and Covaxin, made by a local firm Bharat Biotech.


But it's now thrown open the market to not just 28 state governments, but also private hospitals, all of whom can directly negotiate and buy from the two vaccine makers. And they have to pay far more. The central government still gets 50% of stocks for 150 rupees per dose, but states have to pay double that and private hospitals eight times as much - all while competing for the remaining half.


The big question is, however, not the price of the vaccine but its availability. The chief executive of India’s Serum Institute has warned that shortages of jabs will persist for months and India’s severe vaccine shortage would continue through July, when production is expected to increase from about 60-70m million doses a month now to 100 million.


This was largely because the authorities did not expect to confront a second wave back in January when new coronavirus cases had declined. And when the second wave began in March, the country’s unprepared healthcare system crumbled.



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