The Covid-19 pandemic has shown us the nightmare created by the Modi regime’s disastrous neglect of scientific advice and callous authoritarianism. But this nightmare also rests on the legacy of decades of privatisation of healthcare, dismantling of public health structures, due to neoliberal policies. The millions of deaths in India caused not only by the virus but by shortage, hoarding, and predatory pricing of oxygen, beds, ventilators, lifesaving medicines, vaccines; by shortage of staff and unsanitary conditions in hospitals, especially government hospitals accessed by the poor; by the absence of medical infrastructure and staff in rural areas; and by the collapse of public health system including epidemiological surveillance, to predict and prevent communicable diseases. There are no individual, insurance-based solutions to communicable diseases – Covid-19 in its highly contagious Indian variant underlines this truth.

The goal of healthcare in India cannot merely be to provide individual citizens access to hospitals, through insurance coverage. To predict and therefore prevent the outbreak and spread of communicable diseases and epidemics like encephalitis, malaria, gastroenteritis, tuberculosis, and of course the variety of viral epidemic diseases including Covid-19, a robust public health infrastructure is needed for the surveillance and monitoring of such diseases. Without such a public health infrastructure, it is impossible to interrupt the cycle of transmission of communicable diseases.

In Kerala, where the public health infrastructure is relatively more robust compared to other states, we saw how the deadly Nipah virus could be contained. Privatisation of healthcare across India, and the resulting weakening of public health infrastructure has inevitably weakened the ability to predict and prevent communicable diseases.

Covid-19 Care For All: An Immediate Charter of Demands   

Expanding Medical Infrastructure:

• Provide mobile RT-PCR testing Centres be operationalized in all villages/slums for free Covid testing of all residents.
• Equip primary heath centres, community medical centres, and sub-divisional hospitals with sufficient electricity, water, oxygen cylinders; flow-meters; oxygen masks; oximeters; and oxygen-ambulances. A minimum of 100 ventilators, and expanded capacity for general and ICU beds must be ensured at District hospitals. Upgrading lower-level health structures from PHCs to Community Health Centres to referral hospitals and District hospitals will reduce pressure on city hospitals and save lives.   
• Set up local isolation and Covid-care centres equipped with sufficient oxygen
• Fill vacant posts for doctors and other health workers.
• During the height of the Covid crisis, so-called “jhola chhap” (quack) doctors were found to be providing basic diagnostic care and advice to mild patients in rural areas, and identifying more severe cases needing hospitalisation.  This system should be harnessed in future, providing training and guidelines to the informal practitioners so that they can form a Barefoot Doctors network.  
• Central government/ State governments must take over all private medical facilities/hospitals under governmental control till the pandemic lasts, and must provide free treatment of all COVID-19 affected people.

Transparency and Cooperation:

• Adopt transparency in all aspects of fight against the pandemic and share all data in public domain: this is a crucial requirement for the policy formulation, research and control of the pandemic. All information and data pertaining to administration, availability of the medical infrastructure and research & development must be shared with citizens, social organisations involved in running help centres, and scientific data and facts and research outcomes including corona genome sequencing etc. should be shared in real time with Indian and world scientific community in appropriate forums.
• The Central and state governments should guarantee that all-party meetings are organized regularly on Central, State as well as District level. Such District level co-ordination and understanding can prove very useful in coping with the Covid-19 crisis. A system of regular State to Block level meetings should be developed between the administration, political parties and social organizations, so that we can all face this difficult challenge together.

Universal Free Vaccination For All:

• The Central Government must ensure free supply of COVID-19 vaccine to the State Governments as per the Communicable Diseases Control Programme of the Government of India. COVID-19 vaccine must be given from all government and private medical colleges and hospitals, health centres, private hospitals, nursing homes, community centres, all types of offices and workplaces and also organise special camps at free of cost.
• The Central Government should procure more vaccines from the international community/markets to satisfy the domestic demand in order to ensure vaccination to all citizens in a time bound framework.
• Indian government must strengthen its efforts in WTO for waiver of TRIPS bindings on covid-19 vaccines, other lifesaving drugs and medical equipment.

Home Care:

• Mandatorily provide free of cost thermometers, oximeters, and medicines for COVID-19 patients in home quarantine.

Oxygen:

• Transparent and needs-based oxygen distribution by the Centre must be ensured.  
• In every city, the occupancy and availability of beds in the hospitals, the latest situation regarding oxygen supply should be published in bulletin form at regular intervals of 4-5 hours.
• Details of the planning and progress report of building oxygen plant in the government hospitals must be published in public domain.
• Uninterrupted availability of oxygen cylinders, ventilators, masks, life-saving drugs, hospital beds should not be compromised showing financial crisis or administrative failures.

Ensure Testing, Tracing & Isolation to Stop the Spread:

• Emphasis should be laid on testing, tracing, treatment and social awareness. Without proper testing we will never know the actual gravity of the situation which may lead us to another dangerous wave of the killer pandemic. This scenario will leave an immense uninterrupted space for the viral spread.
• The government should regularly consult various political parties and social and voluntary organizations for discussions on this and expand this at the District /block level.
• Widespread testing and tracing is the key factor for containing the spread of the pandemic. This is not being done adequately in spite of the governmental acceptance of the fact. Mostly symptomatic patients are going for self-testing while large number of populations remains untested in absence of governmental initiative for testing people in far places and in economically weaker sections, particularly in rural India.
• Testing and tracing can not be done in large populations without a centralised coordinated effort which should extend up to lower levels. Hence we can not leave this to concerned state governments only.
• There is need to expand RT-PCR testing at District and block levels. Hence, it is necessary to increase the number of testing centres so that infected persons can be identified, isolated and treated timely and further infection can be prevented. Without involving local governance structures up to Panchayat levels this task cannot be achieved.
• Medical teams should be sent forthwith to all villages to do house to house Covid testing.
• Special arrangements should be made for testing and isolation of migrant workers returning to their home states.

Respect and Care for the Health, Sanitation, and Crematorium/Graveyard Workers:

• Priority vaccination, safety gear and PPE kits, health check-ups must be provided to all workers of these categories including daily thermal screening, a master health check-up, regular health check once a month.
• Government must identify workers who are suffering from co-morbidities and ensure that they are provided sick leave with pay.
• Government must ensure that workers and their families are provided complete medical treatment, in the event of being tested positive.
• Government must ensure that all workers of these categories, and their family members are covered under the Pradhan Mantri Garib Kalyan Yojana and are entitled to compensation of Rs. 50 Lakhs if they lose their life due to COVID-19.
• Workers above 45 years of age must be recused from work,  with payment of full salary and benefits.
• Institutional quarantine facility for isolation must be provided for those workers who require it
• Regularise the services of all the workers in cemeteries and crematoriums, irrespective of whether the burial grounds or crematorium are managed by the government or a private trust. Ensure minimum wages, overtime, and risk allowance.

Ensure Full Funding of Fight against Covid-19:

• At least 10% of the central budget should be allocated to the health sector.
• Covid tax should be imposed on all corporate organizations.
• A tax of minimum 2 % should be levied on the wealth of Ultra-rich having equal to or more than 5000 crores in wealth/assets.
• Strict measures must be taken to stop the exorbitant cost charged by the Private hospitals to treat Covid patients.
• A large number of Covid victims are poor. Therefore, compensation of Rs 10 lakhs each to the families of the deceased victims, and 6 months' rations and employment should be arranged.

Treatment of non-Covid patients Must Continue:

• Treatment of non-Covid patients should not be obstructed under any circumstances. Additional doctors and health workers should be arranged for this.
• Special measures should be taken for the non-Covid chronic patients who need immediate attention and care, like diabetics, cardiac patients and those who need kidney dialysis etc.

Food Security for the Needy:

• Food and nutrition is an essential component of health. Due to the pandemic the poor are gradually beginning to face a food crisis. Therefore, work should be generated in MNREGA and work should be arranged on the same lines in cities also.
• All the poor including migrant workers should be given Rs 10000 subsistence allowance for the next 3 months as well as 6 months' free rations.
• All items of daily needs should be made available through PDS at affordable rates.
• Workers engaged in work at marriages and other functions have been badly affected by the pandemic. Alternative work and subsistence amount for them should also be arranged.

Healthcare For All: People’s Charter

The State of India’s Healthcare Today:

• India’s total healthcare spending (out-of-pocket and public), at 3.6% of GDP, as per OECD, is way lower than that of other countries. Of this, public (government) spending stands at a mere 1.28%. India spends the least among BRICS countries: Brazil spends the most (9.2%), followed by South Africa (8.1%), Russia (5.3%), China (5%). Patients bear 61% of health expenditure: what patients pay out from their pockets is close to double of what the Centre and State governments spend on public healthcare in India.
• India currently has just 0.55 beds per 1000 population. 12 states, which together account for close to 70% of the total population in India, lie below this national level figure: Bihar, Jharkhand, Gujarat, Uttar Pradesh, Andhra Pradesh, Chhattisgarh, Madhya Pradesh, Haryana, Maharashtra, Odisha, Assam and Manipur. Bihar has an acute shortage of government hospital beds with just 0.11 beds available per 1000 population.
• There is an acute shortage of ICU beds, oxygen-beds, and ventilator-beds. India has only 3.63 public ICU beds per 100,000 population  and the per capita availability of ICU beds varies tremendously both between and within states. For instance in Madhya Pradesh, out of the 50 districts, as many as 30 districts had no ICU facility in 2015 , and more than two-thirds of the facilities were concentrated in just four districts. MP had only 2.5 ICU beds per 100,000 population, and 83% of these were in the private sector and almost 9 out of 10 facilities were of low quality, implying that they either lack sophisticated equipment, such as non-invasive ventilator, facility for ABG etc., or qualified medical doctor.
• There is a deficit of 1,240 Primary Health Centres (PHC), 273 Community Health Centres (CHC) and 6,503 Sub Centres (SC) in the tribal areas of the country, according to a report presented by the Standing Committee on Social Justice and Empowerment in 2019. This deficit is highest in Madhya Pradesh (381 PHCs), Jharkhand (228 PHCs) and Rajasthan (225 PHCs). 22.4 per cent of the sanctioned posts of nursing staff at PHCs and CHCs and 27.6 per cent of the sanctioned posts of doctors at PHCs in the tribal areas are vacant. The committee found that the highest shortfall of doctors at PHCs is in the tribal areas of Chhattisgarh (235), Madhya Pradesh (124) and Odisha (90).

Let Covid-19 be a wake-up call – let us demand that at least now, the Government must heed this call and prioritise public healthcare for all.  

We demand:

• Make the right to healthcare a justiciable right through the enactment of appropriate legislation. Such a legislation should ensure universal and free access to good quality and comprehensive health care including the entire range of primary, secondary and tertiary services for the entire population of India.
• Abolish user fees in all government hospitals
• Develop a time-bound, district-wise road map to meet the shortfall in physical health infrastructure all over India.
• Equip Primary Health Centres - PHCs to provide experienced emergency care, and to prevent maternal and natal/neonatal mortality.
• Fill all the vacant posts of medical officers, specialist doctors, nurses, ANMs, pharmacists, radiographers and other frontline health workers at various government hospitals and health programmes within a stipulated time. Make appointments through permanent recruitments, not short-term contractual appointments.
• Recognise ASHAs, anganwadi workers as Government employees and regularised.
• Institute a protocol and comprehensive measures for ensuring the safety of all health, sanitation and relief workers during Covid-19 and other disasters and epidemics, providing safety gear to all.
• A participatory system of community-based monitoring, grievance redressal and planning needs to be implemented to ensure that people can access appropriate health services as their right, seek effective action on complaints, and have a strong voice for improved functioning of health services.
• Open fully staffed and equipped Urban Primary Health Centres at every 30000 population in towns and cities. Appoint USHA (Urban Social Health Activists) on the pattern of ASHA in each Urban PHC to ensure effective linkages between the community and the health facility. In addition, set up mohalla clinics in urban bastis and slums in all towns and cities.
• Stop all forms of privatization of Public Health Services, eliminatePublic Private Partnerships (PPPs) which weaken public health services
• Universalise ICDS programme and expand it to cover under-3 children through community based management of malnutrition and day-care programmes