NEW DELHI, India — Shiv Charan Lal Gupta, the medical director of Batra Hospital in New Delhi, has seen the devastation that follows an earthquake: dead bodies strewn about, patients maimed and in desperate need of care.
None of it prepared him for the day his hospital ran out of oxygen.
It was a Saturday: May 1, 2021. The massive second wave of Covid-19 cases in India, driven by the emerging delta variant, was peaking. At Gupta’s 500-bed private hospital, 80 percent of beds were reserved for Covid patients. Oxygen use was up to four times higher than normal, and the hospital’s reserves were dwindling. The local government had taken over the oxygen supply during the emergency, and Gupta pleaded with officials for more. Nurses tried to reassure panicking patients and their loved ones, who had learned from social media reports that the hospital was running out of air.
Finally, government officials gave Gupta some news: More oxygen was coming, but not for at least 90 more minutes.
It came too late.
The oxygen in Gupta’s hospital was exhausted before reinforcements arrived. For about 10 minutes, there was no air for patients struggling to breathe. And in that brief lapse, 12 people died.
A friend and colleague of 30 years, a senior gastroenterologist, was among the dead. Gupta called it the worst day of his life.
“I was a broken man that day,” he said. “In the aftermath of an earthquake, we would deal with injured or dead people. But here we had people who were alive, who we were treating, and they were dying. I have never felt this helpless in my life.”
Gupta was witnessing firsthand the collapse of India’s health system, buckling under the pressure of a pandemic. Across the country, patients were dying because hospitals ran out of oxygen.
“Every hospital loses patients. But if patients die because there is no oxygen, that is wrong,” said Gupta, a former legislator with the ruling Bharatiya Janata Party (BJP).
Long before an unprecedented wave of infections and death began this spring, there were warning signs that India’s chronically underfunded health system would struggle against the deadly new virus.
Less than 40 percent of Indians have health coverage. The country spends a smaller share of its GDP on health care than most of its economic peers. The country’s health outcomes, such as life expectancy and infant mortality, trail accordingly. Indians pay a higher share of the country’s health care expenditures out of their own pockets.
Indian experts say this reality reflects the government’s failure to invest in a sustainable health system for the world’s largest democracy.
As a result, when Covid-19 hit, there were not enough hospitals, particularly in the rural parts of the country. There were not enough doctors or nurses. Overworked community health volunteers were stretched beyond their limits. The system was so overloaded that some patients died before finding out the results of their Covid-19 test.
The toll has been enormous: The more than 430,000 official deaths from Covid-19 are believed to be a serious undercount. The actual number of deaths may be as high as 3 million to 5 million. A recent antibody study suggested more than half of India’s people have contracted Covid-19.
India’s failures parallel those in other countries both rich and poor. A decentralized health system dependent on private industry pushed much of the cost of medical care onto individuals and families, exposing deep disparities between the haves and have-nots — a familiar narrative in the US. As in other developing economies, including Brazil and Colombia, systemic failures and insufficiencies resulted in overwhelmed hospitals and patients left to die without care.
But in sheer magnitude, no Covid-19 catastrophe matches India’s.
Indian leaders have known for years their health system needed improvement. Prime Minister Narendra Modi, who came to power with the BJP in 2014 on a Hindu nationalist platform, tried to reform it. In 2018, his administration established a new health insurance program that would cover hospital services for more than one-third of Indians, targeted to lower-income groups. But that program has struggled to meet its goals.
“Now a country that aspires to be a global leader is seeing people die because they can’t get oxygen,” Rama Baru, who studies India health policy at Jawaharlal Nehru University, told Vox. “I feel quite shocked. We’ve never had a time in our history when we lost our humanness.”
India’s broken promise on universal care
When India broke from British rule in 1947, its new constitution established health as a human right: “The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties,” the document, ratified in 1949, reads.
Responsibility was delegated to the 28 states and territories that now comprise the Indian Union. States, not the national government, would fund the hospitals where people could get care and cover the cost of providing those services.
But states immediately struggled to deliver on that promise.
In part, India had been set up to fail. After centuries of economic exploitation, the country was left destitute. India had accounted for almost one-quarter of the world’s economy in 1700; by 1952, it represented less than 4 percent. Money was scarce.
But even as the Indian economy exploded in recent decades, the country spent less on health care than other large emerging markets. Brazil spends eight times as much public funding per person on health care as India does. Nearby Thailand spends seven times as much.
“Within their income class, they’re low,” Cheryl Cashin, who studies health system development at the nonprofit research group Results for Development, said of India. “They’re not following the normal pathway as countries become wealthier.”
The lack of funding is due in part to the challenges facing a country pulling itself out of deep poverty. But some experts also blame the national government for failing to provide more support to the states. The result is that a parallel, private health care system has emerged, where prices vary considerably and most expenses are paid out of pocket.
Ultimately, private insurance pays for less than 5 percent of India’s overall health expenditures. Out-of-pocket spending accounts for more than 60 percent. The disparities have deepened over time: Wealthy people could seek top-quality care at for-profit private hospitals, while the less affluent were left relying on an underfunded public system.
Modi’s new health insurance program, established in 2018, was supposed to fix that. But a 2021 review published by Duke University researchers found the program has seen mixed results. Many eligible people in poorer states are still unaware it exists. Its record in providing financial protection to its beneficiaries was “mixed,” in part because it covered only hospital care.
During the pandemic, an analysis by Jeevan Raksha, a public-private partnership from the Public Health Foundation of India and the management consulting firm Proxima, found the program covered less than 1 percent of all Covid-19 tests and 14 percent of all related hospitalization costs in India during the second coronavirus wave.
India’s health care infrastructure has also languished. The Modi administration set a goal of opening or upgrading 150,000 primary care clinics across the country but had only gotten to a fraction of that number when Covid-19 struck.
“Covid exposed the deep fault lines,” said Indrani Gupta, who leads health policy research at the Institute for Economic Growth in Delhi. “Dysfunctional health systems can never cope with pandemics and epidemics efficiently.”
Medical workers were left on their own
During the pandemic, the failure of India’s health system was total. Providers were left ill-equipped to handle the surge of patients. And even the people who did get care often faced unaffordable medical expenses.
“It was an unprecedented situation,” Sandip Datta, assistant professor at the Delhi School of Economics, said. “The health infrastructure we have, both public and private combined, was not adequate to serve everyone who was getting infected.”
In many areas, there are fewer doctors and nurses per capita than is recommended by the World Health Organization. When hospitals ran out of lifesaving supplies, they were blamed and, in a few cases, even attacked.
On his second day working at a Covid-19 care center in Assam’s Hojai district, Seuj Kumar Senapati began treating a patient who had come in with a fever and mild cough; when he checked on the patient later, they were unresponsive. A mob of 30 people chased the young doctor around the hospital, eventually catching and assaulting him.
“I didn’t even get a chance to do anything to revive the patient,” Senapati told Vox.
As major medical centers and clinics were being overwhelmed, India relied on its community health workforce — accredited social health activists, commonly known as ASHAs — to be the vanguard of the Covid response.
ASHAs are quasi-volunteers who receive nominal compensation to raise public health awareness in their villages and neighborhoods. The Indian government created the corps in 2005, as doctors and nurses moved to the emerging private health care sector.
While they confronted Covid-19 this year, those volunteers were often left on their own when they themselves got sick.
Sangeeta Kamble had been working for months as an ASHA in her rural village of Yellapur, near India’s western coast, when she came down with Covid-19 in March 2021. Her husband and son were soon sick, too, and her husband, who has diabetes and two partially amputated legs, quickly deteriorated.
She called the doctor at a nearby government hospital — a 30-minute drive away in the town of Shirala — but no beds were available. They visited two other hospitals before finally getting a bed at a government medical college late in the night.
“Despite helping people during the pandemic, there was no bed for front-line workers like me,” Kamble, 34, said.
Her husband pulled through after two weeks in the hospital with oxygen support, and his care at a public facility was covered by the government. But his family, who are uninsured, have been on their own as he deals with post-infection complications. Kamble does tailoring work on the side, to bring in some extra income.
“But that’s not nearly enough to pay for his medicines,” she said.
Poonam Sharma, an ASHA in Tigra Village, located near New Delhi, has been working seven days a week for the past year, up to 10 hours a day, all for about $50 US every month; bonus pay for Covid-related work expired in the fall, long before the surge.
Sharma, 42, knows of three ASHAs who died of Covid-19 in the region. She said their families had still not received the generous life insurance payout that the government had pledged to provide — equivalent to nearly $70,000.
“No one cared for their families,” she said.
Will Covid-19 lead to reform?
No part of India’s health system has gone unscathed in the pandemic; even patients with private insurance have struggled to pay the bills. Because private health insurance in the country is so unregulated, some plans did not even cover Covid-19 care unless individuals or employers purchased it as an added benefit.
Isha Nagpal has health insurance through her job at a TV network, but when her father was hospitalized for months after a case of Covid-19 and ensuing complications, she faced more than $20,000 in medical bills that her insurer had not paid.
“I couldn’t argue with them at that point because I was just seeing so many patients dying every day in the ICU,” Nagpal told Vox. “But the hospital just went on overcharging us.”
Nagpal covered the costs through donations, with help from the nonprofit group Mutual Aid India, and through her personal savings.
For many in India, such a financial setback is life-altering: “There are studies that suggest that poor people are falling into the poverty trap only because of health care expenditure,” Datta, the economist, said. “They may be barely above the poverty level, but because of expenditure on sudden disease, they are again falling back into poverty.”
Those are the symptoms of a broken health system. But Indian health policy experts appear skeptical this would be a moment for reform in their country.
“This is an opportunity to strengthen the public health system,” Baru said. “But we don’t see that happening.”
As the Indian economy grows, more money will inevitably go to health care. It’s part of the natural life cycle of any health system. But that alone may not fix the problem.
The Indian health system is highly decentralized. It’s largely deregulated, and it pushes a high portion of costs on to patients. That tends to lead to worse outcomes and deeper disparities, in part because powerful industry actors oppose reform.
Baru described the rise of what she calls the “medical-industrial complex” in India. The national government has generally been more interested in accommodating the private sector than in solidifying the public health system.
There was “a capture of policy by the private sector,” she said. “The voice for the need for a public health sector was rather weak.”
In the United States, the influence of the private sector has made fixing the structural problems of the health system extremely difficult. Obvious problems remain intractable. India runs the risk of following the same path.
Shiv Charan Lal Gupta is clear on what went wrong when he lost his friend and 11 other patients, when he heard stories about bodies being dumped in the Ganges River, and when he witnessed his country’s health system’s effective collapse.
“What was the problem?” Gupta said. “There was hardly any structure.”
The pandemic exposed the woeful insufficiencies in the core pieces of the Indian health system. The right to health enshrined in the constitution exists more in theory than in practice. The pieces are there, but they are not good enough in their current form.
The past year has been one trauma after another. Gupta wants change.
“If these systems are actually put in place,” he said, “the problem will be solved.”
Pamposh Raina is a New Delhi-based journalist. Makepeace Sitlhou is a journalist based in Guwahati.
Smita Sharma is an independent photojournalist based in Delhi.