Prasad N, Fernandes E, Lakhotia S, Coelho D, Prasad S. Social protection during COVID-19 crisis in India especially among vulnerable populations. HPHR. 2021; 29.
Over the last 20 years, India’s per capita income has quadrupled, and its poverty has declined at a similar rate17. Despite a significant increase in government spending on social protection, India spends under 3% of its gross domestic product (GDP) on social safety-net programs whereas OECD (Organization for Economic Co-operation and Development) and non-OECD Asian countries spend up-to 15% and 6% of their GDP on similar social protection programs respectively14. The key markers of effective social protection are an expansion of good jobs, maintaining human capital, and offering equal opportunities. Unfortunately, the health sector in India is considerably under-funded with competing priorities of infectious diseases, a growing tide of non-communicable diseases, and continued hammering of natural disasters given the vulnerability of its geographic location19. In 2015, India was among the top three disaster-hit countries, which led to economic damages worth $3.3 billion16. With a pandemic like COVID-19, these cascading risks push India’s vulnerable low and middle class into abject poverty, anxiety, and an at-risk future15.
One of the starkest stories of our era belongs to the year 2020 where the novel coronavirus has disrupted normalcy, hijacked social protection from a policy standpoint, and crippled the achievements towards 2030 agenda of sustainable development goals (SDGs). Both the disease and lockdown have caused immense human and economic costs to the country. Although it is too early to measure the extent of human cost and suffering, the economic cost is trending in a negative direction. Although the future looks hazy at best, addressing this crisis within the lens of social protection is prudent and ethical13. This may be the only viable pathway to stop India from an impending catastrophic downfall.
Vulnerability is a predisposition to harm because of interaction between individuals or communities due to unfair placement in societal strata11. Vulnerable populations are those at risk for poor health, having disparity in terms of access to healthcare, proliferating income security, food insecurity, and depending on a daily wage for survival because of barriers they experience to social, economic, political, and environmental resources20. Even though it is hard to clearly define vulnerable populations in any society, in India, women, scheduled castes, scheduled tribes, children, aged, disabled, poor migrants, people living with stigmatized diseases, and sexual minorities are considered vulnerable. Vulnerable populations in India are victims of poverty-based diseases, are taken for granted by employers, and continue to suffer and co-exist in the same ecosystem that is supposed to protect them2. Vulnerable populations in the era of COVID-19 are at higher risk of contracting the disease and suffer worse in already compromised social determinants of their lives1.
From an end-user’s perspective, health is not just a stethoscope and pills. Unless health is viewed from a social dimension, efforts in singularly shaping healthcare will collapse. This means that we must address social frameworks such as poverty, culture, community well-being, labor laws, doctor and patient relations, regional public health resources, and spending while working on environmental effects such as crime, traffic, green spaces, food destinations, land uses and residential density8. From the service-provider perspective, despite being one of the fast-growing economies in the world, India lags in provider-patient ratio, bed-population ratio, bed occupancy rate, safe work environment to health workers, and appropriate compensation structure to all healthcare professionals, including fair labor safety mechanisms to meet WHO recommendations7,9. Labor market policies in the healthcare sector do not link low-wage health workers and their healthcare needs. Income protection and timely wages are causally linked to workplace motivation and satisfaction12.
Article 41, 42, 43, and 47 of the Indian Constitution calls for social protection through various interpretations. Article 41 states that the government must offer the right to public assistance in case of unemployment, disablement, old age, and other underserved wants. Article 42 offers provisions for just and humane conditions of work. Article 43 offers suitable living wages to all workers to ensure a decent standard of life. Article 47 of the Indian Constitution states the duty of the government to provide optimal nutrition and standard of living to promote public health4,8. Implementing this in heart and spirit to leave no one behind is what good governance must do6. It is no secret that housing, employment, food security, and public distribution systems are among but a few sectors that are disproportionately affected during major disasters. These effects are compounded by a poorly managed public policy system that serves to worsen existing poverty3. COVID-19 has further deepened the crisis by adding an extra 88 million people to existing extreme poverty, for a total of over 150 million people in severe economic contraction5.
While India currently has numerous social protection programs at different levels of government, the few schemes that are implemented benefit only a privileged few. Additionally, the outcomes and effectiveness of these programs are opaque, to say the least. While universal social protection can be viewed from a human-rights-based approach, it must assume a policy-based approach, introducing an algorithm into all pertinent sectors of work and social life on a large scale. Eventually, this should be bridged to evidence-based iteration and an apply-learn-analyze-modify loop15. The pandemic has exposed the fault lines of health systems around the world, particularly those in India. In the wake of this realization, universal health coverage will pose a greater challenge than ever before. India, as an aspirant to achieving Universal Health Coverage as one of the means of social protection, will need to increase spending on healthcare and more specifically on public health to ensure that households do not slip into poverty due to healthcare requirements. In 2017, over 55 million Indians slipped into poverty due to out-of-pocket healthcare expenditure9. While India has made considerable progress, there remain multitudes that do not benefit from social protection as it lacks inclusivity and gets altered with political tones. If India expects to meet the 2030 agenda for sustainable development goals (SDG), there must be a greater focus on the “no one left behind” tagline, especially with an emphasis on vulnerable communities. Inequality may be bridged by a universal basic income package and various social policies geared towards protecting vulnerable sub-populations and allowing them to receive benefits laid out by government processes in a timely manner.
When private and public sector institutions fail to address these glaring inequalities and gaps, the responsibility to protect citizens falls back on the nation’s government. Otherwise, this will result not only in inequity in the prospering ecosystem, but also have direct implications to increasing crime rates, a deteriorating happiness index, and the multiplication of political opportunism. Cascading risks call for long-term social protection to strengthen community resilience and household resilience towards multi-pronged vulnerability. The three main strategic approaches are suggested to help mitigate the deterioration of human capital and social protection during crisis, especially among vulnerable populations in India. First, India should move towards evidence-based reforms instead of populistic-based or policy-based programs. Second, there needs to be a consolidation of numerous social and public health schemes into an integrated system to avoid redundancy, duplication, and inefficient use of resources. This would require a strategic public-private partnership at all levels of government. There should also be monitoring by a non-political overseeing agency to ensure the quality of the social protection schemes does not deteriorate, perhaps an ideal situation would be to work with Non-Governmental Organizations for quality control. Third, the government should consider increasing spending allocations to 6% of the national GDP to at least coincide with the spending allocations of the other non-OCED Asian countries. The way forward will be to create both reactive and proactive social protection while safeguarding human rights and simultaneously increasing fiscal space for inclusive social policy towards securing and achieving the 2030 agenda of SDGs. The ideal way to do this is to build safety net programs that factor in social health outcomes. It is well within the capability of India to overcome the issues surrounding the COVID-19 crisis and provide all citizens with the social protection that are outlined in the constitution.
Narayana Prasad, Physician, public health professional and co-founder of Public Health Literacy