INDIA: Healthcare Inequities Exposed by COVID-19 Pandemic

Migrant labourers wait in queues in Kashmir in order to travel back to their homes. The second wave of COVID-19 in India has seen masses of people leave cities and towns to return to their rural homes. Credit: Umer Asif/IPS

Migrant labourers wait in queues in Kashmir in order to travel back to their homes. The second wave of COVID-19 in India has seen masses of people leave cities and towns to return to their rural homes. Credit: Umer Asif/IPS

By Ranjit Devraj
NEW DELHI, Apr 29 2022 – Public health specialists say that an ongoing wrangle between the Indian government and the World Health Organization (WHO) over the COVID-19 death toll in this country is symptomatic of a long-ailing public health delivery system.

India has consistently challenged estimates published by leading scientific journals such as the Lancet, which placed the number of excess deaths in the country at four million from 1 Jan 2020 to 31 Dec 2021.

“You can argue till the cows come home but the figures are going to be in the range of four to five million deaths as shown in several studies and any contestation would require robust data rather than bland denials.”

On 16 April an official note from the Press Information Bureau in response to a New York Times article said, “India’s basic objection has not been with the results (whatever they might have been) but rather the methodology adopted for the same.”

India’s concern was that the projected estimates in the article, titled “India Is Stalling the WHO’s Efforts to Make Global COVID Death Toll Public,” for a country of its geographical size and population could not be done in the same way as for smaller countries. “Such one size fit all approach and models which are true for smaller countries like Tunisia may not be applicable to India with a population of 1.3 billion,” the official note said.

But independent public health specialists said that the concern was that India’s spat with the WHO was detracting from the more serious issue of the country’s tottering health delivery system failing to deal with the pandemic.

“Forget about the actual number of people who died of COVID-19 or because of comorbidities like diabetes, hypertension or cardiovascular disease — the fact remains that an unusually large number of people died during the pandemic because the health delivery system was overwhelmed,” said Mira Shiva, founder-member of the international Peoples Health Movement.

“One could say that the pandemic worked like a stress test of how good healthcare services were, and they were found seriously wanting,” said Shiva. ”Unsurprisingly, it was the poor and marginalised groups that took the brunt of it all — many more died of undocumented causes than usual as reflected in the several calculations based on excess deaths.”

Shiva said that, at the best of times, a cause of death is not properly registered in India. “We can only guess from the very large number of bodies seen floating down the main Ganges and Yamuna rivers during the second wave of the pandemic in 2021. There were also widely-circulated images of bodies laid out in rows on the river banks — these were obviously of people whose relatives could not afford to buy the firewood for cremations.”

Says Satya Mohanty, former secretary in the government and currently adjunct professor of economics at Jamia Milia Islamia University, New Delhi: “You can argue till the cows come home but the figures are going to be in the range of four to five million deaths as shown in several studies and any contestation would require robust data rather than bland denials.”

“If the crude death rate on average is one per thousand per month, anything above that average over a period of two years can be safely taken as deaths due to a differentiator – in this case the COVID and post-COVID effects,” says Mohanty. “There cannot be any other reason unless other differentiators were at play and to the best of our information there were no other differentiators.”

Sandhya Mahapatro, assistant professor at the A.N. Sinha Institute of Social Studies (ANSISS) in Patna, Bihar state, says “while India has made great strides in reducing inequalities in healthcare, large access gaps by socioeconomic status remain. Our studies show that 38 percent of outpatients in Bihar, a state with a population of 128 million, had no access to public healthcare.”

“There is growing concern about the distributive consequences of welfare initiatives on different socioeconomic groups,” Mahapatro added. “The historical disadvantages of healthcare access experienced by women and marginalised groups continue, with factors like caste, class and gender intersecting at various levels to create advantage for some sections and disadvantages for others,” she said.

A paper published by Mahapatro and her colleagues in the peer-reviewed journal Health Policy Open in December 2021 showed that social status clearly determined whether a person could access healthcare or not, despite pledges to ensure equity in healthcare provision and commitment to the United Nations’ Sustainable Development Goals (SDGs) Goal 3 — providing quality health services to all at an affordable cost.

“The issue of inequity played out during the COVID-19 pandemic affecting the poor and marginalised disproportionately,” said Mahapatro. “Internal migrants were greatly affected by the lockdowns with a staggering economic burden befalling them. The pre-existing inequality has widened and is expected to further widen as a result of the pandemic.”

Mahapatro said a study conducted at ANSISS during the post lockdown period found a familiar pattern of deprivation in healthcare services as in earlier studies. “The burden of unmet healthcare needs was substantially higher among the poor, women and people of low caste,” Mahapatro said. “Unmet healthcare needs were found to be particularly high among women of lower caste groups.”

“Importantly, our studies show that the pattern of health spending has remain unchanged over the decades and that the household remains the main source of financing healthcare before and during the pandemic,” she added.


A local priest and relative of a family member who died from Covid watching a pyre burn at the Garh Ganga Ghat in Mukteshwar, in Uttar Pradesh on 4 May, 2021. (Mukteshwar, Hapur/ File-Amit Sharma)


“The ongoing economic crisis due to the pandemic and inadequate healthcare capacity would obviously constrain healthcare utilisation by the marginalised sections of society, with internal migrants being the worst impacted as a result of the lockdowns,” Mahapatro said.

A staggering 450 million Indians are internal migrants according to the 2011 census, 37 percent of the total population. A national lockdown imposed with a four-hour notice on 24 March 2020 left most of these domestic migrants with no option but to undertake long treks back home with little money or food.

The national lockdown, considered among the tightest globally, went into three more phases with increasingly relaxed restrictions on economic and human activity until 7 June.

“Almost 80 percent of the migrant workers we surveyed had lost their jobs during the lockdowns,” said Mahapatro. This naturally affected their ability to access healthcare, with huge nutritional implications for them as well as their women and children.”

“If the unmet needs of such large and deprived social groups are not catered to then equity in healthcare and the UN SDGs on health will remain a distant dream,” Mahapatro added.


Breaking Vicious Cycle of Trafficking for Sexual Exploitation

Rural women are often targeted by human traffickers and taken across borders in Africa and forced to become sex workers. Credit: Aimable Twahirwa/IPS

By Aimable Twahirwa
KIGALI, Apr 29 2022 – Desperate to escape the rural area where she was engaged in the informal economy in Kayonza, a district in Eastern Rwanda, Sharon* made a long and arduous journey to Kenya in the hope of a well-paid job.

An unidentified individual contacted her, paid for her ticket, and gave her a modest amount of pocket money to travel to Kenya by road. The person told the 19-year-old she was traveling to take up an “employment opportunity”.

However, Sharon found herself in sexual servitude at a karaoke bar on the outskirts of the Kenyan capital Nairobi.

Sharon’s job was to bow elegantly to all customers at the door and usher them inside the bar.

“I was also hired as a nightclub dancer and sometimes forced by my employer to engage in sexual intercourse with clients to earn a living,” the high school graduate told IPS in an interview.

Like Sharon, activists say the number of young women from rural areas trafficked into the sex trade across many East African countries is growing. The young women are lured with the promise of good jobs or marriage. Instead, they are sold into prostitution in cities such as Nairobi (Kenya) and Kampala (Uganda).

Both activists and lawmakers warn that people with hidden agendas could target young women from Rwanda.

The process of trafficking most of these young women into neighboring countries is complex. It involves false promises to their families and victims in which they are promised a “better life”, activists say.

In many cases, traffickers lure young women from rural villages to neighboring countries with the promise of well-paid work. Then, victims are transferred to people who become their enslavers – especially in dubious hotels and karaoke bars.

While Rwanda has tried to combat human trafficking, law enforcement agencies stress that the main challenge revolves around the financial and other assistance for repatriated victims. Limited budgets of the institutions in charge of investigation and rehabilitation of the victims have meant that these programmes are not working optimally.

The chairperson of the East African Legislative Assembly’s Committee on Regional Affairs and Conflict Resolution, Fatuma Ndangiza, warned that if no urgent measures are undertaken, the problem is likely to worsen.

“Most of these young women without employment were victims of a well-established human trafficking ring operating under the guise of employment agencies in the region,” Ndangiza told IPS.

The latest figures by Rwanda Investigation Bureau (RIB) indicate that 119 cases of human trafficking, illegal migration, and smuggling of migrants in the region were investigated in the last three years.

These involved 215 victims, among whom 165 were females and 59 males.

Driven by the demand for cheap labor and commercial sex, trafficking rings across the East African region capitalize primarily on economic and social vulnerabilities to exploit their victims, experts said.

But estimates by the UN International Organization for Migration (IOM)  show that the lack of relevant legislation and needed administrative institutions across the East African region have continued to give traffickers and smugglers an undue advantage to carry on their activities.

To prevent human trafficking, Rwanda has adopted several measures, including passing a new law in 2018.

Under the current legislation, offenders face up to 15 years of imprisonment, but activists say this measure is not enough deterrent.

Although law enforcement officers were trained in combatting human trafficking, Evariste Murwanashyaka, a  fervent defender of human rights who is based in Kigali, told  IPS that enforcing laws is a challenge, mainly because it is hard to detect women who are engaged in sex work or other forms of sexual exploitation in neighboring countries.

Murwanashyaka is the Program Manager of Rwandan based Umbrella of Human Rights Organization known as ‘Collectif des Ligues et Associations de Défense des Droits de l’Homme’ (CLADHO)

“Young women are still more likely to become targets of trafficking due to the growing demand for sexual slavery across the region, ” he said.

Now with the COVID-19 pandemic, activists say there is not only a lack of awareness but people, especially youth, who are unaware they are victims of a human trafficking offense.

“Most informal job offers from abroad for these young people [from Rwanda] are  associated with illicit businesses, such as human trafficking, mainly of women, and their sexual and labor exploitation,” Murwanashyaka told IPS

According to the Africa Centre for Strategic Studies, the increasing unemployment rates, malnourishment, and school closures have increased human trafficking.

Meanwhile, RIB spokesperson, Dr Thierry Murangira is convinced that human trafficking is a transnational organized crime.

“Transnational organized crimes require the involvement of more than one jurisdiction and regional cooperation to investigate and prosecute the crime,” he said.

This article is part of a series of features from across the globe on human trafficking. IPS coverage is supported by the Airways Aviation Group.
The Global Sustainability Network ( GSN ) is pursuing the United Nations Sustainable Development Goal number 8 with a special emphasis on Goal 8.7, which “takes immediate and effective measures to eradicate forced labor, end modern slavery and human trafficking, and secure the prohibition and elimination of the worst forms of child labor, including recruitment and use of child soldiers, and by 2025 end child labor in all its forms”.
The origins of the GSN come from the endeavors of the Joint Declaration of Religious Leaders signed on 2 December 2014. Religious leaders of various faiths gathered to work together “to defend the dignity and freedom of the human being against the extreme forms of the globalization of indifference, such as exploitation, forced labor, prostitution, human trafficking”.

IPS UN Bureau Report


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