Tanvi Choudhari, a 32-year-old architect living in Goa, has fears about how COVID-19 may affect her in the future. If not soon, at some point in the coming months, she believed that she or someone she knows would contract the infection. Her 56-year-old mother lives in Gujarat, where the outbreak has shown a high fatality rate. With respect to both states, Choudhari feared about where she or her mother would go if they were symptomatic. But her biggest concern was the financial strain of getting tested and treated at a private clinic. “I am a freelancer and I am worried that testing costs are too high,” she said. “Then comes the treatment costs. I hear other countries are doing this for free, and am wondering why India is not.”
The question was not unfounded. In India, the test, if done from outside a government facility, is prohibitively expensive, with the Indian government allowing the private sector to charge up to Rs 4,500 per test. According to guidelines issued by the Indian Council of Medical Research, this amount “may include Rs 1,500 as a screening test for suspect cases, and an additional Rs 3,000/- for confirmation test.” The guidelines do not disclose the actual cost of these tests that private clinics have to pay. While India imposes costs that restricts the capacity of citizens to get tested for COVID-19, its neighbours in the subcontinent have ensured that tests are available for free, or minimal costs, as ought to be a priority during a public-health crisis.
Choudhari also recognised that individuals who need to get tested might invariably need to undergo it thrice before they can be discharged. Dr Naman Shah, who works at a rural hospital in Chhattisgarh run by a public-health initiative called Jan Swasthya Sahyog, explained why this was the case. “The majority of tests around the world use a technology called reverse transcriptase polymerase chain reaction, or RT-PCR, which detects traces of the coronavirus in mucus samples,” Shah said. “The patient might need a second test because the initial test may not be accurate as the amount of viral material available in the mucus sample may be too little for the tests to detect the virus. Every subsequent test adds a little bit more information but there are significant costs attached to this. Many hospitals test a third time to check if the patient is negative, before discharge. This is, however, not needed.”
As a result, a patient might be compelled by a private hospital to undergo three tests . “The treatment cost will be over and above the testing cost,” Choudhari told me. “The testing rates of three rounds, at Rs 13,500 per person, is a big concern for me.”
This is in sharp contrast with India’s poorer neighbour, Bangladesh, where testing as well as treatment is free. “We do testing and treatment for free,” Meerjady Sabrina Flora, the director of Bangladesh’s Institute of Epidemiology, Disease Control and Research, in Dhaka, said. “It is very important to make sure that the poor citizens are able to get themselves tested. The only way that can be done is by making both testing and treatment available for free.”
Abul Kalam Azad, the chief of the Bangladesh government’s Directorate General of Health Services, confirmed that tests were free in the country. “Our government policy is that anyone who gets infected with COVID-19—rich or poor—is a government patient,” Azad said. “We will take care of them, for free. Our priority is to test everyone. To make sure that happens, we have provided PCR tests to private laboratories for free on the condition that they cannot charge the patients. We allow the private sector to conduct antibody test at a nominal charge but that is highly regulated. We demand all details from laboratories.”
In Sri Lanka, the COVID-19 testing policy is similar to that of India, insofar as tests at public clinics are free and private tests are regulated by a government-imposed price ceiling. The fixed cap on the cost for private tests, however, is almost half of that in India. “All COVID tests in public sector are 100 percent free to patients, and all testing so far is in public sector,” Ravindra Rannan-Eliya, the executive director of the Institute of Health Policy—an independent non-profit working on issues concerning Sri Lanka’s health and social policies—wrote to me in an emailed response. “Private laboratories are allowed to test, but there is a price ceiling imposed. It is around LKR 6,000”—which amounts to approximately Rs 2,400. “I understand that none have actually started doing this”—he said, referring to private laboratories— “and they all refer tests to public sector.”
As of 23 April, Sri Lanka had reported 330 confirmed cases and seven deaths. “The government has centralized all testing in around 40 key public hospitals which are part Sri Lanka’s well established public health system that provides free healthcare for most of the island’s 22 million people,” Nalaka Gunawardane, a science writer from the country, wrote in an emailed response. “Private healthcare is also available for those who are willing and able to pay for it,” he added. “Testing for COVID-19 is being done at no cost to individuals being tested. All those who test positive are mandatorily admitted to the National Institute of Infectious Diseases (IDH) which is part of public healthcare system and where treatment is free. Treatment for COVID-19 in private hospitals is not allowed at the moment.”
The cost of Rs 4,500 in India leaves a vast section of the population without access to care. According to Malini Aisola, a co-convenor of the All India Drug Action Network, a health-sector watchdog, making low cost COVID-19 tests available to all is “not just an achievable and necessary target, but the right thing to do.”
On 8 April, the Supreme Court allowed a public-interest litigation that challenged the ICMR’s price cap, and ordered that testing should be free at both government and private laboratories. But four days later, following an intervention application that asked the court to modify its order, the court stated that free testing would only be limited to beneficiaries of the central government’s flagship insurance programme, Ayushman Bharat. In the court proceedings, R Lakshminaryanan, an assistant director general at ICMR, submitted an affidavit stating that the court should not intervene in the policy decision taken by the central government. In stark contrast, in its guidelines announcing the price cap, the ICMR had stated, after listing the breakdown of the amount, that it “encourages free or subsidized testing in this hour of National public health emergency.”
According to an official release by the Press Information Bureau, as of 30 January 2020, there were a total of 79,86,811 hospitalisations under the Ayushman Bharat scheme, which is less than one percent of India’s population. The scheme’s official website claims that it covers approximately fifty crore beneficiaries. Evidently, restricting free private testing for beneficiaries of the Ayushman Bharat scheme excludes a vast majority of Indians. In the event that government facilities are unable to admit more patients, those not covered under the central insurance scheme will be compelled to either risk not getting medical help, or rely on and be forced to pay for private medical facilities. This is the worry that haunts many like Choudhari.
According to a 2019 industry estimate by India Brand Equity Foundation, a trust established by the ministry of commerce, the private sector accounts for 74 percent of the country’s expenditure on healthcare. In Lakshminarayanan’s affidavit before the Supreme Court, the ICMR stated that as of 9 April, government labs had conducted 87.28 percent of the COVID-19 tests, and only 12.72 percent—or 18,574 tests—were conducted by private clinics. According to a mathematical model released on 24 March by the Centre for Disease Dynamics, Economics and Policy—a Washington-based public-health research organisation—India would need an estimated one million ventilators when the infections peaked, at which point one hundred million Indians could be infected. Relying on that figure of one million hospitalisations, and taking a conservative estimate that 25 percent of them would opt for private testing, calculated at Rs 13,500 per individual before discharge, that would generate a business of Rs 337.5 crore for the private health sector.
In this context, it is important to note that the ICMR consulted the private sector before fixing the cap of Rs 4,500 for tests at private clinics. Kiran Mazumdar-Shaw, the chairperson and managing director of Biocon Limited—India’s leading biopharmaceutical company—who also advised the ICMR on pricing since COVID-19 broke out, has repeatedly defended the price cap on social media and in interviews to the press. Pertinently, she has also noted in a televised interview with CNBC-TV18 that she was “involved” in the consultations with the ICMR, and that “it was a very very strong public-private partnership, even in terms of the process.”
In another interview to Republic TV, as the anchor Arnab Goswami in his typically aggressive manner addressed Mazumdar-Shaw, “You headed the government-appointed committee constituted to work the modalities for private labs,” she nodded fervently and repeated multiple times, “Yes.” Mazumdar-Shaw has subsequently denied on Twitter that she was on any committee, insisting that she was only “coordinating private labs.” When I emailed Mazumdar-Shaw to ask about the conflicting statements, Seema Ahuja, the senior vice president of Biocon’s corporate communications team responded on her behalf, “What is the basis of this?” The email further noted that Mazumdar-Shaw “would not like to engage any further.”
Mazumdar-Shaw has also stated on Twitter that “there was complete transparency n fairness in arriving at pricing by Govt which Pvt labs accepted without negotiation.” Yet, even the ICMR affidavit before the Supreme Court offers little clarity on how the organisation arrived upon the amount. According to the affidavit, the ICMR consulted a national task force of leading scientists before determining the price cap. But as I reported earlier for The Caravan, members of the task force told me, on the condition of anonymity, that there was no such discussion before fixing the price cap. There is little information about this committee of private sector stakeholders, the number of times they met, the agenda, or the minutes of these meetings.
The ICMR’s affidavit claimed that the amount was “based upon the price of specialized kits which are required for conducting the tests and keeping the basic price of components like swab, disposal tongue depressor, viral RNA extraction kit, primer probes, enzyme+PCR, buffer + NF water, PCR tube, PPE etc into consideration.” According to the affidavit, this effectively amounts to Rs 1,500 for screening and Rs 3,000 for confirmative tests, if necessary.” Mazumdar-Shaw, meanwhile, has tweeted a different breakdown of the costs: “Cost of kit incl viral extraction kit ₹1600 plus PPE n lab consumables ₹1400 Cold Chain Logistics for sample collection plus technicians ₹1500.”
Yet, at the state level, states have kept price caps lower than the ICMR rates. The Karnataka government has compelled the private sector to ensure cheaper access to healthcare. On 17 April, the state government noted that it had fixed the price cap at Rs 2,250, half the amount determined by the ICMR. In a statement issued soon after the Karnataka government’s decision, AIDAN demanded that the centre ensure the burden of purchasing care does not fall on families, stating that “not only is it the government’s duty to provide free testing but this is also a critical tool for containing the outbreak.” AIDAN noted, “Karnataka’s decision to set a reimbursement rate to private labs for testing of government samples at Rs. 2250 shows that the ICMR cap is significantly inflated. We were shocked by the u-turn taken by ICMR in its affidavit to the Supreme Court because it has earlier appealed that tests should be done for free.”
The AIDAN statement continued, “While ICMR put forth an argument for prudent use of resources in Court, our worry is that the Government is doing precisely the opposite by not acknowledging true costs of testing and promoting inflated figures that favour private path labs. Independent experts confirm that tests cost a fraction of the price being permitted. We urge the Centre to reconsider its stand and to make COVID-19 testing free at the point of service. Reimbursement rates should based on rational assessment of costs and must take into account commercial test kits entering the market at disruptive prices as low as Rs. 500.”
Mazumdar-Shaw has also been vocal on Twitter dismissing any possibility of cheaper alternatives to what was fixed by the ICMR. Responding to another question about her statements on the cost of testing, Ahuja wrote to me, “Again what is the basis of this statement?” On 16 April, responding to a user who asked why citizens should be charged Rs 4,500—nine times the cost of Rs 500 per test, Mazumdar-Shaw tweeted, “Pls show me a pcr test that costs ₹500. You r lying thru your teeth.”
In fact, as AIDAN had noted, a Chennai-based medical technology company Trivitron Healthcare has developed a RC-PCR kit that costs Rs 500. GSK Velu, the founder, chairperson and managing director of Trivitron, told me that the advantage of mass production was that it made it possible to produce cheaper testing kits. His competitors have noted that the tests cannot be done at less than Rs 4500 without incurring losses. “Everyone is entitled to their thinking,” Velu told me. “But we think affordability is key, when one has to pay from their pockets. Government and private institutions should think alike at a time of crisis.”
Velu pointed out that his company, too, would incur a loss due to the low cost of the testing kit. “It is true our conventional business revenues are down to 10–20 percent of original revenues, but that is true for all other industries too,” he said. “Everyone should contribute a bit rather than expecting government to pay for everything. This is my individual opinion and do not want to thrust this opinion on everyone. These are extraordinary times and we should have out of box thinking for practical solutions to help our country. We consider this our corporate social responsibility, and are pricing our COVID test kits for as low prices as possible to help scaling of testing in India in a small way.”
Velu told me that Trivitron’s testing kit has been validated by the Indian government and is likely to enter the markets by 3 May. India, which is widely known within the global medical community as the pharmacy of the world for its ability to produce low-cost medical supplies, risks leaving its citizens without affordable treatment while the pandemic surges. By fixing the price cap of Rs 4,500 and insisting on it before the Supreme Court, the Indian government has abdicated its responsibility to provide affordable access to testing. The decision not only undermines an individual’s right to health, but also public health at large, which will remain at risk unless testing is made free at the point of care.