Updated: March 23, 2020 9:55:19 am
The global pandemic of COVID-19 virus, initially labelled the “novel coronavirus”, has forced most of the world into a lockdown, with sweeping spread, mounting mortality and eviscerated economies. While national responses have varied, there are key messages that India must heed as it shapes and strengthens her own response. This is not new wisdom but past prescriptions that were not implemented.
For any outbreak investigation and epidemic containment, we need well-trained human resources at the primary care frontline. The health sub-centres and primary health centres, both rural and urban, must have staff who are not only trained for clinical care but also for early detection, outbreak investigation, counselling, basic tests, triage and referral, community health education and participation, citizen engagement and mobilisation for collective inter-sectoral action. At higher levels, we need epidemiologists, microbiologists, social scientists, statistical modellers and public health management experts to identify the origins, spread, projected course, health system needs and capacity in a dynamic adaptive response to an evolving epidemic. Such multi-disciplinary capacity is needed not only for infectious diseases but also for other public health challenges, be they non-communicable diseases like cardiovascular illnesses or childhood malnutrition.
The recommendation to strengthen primary health services has been around for long. The setting up of public health cadres was recommended by the High Level Expert Group (HLEG) on Universal Health Coverage in its 2011 report to the Planning Commission. The National Health Policy also calls for public health management cadres to be established. Only Tamil Nadu and Odisha have such defined cadres now.
The fear of viral pneumonitis needing intensive critical care and ventilatory support calls for more tertiary care facilities. The fact that 80-85 per cent of the patients will have milder forms of the illness, requiring home or hospital quarantine and less intensive supportive care, is ignored. Most patients will need to be treated, counselled and monitored in the primary and secondary care chain, ranging from the sub-centre to the district hospital, depending on the severity of the ailment. Even district hospitals should be equipped to provide critical care. The health workforce, too, needs to be substantially expanded, at all levels of care, to meet India’s needs, as the HLEG emphasised.
The Gorakhpur encephalitis tragedy taught us that we should not depend only on a medical college to cater to the sick, but must strengthen district and primary care facilities. The HLEG also emphasised this need and the National Health Policy reiterates it. We should not lose sight of this in the clamour for more intensive care beds in urban tertiary care facilities. Our referral chains, for directional flow between primary and advanced care, must be systematically strengthened. That cannot happen with a weak public sector.
Evidence suggests that countries with Universal Health Coverage (UHC) respond with efficiency and equity to health emergencies. The standout examples of a coherent and efficient response to the corona pandemic have been South Korea and Singapore. South Korea restricted COVID-19 mortality to less than 1 per cent. The United States, in contrast, is fumbling in deciding how to test and treat and at what cost, in its chaotic health insurance system. There is no doubt that countries which have adopted UHC and have a strong public sector component in healthcare delivery can provide an early, effective and organised response to any health emergency.
The HLEG advocated a strong public sector-led UHC, with contracted private sector engagement as per need and availability. A weak public sector and excessive dependence on the private sector can derail timely, effective and equitable responses in a national health emergency. Recent trends which place a premium on private sector leadership for India’s evolving UHC architecture must be reviewed in the context of COVID-19, by revisiting the private, tertiary care dependant models that are being considered for long term delivery of UHC. The World Health Organisation also calls for a primary health care-led UHC. This demands a strong public sector.
The HLEG had also recommended an increase in the domestic capacity for producing active pharmaceutical Ingredients (APIs), which are basic chemicals for manufacturing medicines, and also for producing more quality assured generic drugs and essential vaccines. Apart from incentivising the domestic private sector capacity, it also called for public sector capacity to be revived and boosted. The recommendation to revive the public sector in pharmaceuticals was criticised by some economists as return to socialist dogma.
The corona crisis shut down the API supply chain from China, which meets over 60 per cent of India’s needs. This is a signal to rev up the country’s domestic manufacturing capacity. Apart from APIs, we also need the public sector for using the compulsory licence route to produce life-saving but patent-restricted drugs, if the need arises. The need to protect and promote domestic pharmaceutical security goes beyond COVID-19.
It seems the planet, exasperated by our collective failure to act decisively to slow down climate change, has decided to release the coronavirus to shut down travel and transport globally to reduce emissions and pollution. Even if that thought appears to be a flight of dramatic speculation, there is little doubt that zoonotic viruses are now prancing around with greater frequency and gay abandon, because humans have set up conveyor belts for their easy travel – from wildlife to captive-bred veterinary populations and then on, to human habitat. We need to review our production and consumption patterns – in agriculture, food, mining, urbanisation, transport of persons and commodities – and see how we can break this chain, from stopping deforestation to shifting to mostly plant-based diets.
This article first appeared in the print edition on March 23, 2020 under the title “New crisis, old lessons.” The writer is president, Public Health Foundation of India. Views are personal
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