The response to Covid-19 provides us an opportunity for meaningful health reform; India needs to be in the driver’s seat to make low-cost, client-centred medical and health innovations.
Covid-19 has led to an unprecedented global crisis exposing the new nature of health threats and emergencies, linked to food systems, human-wildlife and anthropogenic conflicts and the dynamics of globalisation. To counter this health emergency, an unrivalled response has been initiated by all governments, the scientific community and citizen groups, fighting a virus unknown to mankind. On March 25th, despite fewer notified cases compared to other countries, India initiated a 21-day national lockdown, adopting social distancing and citizen isolation, state border closures and a call to action for low-cost innovations to support the government through this crisis. There is widespread recognition that given the demographic character and socioeconomic vulnerabilities of India’s populations, such as the large informal workforce, the spread of Covid 19 and the subsequent lockdown will lead to profound impacts in scale.
While India’s health system attempts to ramp up for what seems like a long battle ahead, it is evident that this is a wake-up call and a case to invest in health systems like never before. India’s investments in the health sector have historically been low, at no time over 1.3% of its GDP. Compare this to 5% in China, 8.1% in South Korea, 10.9% in Japan. Despite instituting one of the earliest architectures of a rural primary care system, the Indian public health system is struggling to comprehend the challenges which Covid 19 will bring with it. In 2005, the National Rural Health Mission (NRHM) now known as National Health Mission (NHM) attempted at strengthening primary, secondary and tertiary health services, however, these initial gains were not followed through with robust investments in health infrastructure, workforce, supply chains, and community models for delivering care. While the Prime Minister’s ambitious ‘Ayushman Bharat Scheme’ has led to risk pooling and greater health access for poorer households, an already overstretched public health system along with underregulated private health providers leaves the question of quality assurance unanswered.
The response to Covid-19 provides us an opportunity for meaningful health reform; India needs to be in the driver’s seat to make low cost, client centred medical and health innovations. Central and state governments supported by the civil society are currently engaged in rapid responsive measures and several initiatives from the private sector coming in each day are reaffirming collective action. The economic package offered by the finance ministry also sets the tone for these steps, rallying behind our medical workforce that is at the battleground. Envisaging a much stronger health system which could sustain shocks of pandemics such as COVID 19, we should consider a four-pronged approach.
Firstly, we need to invest in human resources for health now and in the future. Recent estimates indicate current total human resource density at 29 per 10,000 with wide state variation. It is crucial for India to aim reaching the WHO norms (as of 2016) for health workforce density of 44 health workers per 10,000 population. While India increases this number it needs to also look at enhancing quality through upskilling. By emergency response training, competencies such as testing, referral, quarantining, using medical equipment (e.g. ventilators and other lifesaving equipment) will develop. The fight against Covid 19 cannot be won without active involvement of the private sector and other health care providers who could play an important role in identifying potential cases and ensuring quarantines. A re-think is also necessary on the roles and responsibilities of the front-line health workers such as ASHA, ANMs and multi-purpose workers matched with the skills they have.
Secondly, as populations are under lockdown and mobility is limited, the role community health centres and district hospitals will be key. State and district administration will need support from local community bodies, panchayats, urban local bodies, and citizen groups to ensure that cases are isolated early and supply chains for drugs and essential equipment are functioning optimally. A communication plan to spread the right messages will be important. District hospitals need appropriately trained staff and medical equipment to ensure cases can be managed effectively at the facility and mortality is minimized. This is an opportunity for the effective use of tele-medicine which can deal with complicated cases, especially in hard to reach areas. We should be careful of not concentrating services in some cities alone.
Thirdly, government to encourage low cost innovations in medical technology to meet the needs of essential equipment both to respond to the epidemic now and in order to develop the capacity for the next flu season. Identifying and easing the regulatory frameworks for developing new medical products can help enable rapid response. Regulating prices of essential drugs, low cost mass development of masks and protective gear, will ease the burden on the system. In the medium to long run, India needs to further strengthen its bio-medical research capabilities, invest in cutting edge- ‘made in India’ health technologies and make it easier for health technology start-ups to function with tax cuts. Scientific innovations hold the key to solving social crises; these need our attention through vision and sustained financial investments.
Finally, a taskforce to understand impacts of Covid 19 on the health system and on households is required. Covid 19 presents an opportunity for expanding the coverage of the Ayushman Bharat Scheme, including considering a universalised health insurance model. Social distancing in the Indian setting has been an experiment so far and may lead to new challenges of anxiety and mental health, both for the healthy and the sick. The costs of this pandemic are being borne by other health and nutrition programs as services and attention are both diverted. We require state level task forces that represent not just administrators and doctors but engage wider civil society to address some of these long-term effects.
Covid 19 has brought the focus back on India’s public health care. It represents an opportunity to bolster India’s health system, sustained investment in technology and reorienting budgeting priorities towards what is truly essential – our own health. As our medical workforce fights this invisible enemy, India owes them a robust health system that can facilitate all their efforts.
Madhavi Misra and Nandita Bhan have extensive experience of working in the Indian Public Health system. Views are personal.
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Madhavi Misra is a public health implementer and researcher with over a decade of experience working closely with the India Public Health System.
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Nandita Bhan is a public health researcher working on issues of equity gender and social context in health access and health systems.
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