PHM-Exch> Ten lessons from theCovid-19 pandemic for India’s health system -Abhay Shukla

[Claudio Schuftan]

*Ten lessons from the Covid-19 pandemic for India’s health system*

*We must start by recognising the centrality of public health services and
initiating a system upgrade.*

It is said that good decisions come from experience, although experience
often comes from bad decisions. While we debate official decisions taken
during the novel coronavirus epidemic in India, *we need to use the
experience generated in this process as a source of learning, both for the
present and the future*.

In a two-part series, I focus on the health system aspects of this
epidemic, which has produced the most devastating public health emergency
in the last century of human history. I distill ten key lessons which might
make us somewhat wiser, at least in hindsight. Here are the first five.


*1. Public health services, the lifeline of societies, need an upgrade.*

*Public health services, politically neglected for decades *in most Indian
states, *have proven their irreplaceable value during this crisis. Although
despised by the rich and middle classes, they are shouldering the lion’s
share of not just preventive and outreach services but also clinical care.*
Nearly 80%-90% of critical Covid-19 cases are currently being treated by
public health services.

*States with robust public health systems* like Kerala *have been far more
successful* in containing Covid-19, compared to richer states like
Maharashtra and Gujarat, which have under-staffed public health systems.

Given this background, *now is the time to reinvent and rejuvenate public
health services across the country, for which health budgets must be
substantially upgraded.* India’s measly public health expenditure – at
1.15% of its gross domestic product – must take a quantum leap and be more
than doubled to reach the goal of 2.5% set by the National Health Policy
2017, while being further increased to 3%-4% of the GDP in medium term.

For large states like Uttar Pradesh, Bihar, Maharashtra and Gujarat, per
capita spending on health is well below national average of Rs 1,765
annually – under Rs 5 per day. All states should upscale their health
budgets to reach Rs 3,800 per capita, at 2019 prices – the level attained
by Himachal Pradesh and surpassed by smaller states like Goa, Mizoram and
Sikkim. This is possible if state governments spend at least 8% of their
total budget on health and the Union government share is hiked, bringing
this to 50% of total public health spending.

Further, *we need to critically re-examine* Niti Aayog’s *recent proposal
to privatise large district hospitals. Imagine if hundreds of district
hospitals across the country had been managed by a large number of
disconnected, profit-oriented private medical colleges during the epidemic.
Rapid response and district-level coordination would have ended in chaos.
While planning for public health systems expansion and rejuvenation,
proposals for handing over public health assets to private players should
now be permanently shelved.*

*2. Primary healthcare must be given primary importance within health
services.*

*Wherever the Covid-19 epidemic has been well contained*, as in Kerala, *it
has been primarily due to action at the primary health care level.* All
public health activities required for epidemic control – including testing,
early detection of cases and various preventive measures – are being
carried out by PHC-level staff, despite often being overburdened due to
inadequate staffing in many states.

In this context, we see that the proportion of the Union health budget
allocated for the National Health Mission, which is focussed on supporting
primary and secondary health care, was reduced to 49% in 2020-’21 from 56%
in 2018-’19, while the share for health insurance schemes, focussed on
higher level hospitalisation care, has more than doubled to 9% from 4% in
the same period. *The declining trend for support to PHC must be reversed
and at least 70% of all health budgets must be earmarked for this less
glamorous but vitally important frontline level of care.*

*3. Outreach-based strategies are core to epidemic control, while
generalised lockdowns come at high costs.*

*Most known models of effective control of Covid-19 *– South Korea, Kerala,
Bhilwara, Sangli and others – *are based on rigorous implementation of
intensive outreach-based public health measures. These are centred on
extensive testing and case identification, isolation and treatment of
cases, meticulous contact tracing, home quarantine of contacts, and
localised restrictions on movement in some cases.*

Although implementing these measures requires certain health system
preparedness, *there is no substitute for such outreach strategies. *

On the other hand, various modelling exercises and expert public health
analyses have argued that *generalised lockdown-type restrictions imposed
on the entire population are of relatively less value for containing
transmission, and definitely cannot supplant the set of outreach measures
mentioned above.* Now, despite huge social and economic costs being exacted
by widespread lockdown, the level of political and administrative emphasis
given to this generalised restrictive measure is much higher than the
attention given to implementing outreach measures.

Looking at the South Korean experience, where the epidemic was largely
contained through intensive testing and outreach measures without resorting
to general lockdown, it is worth speculating whether the Covid-19 outcome
in India might have been qualitatively different if the level of political
priority for lockdown versus outreach-based public measures had been
reversed.

*4. Frontline health workers are critical to protect and care for us.*

Daily news tells us that *the real heroines and heroes during Covid-19
response have been the frontline health workers* – including nurses and
doctor, auxiliary nurse midwifes, accredited social health activists, field
and hospital health staff. *Working at considerable personal risk*, often
without adequate personal protection, toiling long hours daily, sometimes
even subjected to violence, these lakhs of unnamed stars are protecting all
of us.

At least in keeping with enlightened self-interest, *what we need to ensure
is that health workers are provided with the minimum basic requirements to
fulfil their duties effectively, now as well as after the epidemic*. This
requires large-scale regular appointments to ensure that huge understaffing
is eliminated and workload of existing staff is rationalised.

In Maharashtra alone, there are estimated over 17,000 vacancies in public
health and 11,000 vacancies in medical education, where long-overdue
recruitments are expected now. Linked with this, *large numbers of
contractual health staff working without job security need to be urgently
regularised*.

An estimated 275,000 contractual staff work and around nine lakh ASHAs work
at various levels as part of the National Health Mission alone, often
receiving less than one-third the salary of permanent health staff
performing similar tasks. Major shortages of personal protective equipment
for frontline health staff during the epidemic highlight the need to *ensure
proper working conditions for all health workers, including living quarters
and transport in rural areas. Much more than occasional clapping and thali
beating, it is imperative to ensure that those who protect our health and
lives can themselves live and work with dignity.*

*5. Wealthy cities may not be healthy cities, unless urban health systems
are created.*

The coronavirus epidemic is highly urban focussed – half of the confirmed
Covid-19 cases have been reported from 15 predominantly urban districts of
India, including Delhi and Mumbai. *This epidemic has exposed the
vulnerable underbelly of India’s glittering metropolises, where major gaps
exist in urban health services and urban planning. Many large urban
conglomerations lack comprehensive public health services, especially in
suburbs and newly-developed areas.*

The National Urban Health Mission launched in 2013 seems stuck in a policy
traffic jam – even in the current year, its allocated budget was just Rs
950 crores, barely 1.4% of the Union health budget, amounting to just Rs 2
per urban person per month.

*Municipal corporation funds for health are often focussed on existing
hospitals, leaving little scope for expansion of services to newer areas or
strengthening primary health care. The status of basic urban services –
housing, water supply, sanitation and environmental management – is even
worse, especially in slums* which house at least 30% of urban India.

*Hence, the urgent need to launch a massive programme for revamping of
urban health services focussed on primary healthcare, along with major
upgradation of urban living conditions, especially in “non-notified” slums
which must be recognised as integral to the city. Our cities cannot be
considered “developed” without developing their health-related systems.*
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Lessons from a pandemic: How India can reform its private healthcare sector

The novel coronavirus pandemic is the most devastating public health
emergency in the last century of human history. It is making countries
around the world take a hard look at their health systems.

In India, instead of just planning a “return to normal” once we are past
the immediate crisis, *it is time to begin a society-wide debate about the
need for a paradigm shift in our health system.*

In a two-part series, I have attempted to distill ten key lessons for
India’s health system. The first part focussed on why it is imperative to
recognise the importance of public health services and the need to upgrade
them. This part looks at what lessons can be drawn from the epidemic for
better engagement of the public and private sectors.

*6. Tertiary healthcare schemes must not be given primary importance.*

The much-projected Pradhan Mantri Jan Arogya Yojana under Ayushman Bharat
was supposed to be a game changer: it allows patients to access private
hospitals using a government insurance scheme.

However, one month after National Health Authority offered free Covid-19
testing and treatment in private hospitals under this scheme, only 300-odd
patients had used this insurance scheme for Covid-19 treatment. This is a
miniscule number, considering that around 10%-15% of Covid-19 cases –
around 9,000 to 13,000 patients – might have required hospitalisation until
now.

*While accepting that private hospitals have a role to play in caring for
severely ill Covid-19 patients, the health insurance scheme mode of
engaging private providers appears inadequate. *No wonder several state
governments have decided to requisition private hospitals to supplement
public health facilities, as a more dependable arrangement.

It is also notable how *certain “medical superstars” from prominent
corporate hospitals, who regularly speak on TV programmes championing such
schemes, have nothing substantial to offer during this unprecedented health
emergency.* If we compare the responses of public health services and
health insurance schemes in the current epidemic, we might agree that
actions speak louder than words, especially during a crisis.

*7. The market never regulates healthcare in public interest. States must
ensure this.*

*While the public health system has gone into overdrive to tackle Covid-19,
the response from private healthcare providers – responsible for 70% of
healthcare provisioning in India – has been muted.* There have been reports
of massive overcharging of Covid-19 patients, with rates charged in Mumbai
by certain private hospitals being up to Rs one lakh per day.

*Many private hospitals and clinics have shut down or have been refusing
suspected Covid-19 patients. This has highlighted once again that
unregulated markets invariably fail in case of healthcare, being unable to
allocate this essential service rationally or equitably.*

In light of frequent overcharging, it is notable that the Maharashtra
government issued an order requiring all private hospitals in the state to
cap rates for over 170 medical procedures, based on the charges agreed upon
with insurance companies.

Regulation of private hospitals, on the backburner in the state for six
years, is now back on the agenda. *As we move past the epidemic, it is
important that comprehensive regulatory measures, resisted by influential
private sector lobbies until now, be systematised and legally
institutionalised *through implementation of appropriate Clinical
Establishments Acts.

*Concerns over overcharging, problematic quality of care, and unnecessary
procedures by unregulated private hospitals require long term solutions.*
The Covid-19 crisis can open opportunities for change.

*8. Private healthcare providers must fulfill public health obligations,
now and in future.*


*For decades, governments encouraged private healthcare to run as a
lucrative “industry” led by profit-maximising corporate hospitals. During
the epidemic, it became obvious that commercial private players cannot be
left to their whims as they need to fulfil important public health
obligations. However, there is hardly any legal framework to ensure that
these obligations are routinely ensured.*

For example, the Maharashtra government has invoked the archaic Epidemic
Diseases Act 1897, among other laws, to ensure that private doctors
mandatorily treat Covid-19 patients. State governments in Rajasthan, Madhya
Pradesh and Chhattisgarh have taken over private hospitals for Covid-19
care. While requisitioning private hospital beds for Covid-19 care in
Maharashtra, officials emphasised that “charitable” private hospitals
running on government-subsidised land have public obligations.

*Emergency measures, like requisitioning private hospitals highlight the
fact that private healthcare providers have public health obligations that
should override commercial considerations if required.* These include
notifying cases of communicable diseases, cooperating for implementing
public health measures, observing patients’ rights, and treating poor
patients free of charge in case of “charitable” private hospitals. Now is
an opportune time to discuss robust frameworks to ensure that these
obligations will be observed by private hospitals even in “peacetime”.

*9. Public health demands active public involvement. States and people must
work in synergy. *


Kerala’s Covid-19 control experience demonstrates that *outreach-based
public health strategies become effective due to proactive social
engagement.* Panchayat representatives, community volunteers and women’s
groups worked with public health staff to implement public health
activities. *Pending any vaccine or definitive treatment for Covid-19, the
main plank of epidemic control currently is various forms of modification
in social behaviour that can be ensured only with high-level social
awareness and people’s informed participation.*

*Hence, public health services need to develop platforms for health
system-community interface,* including active community members, panchayat
representatives and civil society groups, from village and primary health
centres to district and state levels.

*These participatory bodies, relevant during and beyond public health
emergencies, must foster “broad spectrum involvement” – not just
implementing official programmes, but also promoting awareness campaigns,
facilitating entitlements for vulnerable and excluded groups, monitoring
delivery of services towards addressing service gaps, and providing inputs
for local health planning.* Frameworks such as community-based monitoring
and planning in Maharashtra, and social audit-based models in several
states need to be generalised as core components of public health
initiatives, since *health programmes initiated from above are most
effective when working in tandem with social mobilisation from below.*

*10. Illness can attack anyone. We need Right to Healthcare to protect
everyone.*


The Covid-19 epidemic is concentrated in cities and has affected the middle
class. Therefore, “public opinion” – often another name for middle class
opinion – is currently focussed on health concerns. With the critical role
of public health services highlighted and “ailments” of commercialised
private healthcare further exposed, *this epidemic might change the way
society views healthcare. Since Covid-19 affects everyone, it holds
potential for building social solidarity around health concerns,
traditionally weak* in most of India.

*This setting is appropriate for taking forward Right to Healthcare, which
by definition must be universal. Legal provisions for ensuring this would
primarily involve revolve around state governments, while national
frameworks must be supportive. Health system transformations required to
support the Right to Healthcare would involve developing Universal Health
Care systems in various states – based on expanded public health services,
massive increase in public health spending, and regulated involvement of
private providers – organised to provide free, quality healthcare for
everyone.*

Assuming action upon the lessons outlined in this two-part series, there is
no reason why the Right to Healthcare and Universal Health Care cannot be
achieved in most states across India in the next five years. *This can
become reality, provided political will is generated within governments
from above, and is mobilised among wide sections of people from below.*

*It may soon be an opportune time to launch a massive and sustained social
movement, demanding sweeping health system reforms and health rights for
all. This should involve diverse sections of society*, which together
constitute the silent majority – working people in rural and urban areas,
socially oppressed sections of the population, groups among the middle
class, health workers and professionals – *who all have a stake in
transforming the health sector.*

These 10 lessons could be signposts while developing the movement for a new
kind of health system in India, which ensures universal health care based
on health rights for all. *We owe it to ourselves, and to coming
generations of Indians, to draw lessons from this once-in-a-century
pandemic, and do our best to act upon hard earned lessons. We may not
experience such a turning point again in our lifetimes.*
------------------------------

*This two-part article published in Scroll is by Dr Abhay Shukla, a public
health professional and national co-convenor of Jan Swasthya Abhiyan
(People’s Health Movement, India). The author would like to acknowledge the
contribution of Ravi Duggal.*

https://scroll.in/article/962794/what-lessons-does-the-covid-19-pandemic-hold-for-indias-health-system

https://scroll.in/article/962793/lessons-from-a-pandemic-how-india-can-reform-its-private-healthcare-sector
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