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.
This is part one of two articles by Dr Abhay Shukla, a public health professional and national co-convenor of the Jan Swasthya Abhiyan. The author would like to acknowledge the contribution of Ravi Duggal.