Covid-19 should lead to more investment in health

Invest in human resources and technology; strengthen district hospitals; and consider universal health insurance

The coronavirus pandemic (Covid-19) has exposed 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 emergency, an unrivalled response has been initiated by all governments, the scientific community and citizen groups.

On March 25, 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.

While the health care system attempts to ramp up for what seems like a long battle ahead, this is a wake-up call and a chance to invest in health care 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 rural primary care, the Indian public health system is struggling to comprehend the challenges that Covid-19 has brought with it.

In 2005, the National Rural Health Mission (NRHM), now known as National Health Mission (NHM), attempted to strengthen the primary, secondary and tertiary health services. But this was not followed through with robust investments in health infrastructure, workforce, supply chains, and community models for delivering care. While the Prime Minister’s Ayushman Bharat Yojna (PMJAY) has led to riskpooling and greater health access for poorer households, the issue of quality assurance needs more attention in the future.

The response to Covid-19 provides an opportunity for meaningful health reform. India needs to make low-cost, client-centred medical and health innovations. A fourpronged approach may help.

First, we need to invest in human resources for health, now and in the future. India must strive to meet the World Health Organization norms (2016) for health workforce density: 44 health workers per 10,000 people. Recent estimates indicate that current total human resource density is at 29 per 10,000, with wide variations among states. While India increases this number, it needs to also look at enhancing quality through upskilling. Through emergency response training, competencies such as testing, referral, quarantining and using medical equipment can be developed. The fight against Covid-19 cannot be won without the active involvement of the private sector and other health care providers who can play an important role in identifying potential cases and ensuring early quarantines. We need to rethink the roles and responsibilities of frontline health workers such as Accredited Social Health Activists, Auxiliary Nurse Midwives and multi-purpose workers, taking into account the skills they have.

Second, with citizens under lockdown and their mobility restricted, the role of 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 that cases are managed effectively at the facility and mortality is minimised. Effective use of telemedicine can deal with complicated cases, especially in inaccessible areas. We should be careful to not concentrate services in some cities alone.

Third, the government must make all efforts to encourage low-cost innovations in medical technology to meet the needs of essential equipment, both to respond to the pandemic now and to develop the capacity for the next flu season. Identifying and easing the regulatory frameworks for developing new medical products can help enable rapid responses. Regulating the prices of essential drugs, low-cost mass production of masks and protective gear, will ease the burden. In the medium-to-long-term, India needs to further strengthen its biomedical research capabilities, and invest in cuttingedge “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.

Finally, a task force to understand the impact of Covid-19 on the health system and households is required. The pandemic presents an opportunity to expand the coverage of the PMJAY, including considering a universalised health insurance model. Social distancing may lead to new challenges of anxiety and mental health all round. The costs of this pandemic could also be borne by other health and nutrition programmes as services and attention are likely to get diverted. We require state-level task forces that represent not just administrators and doctors but that engage wider civil society to address some of these longterm effects.

Covid-19 presents an opportunity to bolster India’s health system, sustain investment in technology and reorient budgeting priorities towards what is truly essential — our health. As our medical workforce fights this invisible enemy, India owes them a robust health system that can facilitate all their efforts.

WE REQUIRE STATE-LEVEL

TASK FORCES THAT REPRESENT NOT JUST ADMINISTRATORS AND DOCTORS BUT THAT ENGAGE WIDER CIVIL SOCIETY TO ADDRESS SOME OF LONGTERM EFFECTS OF COVID-19

Madhavi Misra and Nandita Bhan have extensive experience of working in the public health system The views expressed are personal