Investing in frontline health staff is crucial

The administration of 1.91 billion Covid-19 vaccine doses (May 19) at an unprecedented pace is India’s story of celebration. This was possible due to the nation’s internationally benchmarked vaccine-manufacturing capability, a welloiled cold chain, well-trained human resources, a strong technology backbone (CoWIN), and the united efforts of the central and state governments. A deeper analysis of the successful delivery of vaccines throws up several positives, including the role of frontline teams, and ideas for building India’s public health care capacity, which was hobbled by chronic low investment for decades.

First, Accredited Social Health Activists (ASHA), the only activists in a public health care system, made a perceptible difference. An ASHA is a local person, who receives performance-based payments. Many ASHAs received capacity development training, enabling them to transition from community worker to basic community health worker. This journey is a success of the National Health System Resource Centre, in partnership with the states, and the National Rural Health Mission Framework for Implementation, which argued for strengthening the public system of delivery and providing human resources (HR) with flexible financing and decentralised management of services. The importance of robust HR in the public health system has to be recognised, while making further investments in the sector.

Second, frontline teams now have the ability to work with panchayats and community organisations such as self-help groups (SHGs). With 43% of the elected 3.1 million panchayat leaders being women and over 80 million women in SHGs, under the Deendayal Antyodaya Yojana National Rural Livelihood Mission, an all-women frontline leadership has emerged across the country. The ASHA, auxiliary nursing midwife and aaganwadi workers form a formidable team; this cohort, along with an adequate cold chain and good ground-level planning, can lead to high levels of coverage. The success of this integrated approach was also reflected in Mission Indradhanush for immunisation coverage. Institutionalising this partnership will ensure rich dividends.

Third, the National Health Mission and Mission Indradhanush made substantial investments in building a functional logistics and cold chain. Thanks to this and improved availability of electricity and physical infrastructure in rural areas, there is an effective delivery system in remote regions.

Fourth, the urban primary health care system does not match the rural one in most states. So, it is good that the Pradhan Mantri Atmanirbhar Swasth Bharat Yojana focuses on urban primary health care. There is a need for investment in human resources to provide extension services. An equally active urban local leadership at the basti- and wardlevel is required to make more effective frontline connections with households in urban areas.

Fifth, India’s production capacity in vaccine manufacturing and State support for research and product development have made innovation possible quickly. The expansion of laboratories and research helped India develop a range of vaccines with global demand. In addition, repurposing production lines made ramping up production faster without losing out on basic standards.

Sixth, ramping up testing facilities and the CoWIN platform and ease of getting vaccinated made the difference. This was possible due to meticulous planning and identifying weak areas for supplementation. This proves that when a whole of government, whole of society approach is adopted, gains are made faster. Everyone geared up for a common purpose, and this speaks volumes about the importance of a people’s movement. The private sector was also engaged, aligned with a public purpose, as outlined in the National Health Policy 2017.

Seventh, the use of technology such as drones for delivery, keeping the remote health worker motivated by recognising the efforts in challenging areas through a communication strategy all added to a spirit of public service. The Covid-19 experience showed that while the private sector can supplement, public health is essentially a public-funded sector. It needs a proactive State to build public health capacity with equally solid and well-equipped critical care systems.

Given the information asymmetry, a functional system of public health care has great relevance as a countervailing presence for the private sector’s cost and quality of care. Therefore, we need to invest in crafting credible public systems in partnership with states, focusing on HR for health. A system of upgrading, multi-skilling, reskilling and upskilling frontline health workers to meet the challenges of changing public health needs is our best guarantee for the safe health of citizens.

Ninth, the thrust of the finance commission recommendations on decentralised management of primary health care augurs well for a people’s-health-in-people’s-hands approach. Technology is a great enabler to connect communities and households to health facilities. But technology is not an end in itself, and the focus must be on the lastmile community connect and facilitation with adequate handholding and community oversight. The panchayats must work together across the 29 sectors assigned to them; the same holds for the urban local bodies in the 18 sectors assigned to them. We need to make the local government a gram panchayat-led convergence across the identified sectors. Then, the results will be remarkable.