Op-ed: What India’s public health system needs to pass the COVID-19 acid test

The coronavirus pandemic has brought the efficiency of our health systems into sharp focus. As the numbers continue to rise and the spread to marginalised sections becomes reality, the training and preparedness of community health workers and local practitioners will be critical.

The situation has never been so fluid. The number of COVID-19 cases is constantly changing and as new data is collected, responses to the pandemic are evolving. It is still too early to comment on or analyse either the numbers or where this will all end. However, it is certainly a ripe time to look at India’s healthcare system as it reveals itself today in the face of the coronavirus emergency.

A TEDx talk by Bill Gates of 2015 is making the rounds on social media. In his talk, Gates describes how health systems need to gear up for future epidemics in an interconnected world. This would be an agile health system which works with military discipline and reaches out to even the most remote corners. The ongoing COVID-19 pandemic has brought into sharp focus the health systems around the world and our health system is no exception.

What is a health system or healthcare system? A health system or healthcare system includes the organisation, financing and provision of healthcare services to a population. This encompasses all the personnel, institutions and resources that are necessary to achieve the desired health outcomes for that population.

Supplementary to these are the policies, regulations and laws that enable and govern the functioning of different components of the system. All countries design and develop health systems that suit their context and available resources.

In India, the health system evolved from the Bhore Committee Report, 1946. The right to life is enshrined in the Constitution of India. It places an obligation on the Government to provide health care to its citizens. It places health in the State list of subjects with the onus on States, but the Centre also spends on health through centrally-funded schemes like the National Health Mission (NHM).

The local self-government institutions are also involved. We have a three-tier public health system for providing primary (first point of contact for the patient), secondary (provided by a specialist on referral from primary care provider) and tertiary (highly specialised medical care) care. The manifestations of this are the sub-centres, primary health centres, community health centres, first referral units, sub-district hospitals, district hospitals and medical colleges.

Private practitioners and hospitals are also a part of the health system and are said to provide 80 per cent outpatient and 60 per cent of inpatient care. This also includes private labs, pharmacies, diagnostic centres, blood banks, ambulance services, etc. Confounding policies, lack of regulation or overregulation and overlapping authorities have resulted in skewed distribution of healthcare facilities across and within the states, with a shift of focus from primary to tertiary and more. The rural-urban divide is never more pronounced than in healthcare availability, quality and costs. This provides the background for the analysis of India’s response to the pandemic.

The initial reported cases were those who had come back after visiting countries where the infection was already assuming epidemic proportions. Naturally, these cases were identified in metro/tier 1 cities wherein multi-speciality hospitals (both public and private) are located, well-supplied by advanced technology including testing facilities, critical care units, ventilators and trained personnel. Contact tracing led to identification of more cases which were still treated in these hospitals where isolation wards were created.

Even in a situation as this, there was significant concern over the lack of hazmat suits or Personal Protective Equipment (PPE) for medical and ancillary personnel dealing with such cases, number of critical care beds, number of ventilators, availability of pulmonologists and treatment modalities. These are genuine requirements that would prove critical in deciding the outcome of the pandemic.

As the number of cases increase, community transmission is an impending threat. If some experts are to be believed, it is no longer just a threat but a reality. This also includes geographical spread from Tier 1 cities to districts, blocks and villages. And herein lies the acid test of our healthcare system. As hundreds of migrant workers are in transit to return to their villages, the risk of spread of infection multiplies further.

The focus now, therefore, has to be definitely on preparing the foot-soldiers. Are the sub-centres, primary health centres and community health centres equipped to handle such cases? How well are the personnel deployed at these institutions trained to identify, diagnose, isolate and treat such cases?

Preparation at the grassroots

A discussion with a colleague who works with a local grassroot NGO in the villages of Beed district of Maharashtra is revealing. Traditional and mass media have created awareness about the pandemic here, but along with information, misconceptions also prevail. There are no trained personnel to dispel the misinformation. The local communities are resisting migrant workers who are coming back from different parts for fear of infection.

Severe summers, prevailing drought-like conditions and hence poor nutrition have been adversely affecting health. COVID-19 is an additional infection. So the NGO roped in willing local private practitioners to inform people and other NGO workers on the precautions to be taken when COVID-19 cases are suspected. Testing and treatment facilities require suspected cases to travel—a hazard in times of a lockdown.

Any system is only as strong as its weakest link and right now the primary healthcare system (in urban and rural areas) seems to be the most vulnerable. An epidemic of such proportions curtails the possibility of shifting resources including manpower to these centres. Telemedicine has its limitations in terms of outreach and providing treatment modalities. How ready are the foot-soldiers of our health system— the first point of contact between patients and institutional care?

Identifying and empowering the foot soldiers

The ASHA (Accredited Social Health Activist), anganwadi workers and ANM (Auxiliary Nurse Midwife) are the backbone of our health system. Their role in maternal and child health and promoting institutional deliveries is one among their many achievements. And in such a crisis, the independent allopathic and non-allopathic registered practitioners, the local family doctors for most rural and urban poor, could also be counted in the ranks.

Though they may not be able to provide advanced treatment support, their role in identification of cases, contact tracing, quarantine and isolation monitoring, and referrals would prove significant. Their preparedness would depend on their training about the infection and its identification, transmission, diagnostics and treatment support.

The preparedness and efficiency of these workers also depends on the availability of PPE they receive and how effectively they use it. Such training would also help them to design isolation units from the available facilities to ensure that patients/suspected cases need not travel.

Preparedness of ambulance services in cases of emergency is also important as it is estimated from preliminary data that about 5% of the patients may require critical support  And all this will have to be done while managing existing cases of non-communicable diseases like diabetes, hypertension, heart ailments, routine ante-natal care, accidents, among others.

The services provided by doctors, nurses, technicians and other hospital-based staff have received justifiable praise. But as the epidemic spreads, more tests are carried out and as cases increase, it will test the mettle of the community-level health workers and individual practitioners. WHO has already released its guidelines for health workers to be followed. Closer home, the Facilitator Guide–COVID-19 released by the Ministry of Health and Family Welfare is a step in the right direction.

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