When the dust settles on Covid-19, we must move on with the everlasting appreciation that health is much more than a ‘social sector’. When the pandemic came around, Taiwan, Singapore and South Korea seemed better prepared than others. Closer home, the “Kerala model” has been widely acknowledged. The common thread linking all of them is a consistent investment in healthcare and systemic changes based on lessons learned from SARS, H1N1 and Nipah. Hence, once this crisis is over, India must use the opportunity to learn and focus on five key health system reforms.
First, India’s public financing for health remains at less than 1 per cent of the gross domestic product (GDP). While the Centre is committed to raising this figure to 2.5 per cent by 2025, States, too, need to ramp up healthcare spending to at least 8 per cent of their budgets. Moreover, within the investments we make, public and primary health must get greater priority. Prevention is our best bet. Once diseases begin to spread, any number of hospitals and doctors seem inadequate. The US, the latest epicentre of Covid-19, is a case in point. In 2019, the country’s healthcare spending was equivalent to 17.8 per cent of its GDP. Still, health outcomes in the US are far from the best; perhaps due to the predominance of private insurance and hospitalisation.
The neglect of public health in India goes back to 1943, when medical and public health services were amalgamated upon the recommendation of the Bhore Committee. Disease-specific programmes for targeting high-priority conditions were introduced but they diverted attention from public health. In recent years, programmes such as the Poshan Abhiyaan and the Swachh Bharat Mission have been launched. However, more is needed for comprehensively addressing the social and environmental determinants of health. For instance, while we have scaled up access to toilets considerably, we now need to focus on ensuring the availability of running water and soap for hand-washing across the country.
To bring public health to the centre-stage, we must designate a focal point within the Union Health Ministry (with State-level equivalents) for leading and coordinating disease surveillance, informing citizens as well as enforcing public health regulations. Further, dedicated public health cadres in States should be prioritised. Clinicians are important, no doubt; but we also require epidemiologists, microbiologists, bio-statisticians and health economists.
Primary benefits
Second, we must focus on operationalising the network of Health and Wellness Centres (HWCs) envisaged under the Ayushman Bharat programme. Catering to clusters of about 5,000 people each, these centres can perform a key role in the prevention and early detection of diseases. It was Nigeria’s primary health system that allowed early identification of the signs and symptoms of Ebola. HWC teams consisting of mid-level providers and frontline health workers can also promote good hygiene habits, like hand-washing, in communities on a regular basis.
Third, disease surveillance and response at the urban ward/rural block-level need to be strengthened to detect outbreaks at an early stage and initiate a coordinated response. The list of notifiable diseases should be expanded and we should prioritise measures to integrate private-sector health facilities in disease reporting as part of regular surveillance systems.
Reforms, a must
Fourth, investments in data and technology constitute an important part of the reform agenda. India must create institutions, perhaps at the regional/State level, for generating credible population-level data at frequent intervals to guide health system action. Technologies such as telemedicine should get a boost in the current and post-Covid environment. Once training protocols and monitoring mechanisms are in place, health professionals beyond medical doctors could also be engaged in conducting teleconsultations in a calibrated manner.
Fifth, health system reform will be incomplete without accelerated efforts for developing new vaccines, diagnostics and drugs. Multidisciplinary research units should be linked with each other for enabling data sharing. Disease-specific or thematic data repositories pertaining to biomedical research should also be developed.
Additionally, infrastructure for research, such as viral research and diagnostic laboratories, needs to be reinforced. Investments in research can pay rich dividends. For instance, Hong Kong, Japan and Singapore were able to develop their own tests for Covid-19 as soon as the genetic sequences for the virus were published.
India also needs to develop appropriate policies for sharing research data across national and international platforms. Tuberculosis — hitherto considered a poor man’s disease — has killed more people than all other pandemics, but has consistently lacked global investment. With diseases such as Covid-19 not sparing even heads of state, countries will have no choice but to protect themselves from future health threats through sustained, cross-border research partnerships.
Prasad is a public policy specialist and Shekhar is a young professional with NITI Aayog. Views are personal