The Covid-19 pandemic has highlighted the gaps in healthcare systems across the globe. Countries worldwide have experienced challenges like lack of medical supplies, inequity in health services, and ill-equipped infrastructure to treat a rising surge of patients. These challenges have resulted in high mortality and morbidity over the course of the pandemic.

India, too, faced a similar brunt when it was hit by a fresh wave of infections this year. Now more than ever, it is important to evaluate how we can have our health systems prepared for future pandemics.

To prepare for the future, we need to look at what has worked in the past. India has seen significant progress in health infrastructure over the past few decades. Schemes like the National Health Mission, Mission Indradhanush, and the Integrated Child Development Services helped revolutionise access to healthcare systems.

More recently, the government launched the Ayushmann Bharat programme to strengthen the healthcare system. Though significant progress has been made through these programmes, India needs accelerated reform over the next few years to revolutionise the health landscape .

This reform needs to start with an increase in investments, where India has been historically lagging. Though public expenditure on health has witnessed an upward trend in recent years, it still falls short of the country’s target of 2.5 per cent of the GDP.

An increase in investments in health must be accompanied by the acceleration of key policy efforts around public sector reforms, human resources for health, and health infrastructure.

Focusing on the public sector

In a country with 1.3 billion people, there are multiple complex challenges to upgrade health systems, both at the policy and implementation levels. One key factor is the declining role and image of the public sector in providing these services. Health care has historically been a government service paid from tax-funded revenues.

The founding principles were that services should be comprehensive, universal, and free at the point of delivery. Over the years, we have seen the public health system decline due to several factors, including under-resourcing, poor management, and competing government priorities.

This created a second system, the urban private sector, which emerged as a major player in the delivery of health care, even though it was out of reach for most of the country’s population due to its high costs. In a country like ours healthcare must primarily be a public commodity for it to be equitable, and to help achieve the goal of Universal Health Coverage (UHC).

The over-reliance on the private sector leads to high out-of-pocket expenditure. These factors directly affect the household spending of millions of people, leading them into debt, or worse, into poverty.

The recent decision to enhance India’s tertiary care health public infrastructure through replicating the All India Institute of Medical Sciences (AIIMS) in every State is commendable. However, we must now make a concerted effort to ensure quality care facilities to not only in the metropolises but also smaller towns and cities.

The focus has to be on improving existing infrastructure of district hospitals and medical colleges, which have always been the backbone of the health systems in the country.

Currently, these hospitals suffer from a slew of infrastructural and maintenance issues. These need to be spruced up to make them more pleasant, cleaner hospitals; they should be declared as stray-dog free zones.

Acceleration and implementation of such maintenance schemes should be prioritised by State governments, which can create stringent monitoring systems to oversee progress. Primary health care centres also need to be spruced up with proper electricity, water supply, clean toilets, lighting and equipment.

Building skilled manpower

India has one of the highest numbers of medical colleges in the world. The Health Ministry’s recent ruling of converting district hospitals into medical colleges under its Human Resources for Health and Medical Education is a step in the right direction.

However, India continues to face critical shortages of medical professionals especially in under-resourced settings. The worrying trend can be highlighted by the fact that India has 0.7 per thousand physicians in the country as opposed to the WHO-recommended 1 per thousand; and regional disparities compound this problem.

The demand for trained doctors and paramedical staff only increases during a public health emergency like we are facing right now. Recent experiences in the pandemic have also shown us that doctors’ training and education should be a part of pandemic preparedness and not response.

In the public sector, the burden on healthcare workers is even higher, with there being a severe lack of general physicians specifically in rural areas. To put things into perspective, a General Physician (GP) in UK treats about 20 patients per day compared to treating up to 250 patients per day in India.

This burden worsened during the Covid-19 pandemic, wherein due to lack of facilities in rural settings, urban hospitals and practitioners were thronged with hordes of patients. While rural community service is incentivised for medical professionals in India, the country needs to bridge the gap between their wages to their private sector counterparts.

We need to also focus on quality training so that good MBBS doctors are motivated to pursue general practice as a career of service and fulfilment. Setting up of colleges and training facilities for medical education in rural and semi-urban settings can also help improve these professionals’ retention rates. These interventions should be in conjugation with sensitisation of communities in rural areas on health-seeking behaviour.

The Covid-19 pandemic highlighted several issues in healthcare systems like high treatment costs, overburdened health facilities, lack of access to medical equipment and even over-prescription and unnecessary usage of over-the-counter drugs, as we have seen with steroids and mucormycosis. The issue of the availability of over-the-counter tests is peculiar to India.

These issues have to be combated by moving towards a more patient-centric, affordable, accountable, model rather than a more investigative, aggressive, expensive, commercial model. What works for developed countries might not work for a country such as ours — where access to health care is still a challenge for many marginalised communities.

Though the pandemic has given a barrage of news of despair and lost hope, we must now rise to anchor a revolution to change the face of health services in the country rooted in sustainable, evidence-based changes. Only then can we solidify India’s commitment to providing an equitable and inclusive healthcare service model to its citizens.

The writer is Director General, Indian Council of Medical Research

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