India needs to revisit the past, think twice about healthcare conditions and fill the gaps to combat the present crisis
Many experts have said the three important pillars in any country’s strategy to tackle the novel coronavirus disease (COVID-19) are trace, test, and isolate.
There is a pre-requisite for each of these components. Well-trained manpower (epidemiologists), equipped laboratories and essential diagnostics are crucial, as has been observed from successful models.
At the secondary level, a hospital infrastructure is required to treat symptomatic cases, besides well-equipped facilities for isolation of positive cases.
This article aims to determine India’s capacity for doing these activities effectively and efficiently and the preparedness of the Indian public health system towards fulfilling the gaps.
Global Health Security Agenda and COVID-19
In 2014, the Global Health Security Agenda (GHSA) was established among a group of countries, organisations, non-profits and private sector companies, with a view to making the world safe and secure from infectious diseases.
GHSA builds on the World Health Organization International Health Regulations (WHO IHR) that provide guidance for countries to assess and manage serious health threats that have the potential to spread beyond borders.
To carry out this agenda of GHS and IHR (2005), the United States Centers for Disease Control and Prevention has granted $30 million to 17 governments, private, non-government and international organisations. A total of 17 GHSA projects have been started in India, with different government and private organisations.
The COVID-19 crisis could have been handled well in India if the action packages of GHSA had been implemented effectively. In India, GHSA focuses mainly on “Core-4” public health functions.
These include increasing real-time surveillance of potential public health threats, strengthening laboratory systems, workforce development by ensuring better trained health workers in key epidemiological capacities and establishing emergency strategic health operations centre (SHOC) with rapid response teams capable of activating a coordinated emergency response.
Availability of trained public health personnel is a key component of the surveillance system to ensure continuum of care on a sustainable basis. In India, to strengthen the surveillance and management of disease outbreaks, the Integrated Disease Surveillance Program (IDSP) was launched in 2004, as a part of the National Centre for Disease Control (NCDC), which is the executing agency under the Union Ministry of Health and Family Welfare.
There should be one epidemiologist per 0.2 million population. An epidemiologist is a technical person to guide and monitor the process of contact-tracing, marking containment zones and isolating suspected cases.
Capacity-building of the healthcare workers for surveillance and outbreak investigation is a vital step under workforce development of GHSA’s action package. One of the institutes responsible for workforce development under GHSA is the National Institute of Health and Family Welfare (NIHFW), that has implemented the “Public Health Systems Capacity Building in India” project.
Under this project, NIHFW was given the responsibility to conduct training for rapid response teams, public health management and three months of frontline epidemiology. One of the nine responsibilities of NCDC is to strengthen workforce development under the India Epidemic Intelligence Service (EIS) Programme. There is no official evidence /document available in the public domain related to how many public health personnel have been trained under this project.
Availability of trained epidemiologists is an issue due to low salary and job insecurity in the health system. According to the letter dated April 7, 2020, by the Union Health Secretary, there are 216 (30 per cent) vacant positions of epidemiologists (including 11 state level positions), 28 of microbiologists and 24 of entomologists.
Epidemiologists are recruited on a contractual basis in IDSP with a major salary difference from permanent employees of a similar grade and without any job security. The average salary of epidemiologists in India is Rs 30,000-35,000 per month, with 11 months’ contract for a person holding a professional medical degree and specialisation, either MD or MPH.
Maharashtra is India’s worst-affected state, with 27.8 per cent of the total cases in the country; Epidemiologist positions in 50 per cent of the state’s districts are vacant. Tamil Nadu, another severely-affected state with 170,693 cases, has five vacancies of epidemiologists.
In Madhya Pradesh, only 39 per cent of epidemiologist positions are filled in 50 districts. The state has 22,600 cases. Rajasthan and Uttar Pradesh have 11 vacant positions each, while Gujarat has 22 vacant positions out of 33 districts.
Testing is extremely important as an early diagnosis of patient helps in tracing and controlling the spread of COVID-19. In January 2020, India had only one laboratory (National Institute of Virology (NIV), Pune) capable of testing and confirming the coronavirus infection.
According to the Indian Council of Medical Research (ICMR), the strength of laboratories has expanded to 1,049 including private and government labs. A total of 1,40,47,908 cumulative samples have been tested in 890 government laboratories and 378 private laboratories approved by ICMR as on July 20, 2020.
Under laboratory strengthening action package of GHSA, NCDC was given the responsibility to strengthen laboratory systems: Establish lab QMS in IDSP Labs amongst its eight other activities.
NIV, Pune, has also been given the responsibility for consolidating a laboratory network to enhance diagnostic capabilities for surveillance, outbreaks and epidemic investigations of high risk group viral pathogens causing respiratory infections (RI). NIV has also developed India’s first antibody testing kit for COVID-19.
Disparity in public health infrastructure
The third important pillar in combating the crisis is to treat and isolate. This doesn’t come under GHSA actions packages but is very important in limiting damage due to the COVID-19 pandemic.
As Prime Minister Narendra Modi has promised to double India’s public health spending to 2.5 per cent of the gross domestic product by 2025, the sector expects a higher allocation from the 2020 Budget. Through the National Health Mission (NHM), India has tried to strengthen its primary healthcare system. But for secondary and tertiary healthcare, it is mostly dependent on the private sector.
According to the National Health Profile 2019 data, there are 7,13,986 government hospital beds available in India. This amounts to 0.55 beds per 1,000 population. Many states lie below the national level figure (0.55 beds per 1,000 population).
Union Minister for Health and Family Welfare, Harsh Vardhan, said a total of 968 dedicated COVID-19 hospitals have been identified across the country, with over 250,000 beds. He said over 2,000 dedicated COVID-19 health centres, with over 176,000 beds and over 7,000 COVID-19 care centres with over 646,000 beds have been identified. All this was done after COVID-19 ran riot across India, but not before the pandemic, according to the preparedness plan.
“It’s no use saying, ‘We’re doing our best.’ You have got to succeed in doing what is necessary,” Winston Churchill once said. Emerging and remerging infectious diseases with pandemic potential is a warning to India that a well-functioning health care system is the need of the hour.
COVID-19 has brought back the focus on the unfinished agenda of GHSA to face any such upcoming pandemic. COVID-19 exposed how unprepared India is to combat the crisis.
India needs to revisit the past, think twice about healthcare conditions and fill the gaps to combat the present crisis. Making temporary arrangements doesn’t work as COVID-19 is not the end of the story. Simultaneously, India needs to tackle existing communicable and non-communicable diseases which are backlogged due to this crisis.
Views expressed are the authors’ own and don’t necessarily reflect those of Down To Earth
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