The Centre and States have been taking extensive measures to prevent a large outbreak of the coronavirus in India. The strategies include quarantining patients coming from countries reporting local transmission, testing and isolation of suspected patients and a broad campaign to improve community hygiene practices.
The people have responded positively to the hygiene practices. Hand-washing kiosks have come up at public places in many states. The public has been using it. This is remarkable for a country where only 60 per cent of houses have access to soap and water, according to the latest National Family Health Survey.
This renewed interest in hygiene should extend to healthcare facilities also. Studies have shown varying levels of hygiene practices in healthcare facilities in India. Observational studies suggest only 23 per cent people follow standard hand-washing recommendations at India’s newborn-care facilities. Large studies to evaluate injection practices in the country show more than 60 per cent of injections were unsafe. India has made significant progress in improving the quality of healthcare and hygiene practices through the National Accreditation Board for Hospitals. But this is limited to bigger hospitals and urban areas. The ‘Kayakalp’ initiative of the Centre has tried to take the philosophy of hygiene to small facilities. But the success has been varying.
Traditionally, the focus of all government spending on healthcare delivery has been to manage supply. There has been investment in hospitals, health centres, sub-centres and centres for excellence in medical research. Government spending on healthcare as a proportion of GDP has seen only a minimal increase. Still, there has been an improvement in the coverage of essential healthcare services. There are existing guidelines such as the Indian Public Health Standards, which describe the infrastructure and staff pattern in an ideal scenario. But even States such as Kerala and Tamil Nadu, with strong public healthcare delivery systems, struggle to follow these standards. The key issue here is the focus on coverage of healthcare services and not quality of care. And hygiene is a quality issue.
Hygiene in healthcare delivery is not just limited to hand-washing and safe injection practices. It needs the entire system to facilitate Infection Prevention and Control at a healthcare delivery institution. This includes adequate staffing, optimal training on infection prevention, facility-level guidelines, surveillance of Healthcare-Associated Infections (HAI) and improvements in the built environment of the health facility. The idea behind these programmes is to improve the general hygiene in hospital settings and reduce infections contracted through healthcare. India has one of the most challenging HAI rates in the world. Some studies report rates as high as 30 per cent among intensive care patients. Now, Covid offers a great opportunity to change all that.
HAIs increase morbidity and mortality and drive up healthcare expenditure. They can also lead to a loss of trust in the healthcare system and cause a sharp increase in the use of antibiotics. High use of antibiotics, in this case, newer and more powerful ones, can lead to antibiotic resistance and loss of functionality of these life-saving medicines. Many experts have warned of outbreaks with antibiotic-resistant bacteria. This can cause similar disruptions in the healthcare system as we are witnessing now. The Covid-19 outbreak may end with mass administration of vaccines or discovery of an effective treatment method. But issues such as antibiotic resistance are much more long term and the cumulative losses to the global economy can be very high.
Change we must
In this context pushing for improvements in the quality of healthcare delivery, especially for infection prevention and control, seems ideal. But this will not happen through rhetoric and campaign slogans alone. We need to systematically invest in increasing the staff capacity and improving the environment at the healthcare facilities. We should not have a shortage of hand sanitizers and masks. The supply chains have to be strengthened, with necessary surge capacity and diversification of procurement. A surveillance and reporting system for HAIs needs to be designed so that there is accountability and pressure on the healthcare system to improve. In other words, this issue has to be approached methodically and adequate funding needs to be mobilized through public pressure.
It was in 1854, John Snow, a British physician, proved cholera outbreaks were a result of contaminated water from a particular pump in the Soho area of London. It took several such outbreaks for the people of London to understand the importance of clean drinking water and change their practices accordingly. Houses started having sanitation facilities and piped drinking water and the government stopped the practice of dumping waste into the Thames river. More than 150 years down the line, it is high time the importance of hygiene became an integral part of our daily behaviour as well as healthcare practice in India, and the whole wide world.
Authored by Philip Mathew for The Hindu Businessline The writer is an associate professor of community medicine at PIMS & RC in Kerala