Covid-19 has upended the most developed health systems worldwide, sickened over three million people, and led to over 2,35,000 deaths and still counting. Sudden, frequent and disruptive public health emergencies could be the new normal. The Covid-19 public health emergency could be an opportunity for India to explore how best to build upon our strengths and address our revealed failings.
Covid-19 compels us to candidly confront the following ethical questions in terms of healthcare:
Where do funds go?
First, should the state outsource to the private sector, its moral responsibility of providing basic and essential healthcare? Even where vulnerable segments are covered by public health insurance, purchasing healthcare services from private hospitals will involve higher lifetime costs to the exchequer (capital and O&M), than if provided directly by the state.
The public primary healthcare system, a vehicle for extending basic and essential healthcare to all of rural India, was unable to deliver on its promise. It remained under-funded, under-supplied and under-staffed. The answer does not lie in abandoning it.
Second, there is a trade-off between expenditures on public, primary and referral care on one hand, and secondary tertiary healthcare on the other. The greater the investment on the former, the less will be the demand on the latter, and the reverse. The demand-driven profits of privatised secondary and tertiary healthcare, whether or not supported by the public exchequer, will eventually choke fiscal support for public primary healthcare.
This is because a large privatised healthcare sector will be able to pressurise the political class to reduce allocations assigned towards public primary healthcare and instead divert much of these to the privatised healthcare sector. At that point, who will the daily-wager, migrant, slum-dweller, and other vulnerable segments turn to?
Is it not more cost-effective for the government to equip, modernise and strengthen its own assets — the numerous AIIMS already built and waiting to be utilised — at tertiary levels, as well as the continuum of public primary healthcare (HSCs, PHCs and district hospitals) in many States, lying unmanned/abandoned? Get these going. Wherever there remain shortages in human resources or in machinery/ equipment, contract in services as required, but do not throw out the baby with the bathwater.
Third, is the responsibility for healthcare provision better discharged at State levels or through decentralized, constitutionally elected bodies like the panchayats/nagar-palikas (local government units/LGUs)? A gold-standard example in India is Kerala. Decentralised governance has driven Kerala’s extraordinary success over Covid-19. People are not irrational. They trust ground-level public service delivery because they can monitor quality, receive feedback, see the response of authorities to said feedback, and then vote with their feet. These LGUs are our assets, which we are failing to use.
Covid-19 has demonstrated that to reduce overall disease burden as well as healthcare costs on a country-wide basis, there is no alternative to the State providing comprehensive public primary and referral, publicly-funded, secondary and tertiary healthcare. If citizens want a need-based, demand-driven, and people-centric architecture for healthcare, why push it into the hands of private entities when we can easily take the more cost-effective, ethical route?
Expand the scope of public health: The Swachh Bharat Abhiyan (SBA), an excellent primer, remains an unfinished agenda. We need to widen the scope of the SBA to include sewage and effluent treatment powered by solar panels; and in the process, recover valuable materials i.e. organic fertiliser. Organise systemic clearing of landfills (the Indore district provides an outstanding, recent example), ensure that toilets have running water, and routinise waste management. These are best-managed at the LGU levels, not from Delhi or Bengaluru. An expanded SBA will address holistically, the social determinants of health.
More money for health: The absence of resources for the health sector has been a story of malign neglect for over seven decades. An initial assignment of 2.5 per cent of the GDP in the current year should be escalated to roughly 6 per cent within two years. Any increase in allocation ought to be so apportioned that at least 70 per cent is assigned towards the continuum of the preventive and primary care, including referral healthcare up to public tertiary facilities, as opposed to the current practice of assigning over 60 per cent to curative care.
The first port of call: Merging of the health sub-centre and the primary health centre is an excellent initiative, leading to the creation of 1,50,000 Health & Wellness Centres (HWCs), close to the homes of the vulnerable segments. It is critical that these HWCs exercise serious gate-keeping functions. The patient presenting herself at the HWC should, with the exception of medical emergencies, be entitled for further PM-JAY insurance cover for secondary/tertiary care, only when referred by the HWC.
Second, the comprehensive primary healthcare (CHPC) dispensed at the HWCs should become part of the ongoing PM-JAY health insurance package, like in Thailand, for example, where state-funded health insurance famously includes primary healthcare.
Disease Prevention and Control: Planning for disease prevention and control begins with a regular feed of reliable, accurate data. India’s National Health Profile 2019 was a grim reminder that we continue to have a 36 per cent communicable-disease burden, of which over 50 per cent deaths were ascribed to pneumonia and acute respiratory diseases (symptoms common with the SARS and Covid-19). That was a wake up call!
There is a new urgency to upgrade health security across the country. Can we not equip the National Centre for Disease Control (NCDC) with a web-based ‘computerised infectious diseases reporting’ (CIDR) system to build health situational awareness, and early event detection? A CIDR would require all hospitals, medical practitioners and clinical directors of diagnostic laboratories (across the public and private sectors), to notify the Director General, NCDC-Ministry of Health, in respect of specific (infectious/other) diseases, which government will declare as notifiable.
The CIDR will compile every incoming information into a single, shared, national information repository. The epidemiology, disease burden, emerging threats to health and public safety within each district, will be adequately spotted, recorded, and investigated 24/7 in real time.
The NCDC was envisaged to serve as an institution at par with the Centre for Diseases Control and Prevention (CDC) of the US. This may be an appropriate time to make the NCDC an autonomous, apex organisation and restore to public health the stature it never acquired in India.
Ghosh is former Secretary, Ministry of Panchayati Raj, and former Special Secretary, Ministry of Health. Malhotra is former Regional Adviser, World Health Organization, South East Asia – Business Line