How a resilient public health system will save us from the next pandemic
Dr Rajiv Kumar & Urvashi Prasad
Coronavirus disease (Covid-19) is now officially a pandemic according to the World Health Organisation. India currently has around 110 confirmed cases, 17 of whom are foreign nationals. The government has been quick to adopt a multipronged strategy, including issuance of clear guidelines to ministries for coordinated action, imposition of travel restrictions, suspension of visas, large-scale screening and contact tracing as well as regular dissemination of information to the public. Mounting a swift response involving all stakeholders in a country of India’s scale and diversity is undoubtedly commendable. With these measures in place we can be confident that India will be able to successfully limit the spread of the disease. Moreover, in recognition of the fact that controlling a pandemic necessitates regional and global cooperation, the Prime Minister’s leadership in bringing together SAARC countries for chalking out a strong common strategy against Covid-19 is laudable.
Having said that, Covid-19 is not the first pandemic we have seen and will most certainly not be the last either. In fact, in an increasingly globalised and rapidly urbanising world, the risk of such outbreaks spreading quickly to all parts of the world is only becoming higher. The need of the hour is to build a resilient public health system that can prevent diseases, promote good health and respond quickly to minimise loss of life when faced with an outbreak of this magnitude.
During the last few years, the Indian government has taken several steps to strengthen the public health system through the implementation of programmes like Mission Indradhanush and the National AYUSH Mission. Flagship schemes like POSHAN Abhiyaan and Swachh Bharat Mission also impact human health as they help to prevent diseases and boost immunity.
So, what else is needed to build a strong and adaptive public health system across India?
Firstly, we need to increase spending on public health. The Central Government is committed to enhancing funding for health to at least 2.5 per cent of GDP as stated in the National Health Policy (NHP), 2017. States too have a critical role to play in meeting the NHP target of increasing health expenditure to more than 8% of their budget by 2020. After all, as highlighted by National Health Accounts data for 2015-16, of total government health expenditure in India, the share of the Union government is 35.6% while that of state governments is 64.4%. Moreover, in addition to increasing overall public spending on health, we need to ensure that a large share of the funds goes towards preventative care.
Second, as outlined in NITI Aayog’s ‘Strategy for New India @ 75’ a focal point for public health is required at the central level with state counterparts. Such an agency would be responsible for performing the functions of disease surveillance and response, monitoring health status, informing and educating the public as well as providing evidence for public health action. In order to be effective, the agency would also need to be legally empowered for enforcing compliance from other public authorities and citizens. This is crucial because several factors require inter-sectoral action to achieve a measurable impact on population health. The legislation, possibly in the form of a Public Health Act, would clearly confer specific powers on the agency for taking action to promote public health, especially in situations of “public health nuisances”. For instance, medical facilities that dispose potentially harmful waste inappropriately need to be held accountable as do residential colonies that allow water to stagnate, thus providing breeding grounds for mosquitoes. The impact of such actions, after all, is not just on one or two individuals, but in fact puts the health and lives of several individuals at risk.
Third, it is essential to institute a public health cadre in states, with officials trained in disciplines such as epidemiology, biostatistics, demography and social and behavioural sciences. To a great extent, such a cadre can be created by training existing personnel in the necessary skill sets, thus requiring only minimal additional staff. NITI Aayog has consulted a wide range of stakeholders for developing a model public health cadre that draws upon various best practices. The good news is that the 13th Conference of the Central Council of Health and Family Welfare (CCHFW) has resolved to establish a public health and management cadre in states by 2022. CCHFW is an apex advisory body which recommends broad lines of policy action in health-related areas.
Fourth, we need to train front-line workers like Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs) and Multi-Purpose Workers (MPWs) for promoting healthy behaviours among people and identifying early signs of a disease outbreak in communities. Given the inherent information asymmetry in health and the fact that we live in world where misinformation can spread rapidly, appropriate channels are necessary for ensuring that people are aware of diseases, their symptoms as well as mechanisms for prevention and treatment. The National Medical Commission Act, 2019 includes enabling provisions for creating a cadre of mid-level service providers who can also play a vital role in screening people for early signs of illness in rural areas.
Lastly, efforts must be made to reinforce disease surveillance and response. This requires the list of notifiable diseases to be expanded along with steps for integrating health facilities in the private sector in disease reporting as part of regular surveillance systems. Infrastructure for surveillance, including adequate numbers of suitably equipped laboratories for testing samples, also needs to be strengthened.
(Dr Rajiv Kumar is Vice Chairman, NITI Aayog. Urvashi Prasad is Public Policy Specialist, NITI Aayog. View expressed are personal)