India is at a crucial juncture in its combat against covid-19. There are daily reports of declining viral caseload and currently less than one lakh new cases a day despite the regional variations. Having suffered the deadly second wave that walloped the country, most only hope the slipping numbers do not lead to a flawed sense of comfort.
Experts have for long maintained that dampening the viral wave is best achieved only with aggressive inoculation drive. It certainly needs to be much more than the 2.7 million doses a day as on June 9th . To put this in perspective, the daily vaccine production of Serum Institute alone is 2.4 million doses and substantially lower than the 10 million doses a day, at the very least, that experts have been seeking for months now.
Delta Variant & New Concerns
There are new concerns now with a more transmissible variant doing the rounds while many states across the country talking of easing lockdowns. Rakesh Kumar Mishra, one who has looked at the virus closely as the former director at the Centre for Cellular & Molecular Biology and in that capacity also the member of the Indian SARS-CoV-2 Genome Sequencing Consortia (INSACOG) which advises the government on virus variants cautions: “Please remember we have a more infectious and potent virus variant (often referred to as the Delta Variant) now therefore we should not let the guard down and strictly adhere to the prescribed Covid-19 safety measures such as masking and physical distancing.”
Currently, the advisor at CCMB, the premier research organization of India focused on the frontier areas of modern biology, he says, the virus tends to attack vulnerable sections of population, which now calls for the most vulnerable section – children and those in the smaller towns and villages that are not as yet exposed to the virus like in the urban pockets. Therefore, battle readiness for the third wave will need focus beyond inoculation and including preparedness with pediatric ICUs, bridging all the gaps in related health-care infrastructure, especially at the primary care level. All to stand better equipped to handle, not just Covid-19 but to also improve on the basic health indicators.
Public health spending and healthcare services access across Indian states
Table source: Ravi Duggal, independent researcher with data sourced from RBI State Finances Report 2019-20; the National Health Profile 2019, MoHFW, Govt of India, 2019; Registrar General India’ s Population Projections.
Avert A Crisis-To-Crisis Swing
Dr K Srinath Reddy, president of the Public Health Foundation of India (PHFI), feels, “we must utilize the time from the time lockdowns are lifted till whenever the next public health emergency arises by strengthening the healthcare system throughout the country. Unless we pay attention to this,” he says. “we will be swinging from crisis to crisis.”
The items therefore on the watch list now: child nutrition, child immunization, anti-natal care, controlling hypertension and diabetes while also ensuring their early detection since these are the co-morbidities that affect Covid and other infectious diseases also.
The apparent mantra now is disease-prevention, early detection, care as well as well as surveillance at the community-level. Dr M Surendranath, former vice president of the Indian Academy of Pediatrics says while priority has to be to vaccinate as many as possible, the second wave also saw children getting infected because many families got infected with Covid-19 and given the large numbers affected in the second wave, there is a risk that a small section of this could show post-covid complications such as multi inflammatory syndrome in children and therefore healthcare professionals in remote locations must be urgently trained to identify such cases early on and refer them for suitable care. One clear symptom is a high grade fever persisting for at least 4 to 5 days.
Protecting The Vulnerable
“Crucial at this juncture is taking care of pregnant women, vaccinating them and this can also go a long way to ensure check on maternal mortality and neo-natal mortality,” says Dr Ramesh Kancharla, the founder of Rainbow Hospitals with a chain of around 15 hospitals across six cities in the country and headquartered out of Hyderabad. Incidently, most have also been expecting government guidelines on vaccinating pregnant women.
Dr Kancharla also sees the need for standardization in terms of defining intensive care for children based on infrastructure, manpower and healthcare expertise required. For example, according to a National Health Mission’s all India health status report on new born care units established as on September 2020, refers to 894 Sick New Born Care Units (SNCU), 2579 New Born Stabilisation Units (NBSU) and 20,337 New Born Care Corners (NBCC) with little clarity on their definitions.
Other than child nutrition, child immunization, controlling hypertension and diabetes after their early detection as these are the co-morbidities that affect Covid and other infectious diseases is also critical as is the surveillance at the community-level.
HWCs & Primary Care
Crucial for these would be strengthening the primary health centres or in the lingo of Ayushman Bharat- Health and Wellness Centres (HWCs).
Official statistics say 75,000 Health and Wellness Centres are already in place but in these times of talent shortage, it is anybody’s guess as to how well equipped all of them are. Afterall, in an article jointly written in September 2019, the then health secretary Preeti Sudan and Indu Bhushan, the then CEO of Ayushman Bharat or Pradhan Mantri Jan Arogya Yojana (PM-JAY), had pointed to the goal of setting up 1.5 lakh HWCs by 2022 and with it an expected 1.5 lakh jobs getting created for community health officers. So, by implication have half that number – 75,000 jobs been created at the moment, most experts from the field do not see this happening especially in these times when even for government hospitals non-MBBS doctors were also sought.
The other need at the moment is ensuring early non-hospital bed oxygen therapy in these locations where a covid centre can also be made to treat patients and not having to rush to a non-reachable hospital.
Healthcare Spending & Access
Analysing some of the health-care trends in India and looking at data from various sources such as health expenditure from the Reserve Bank of India State Finance Report 2019-20 and others, Ravi Duggal, an independent researcher who has been studying health care spending by various states over the years and shared data gathered from various sources in the table on public health spending and healthcare services across India, says, “states that have high per capita spends also have better access to healthcare facilities in terms of availability of government doctors, public hospital beds and Primary Health Centres per 100000 population. So high spending states like Sikkim, Mizoram, Arunachal, Meghalaya, Nagaland, Himachal, Goa, Delhi and Puducherry do very well with access to healthcare (the first six however lack tertiary healthcare services). Kerala may not be a high spender but has a long history of robust investment in public healthcare which has created a strong public health system.” In contrast, he says, “the high income states of Maharashtra, Gujarat, Punjab and a few others like Uttar Pradesh, West Bengal and Bihar -because of their lower budgetary commitments to healthcare- have inadequate public health infrastructure in their states.”
Various reports point out, India not only has a huge inter-state disparity but does not compare well even with its immediate neighbours like Sri Lanka, Bangladesh and Nepal on some crucial health indices, though, given India’s size and diversity, a just comparison may not be possible, the tables here nonetheless do convey the arduous journey ahead.