A medical worker tends to a patient suffering from COVID-19 in Holy Family Hospital in New Delhi, April 29, 2021. Photo: Reuters/Danish Siddiqui
In India, we are currently in the midst of the second wave of the COVID-19 pandemic, and have around three million active cases. We are back to a series of lockdowns in different states. Starkly visible are the gaps in essential infrastructure and drugs in health facilities. An over-stressed frontline workforce is bravely trying to compensate for systemic deficiencies. Concerns are repeatedly being raised on inadequate and delayed testing; and about treatment protocols for COVID-19 that are not in line with current medical discourse. The dire need for collective processes of leadership that can help us tide over the crisis is being felt everywhere.
Where are we going wrong in our pandemic response? Could our health systems have done better? These are questions that we need to reflect on. Epidemiologists, virologists, social scientists, clinicians and other professionals have been offering important and diverse perspectives on this subject. I write here as a health systems researcher.
Health systems past and present
The health system we had visualised for independent India and the one we have at present are very different. Currently, in India, much of our curative healthcare happens in the private sector (70-80%), and mostly through out-of-pocket expenditure: we go to a doctor, get services and pay directly for the services rendered. Despite this, our public health sector, financed from general taxation, plays an important role in providing preventive services (vaccinations, community spraying during malaria season and other such activities) and also in providing treatment to populations who don’t have access to or can’t afford private care.
This role division between public and private health systems was not the original vision we had for India. Indeed, one of the first blueprints of the health system in our country in the year 1946 emphatically defends the building of a universal (for all), comprehensive (covering a wide range of services) healthcare network in India, thinking of health as a right of all people, and of the government as the main player in health. This document emphasises, “No individual should fail to secure adequate medical care due to inability to pay.”
This grand vision of the Indian public health system never came into being. Historically, we did not make adequate financial investments in the public health sector to support this vision, despite small bouts of increased budgets during certain pockets in time when healthcare got slightly higher priority than usual. Overall, our public health spending is a little more than 1% of our GDP, and one of the lowest in the world.
The public health system in most states in India, with some exceptions, has largely remained side-lined in political discourse over the years. The evidence of this neglect is visible the form of limitations in basic structural and functional capacities- drugs, human resource vacancies, equipment, demotivated and overburdened staff- in public health systems. So even before COVID-19, the public health system in most states in India struggled to cater to the massive health needs of a growing population.
We need to remember that an already-struggling public health system in India, with a poor baseline level of functioning, was the one that had to face this pandemic. The immense political capital around COVID-19 suddenly put pressure on the health system to rapidly ‘scale-up’ health services like never before. Some states, like Kerala and Tamil Nadu, that have had the advantage of having health systems with a better base-line level of functioning, have been able to cope better with this pressure than others. But in most places, the public health system has not been able to suddenly increase its capacity, despite intent and effort to do so.
To scale up quickly, many states tried to make stop-gap arrangements, particularly with respect to health infrastructure, drug procurements and operationalising digital platforms. Makeshift hospitals and ICUs have been set up; train coaches and religious places have been converted to temporary health facilities. These stop-gap arrangements have perhaps helped to bolster the response. But the current situation in India shows that these ‘reactive’ attempts at scaling up have not been enough to meet the scale of the pandemic’s second wave.
In these conditions, what should health systems do?
There is evidence from the academic literature on what ‘complex adaptive organisations’ like health systems tend to do when they come under pressure. For one, complexity theory talks of path-dependence: complex systems borrow from organisational memory to react to pressure in ways they are already familiar with. That is, the historical baggage we come with matters. Health systems working in resource-constrained contexts are used to coping with the several day-to-day stressors they face by hiding or tampering with data, by putting additional pressure on the frontline and not taking their voices into account, by moving from one priority to another in a reactive manner, and in doing so, often maintaining a deficient status-quo.
These are routine coping strategies familiar to all in the health system- except that during COVID-19, we are seeing a ‘magnified’ version of these strategies. For instance, we are seeing that the health system tends to ‘ration’ COVID-19 diagnosis and treatment services (say by limiting the number of tests per day) to a level that it can manage. Like before, it is the frontline workers- doctors, nurses, community outreach workers- who are bearing the brunt of systemic deficiencies. They are not only being over-burdened – but since they are the ‘face’ of the system to the population, they are being subjected to violence that is rooted in deeper frustration and anger of people against the system as a whole. To summarise, the way the health system has adapted and worked during the pandemic is, in one sense, only a distorted reflection of its everyday functioning and capacity limitations.
One clear limitation of our public health system comes out in its tryst with the current COVID-vaccination policy that we have adopted. India had begun its vaccination drive enthusiastically in January 2021 with two indigenous vaccines, with initial focus on frontline and healthcare workers. On April 12, it was decided that the COVID-19 vaccination programme in India would be expanded and opened to all above 18 years.
These decisions have been met with some applause as being pragmatic choices as well as criticism as moves against the core principles of health equity. While this is not an article on the pros and cons of the vaccination strategy per say, we do need to ask ourselves why is it that we have had to make such painful choices, complex rules, and rely on the more ubiquitous private sector for the delivery of vaccines.
Why does the public health system of a growing economy like India not have the delivery capacity to vaccinate people at the quick pace that we desire? And do we not have to build it in future if we ever have to be atma nirbhar (self-sufficient)? This issue of limited delivery capacity of the public health system is not confined to COVID vaccines alone. So many of our health policies are ‘good on paper’ and very well-intentioned, but get thwarted in practice due to limitations in the system’s ability to deliver.
A hard lesson
What is the solution? As we start to move out of the second wave of COVID-19, we must not forget the hard lessons that this experience has taught us. India is going through a harrowing testing period now, and it is time to take to heart the lesson that we have all paid a huge price to learn. We have seen first-hand the devastating effects that an outbreak can have on society when the health system is not able to handle the load. We also now know that it becomes too late to begin building our boats in the middle of the raging storm. Viral mutations are going to happen, and we are uncertain to what extent; so perhaps the question to ask ourselves is how can we build health systems that can help us cope so that even repeated outbreaks remain less painful and disruptive.
COVID-19 has brought the spotlight on issues that have been plaguing the public health system in India for many years. We now have a window of opportunity to garner political will to combat these issues. We cannot afford to merely ‘bounce-back’ to a deficient way of functioning again. One can, of course, argue that even with these deficiencies, we have been making steady progress in some arenas like polio eradication, maternal mortality and child survival.
But these are silver linings and we cannot afford to ignore the dark cloud in the background. We have to invest more in our public health system. We have to build back a stronger health system with better capacity and interconnectedness. Our health system has to have legitimacy in society- for people’s trust cannot be built overnight in the middle of a pandemic. We have to work towards a fairer health system that has explicit intentions to work towards a more inclusive and equitable society.
Smaller ‘patchwork’ efforts at health systems strengthening are not enough. It is time for us to bring in as much change as possible, and dismantle older structures and processes that have hindered our public health system for years. Nurturing an atma nirbhar health system in India needs bold reforms from bold leaders.
Sudha Ramani is a public health professional whose research focuses on health policy and systems in India. More details of her work are available here. The views expressed here are the author’s own.