Effective Healthcare Systems Cannot Ignore Social Design

Pandemics cannot be controlled by governments without people’s participation. However, people’s engagement should be based on scientific principles and not publicity gimmicks.

LILA: The rapidly spreading COVID-19 has put healthcare systems across the world to the test.  While India’s proactive management of international travellers has been commended, our poor monitoring of local transmission has raised questions. What is your assessment of the impact of this pandemic in India so far, and our response to it?

Kapil Yadav: India is in the community transmission phase, wherein the disease spreads through domestic carriers irrespective of their travel history. While the Indian Council of Medical Research (ICMR) claims that we are still in the local transmission phase, wherein an imported case of COVID-19 transmits the disease to their contacts, the generalisability of the surveillance data may be questionable because of the limited testing methodology used – only patients with severe respiratory illness. As per the current increase in the number of cases, India seems to be headed for a full scale outbreak of the COVID-19 pandemic. If the transition happens within weeks then the healthcare infrastructure will crumble and mortality will increase exponentially.  If the transition happens over months along with suppression measures like social distancing, case isolation, home quarantine and closure of schools and colleges, the peak number of cases will be less, which the healthcare infrastructure can handle. There is an urgent need, therefore, to strengthen the measures being undertaken by the central and state governments, including upgrading health systems in terms of infrastructure (specially for critical care), ensuring strict compliance of lock down measures wherever imposed and setting up social support mechanism for the poor and vulnerable. We all need to buckle up and be ready for a prolonged period of emergency preparedness.

LILA: Most severely affected countries have long-established public healthcare systems which they have been able to rapidly mobilise to respond to the disease. In India, however, the main source of healthcare delivery is private, with 70-80% of the population visiting private institutes for their medical needs despite up to a fourfold difference in cost (WHO study, 2017). What do you think are the reasons for such a preference? Do you think this difference in medical infrastructure is likely to influence India’s response to the COVID-19 pandemic?

KY: Much of the private healthcare in India comprise small and medium scale private clinics, which are easily available round the clock, and are made affordable through reduced per consultation charges. The healthcare purchasing capacity of the population also varies in both urban and rural areas. On the other hand, public healthcare is physically inaccessible in rural areas, and functionally inaccessible in urban (including for the urban poor population). The comparative crowding of public healthcare hospitals may be another reason for a preference towards private institutes.

As far as COVID-19 is concerned, India has already roped in private laboratories accredited by the National Accreditation Board for Testing and Calibration Laboratories for testing patients suspected of the COVID-19. If used judiciously by the government with due regulatory checks, private healthcare delivery systems may also play a crucial role in the control of the pandemic – they are spread in most of the districts and their resources can be used effectively to detect and treat COVID-19 patients. Some countries have marshalled all resources to health systems and even nationalised private health services, like in Spain. India also may need to develop some strategy to use resources available in private health care sector and also ensure integration and synergistic action between both public and private health care sector. What is interesting in this context is that the Government of India has been gradually shifting to service buyer instead of service provider role as far as health care is concerned. By setting up insurance programmes for healthcare in India, such as Ayushman Bharat, the government has also set standard rates at which these services can be delivered. These rates are difficult for the small and medium clinics to absorb, which makes their services unviable. Such a progression will have catastrophic consequences in the long-run, as it is likely to allow larger private players to monopolise healthcare and dictate its intent and direction. We must be mindful of this when designing our policies on healthcare.

LILA: Should the efforts of such policies then be towards improving public healthcare infrastructure and services in India, or ensuring accessibility to such services by all, irrespective of their public or private providers?

KY: Universal Health Coverage should be achieved in India with the government being the primary and major provider of health care. Private sector also has a role in healthcare provision but it should be complementary to the government and must be closely monitored and regulated. Schemes like Ayushman Bharat with focus on buying of service by the government have serious pitfalls and may be closely relooked at, as elaborated above.

LILA: Even as healthcare services provided by the government need a boost, the latest budget (2020-2021) has reduced spending on healthcare. What does this mean for our system, especially as we stand on the brink of a potential healthcare crisis?

KY: There is no doubt that the government needs to increase the spending on healthcare. Health expenditure by the government should be at least 5% of the Gross Domestic Product so that each and every citizen of India has access to optimal good quality healthcare. Health being a State subject, funding from the state government should also increase, and other health-related departments should realise the importance of improving the general health environment of the population. The Government of India should walk the talk, and the policy rhetoric be backed up by finances.

LILA: Apart from the state and private stakeholders, what role do you think the larger public plays in a healthcare system, especially with regard to setting demands from such a service?

KY: Public demand from the healthcare system varies depending on the health problem they experience. A strong public or private healthcare system should be able to meet the variegated demands of the population that they cater to. However, such demands are also dependant on the level of knowledge the public holds and the larger social milieu of the country. Community empowerment has to go hand in hand with community participation in healthcare delivery. It is important for the need of the public to be realised with the help of local community members and frontline health workers. Several successful examples of the same are available from India and across the states, such as People’s Health Movement, Sathi Cehat and many others, which have shown that communities can be entrusted with healthcare systems. Community participation in both demand as well as monitoring is key to Universal Health Coverage.

LILA: Another form of medical demand that have been prevalent in India for many years are alternative medical practices. While its sociological relevance has been critiqued and established many times, how would you view it as a medical professional working on public health?

KY: Since the emergence of modern medicine, which is based on evidence of data, alternative medical practices have seen a setback in India. AYUSH has been integrated with modern allopathic health care in India. However, there is a need to incorporate evidence-based medicine for AYUSH also and assess various interventions of the same on the principles of science as we know today. Currently, in the name of AYUSH, everything is being peddled with serious consequences on the health of the Indian population. A case in point is the claim that consumption of gaumutra would help prevent the COVID infection. Such claims, as we have already seen, can cause a lot of harm not only to the health of the individual, but also the understanding of health by the larger public. Such practices must always be called out.

The Indian System of Medicine (ISM) may still have a role to play in health care provision in India as it could help achieve Universal Health Coverage. For this, the best of both modern medicine and ISM may be integrated by generating evidence for the latter. At the same time, false claims of ISM having cure for all illnesses should not be promoted. Only trained qualified ISM practitioners should be encouraged and crosspathy should be minimised.

LILA: Recently we saw a catastrophic response to the call for the Janata curfew, with large crowds assembling on the streets and completely missing the point of the quarantine. At the same time, concerns about the quarantine severely affecting communities from poorer socio-economic backgrounds are also being raised. Are the strategies we have employed to engage the public in the prevention of the COVID-19 pandemic unreasonable for the Indian context, or does our public medical communication and education need to improve? Are there any insights you can share from your experience in public healthcare? 

KY: The idea of ‘janta curfew’ was a nice one, and adherence of the people to the call of the Prime Minister was also appreciable. However, the celebration at 5 pm slightly marred the overall objective of the exercise. You can see people like Amitabh Bachchan sharing pseudoscientific information that vibrations kill the viruses and lo, at 5.05 pm a sea of people came onto the streets, thinking that “cronosaur” was dead… celebrating its wadh (who knows). Such stuff gives people a false sense of protection. In times of the spread of an infection, public education is one of the most important strategies that should be implemented at a war footing. One should understand that apart from COVID-19 we must fight against fake and unscientific claims. Pandemics cannot be controlled by governments without people’s participation. However, people’s engagement should be based on scientific principles and not publicity gimmicks.

LILA: What according to you would comprise an effective healthcare system, considering matters of healthcare often tend to go beyond medical expertise, and involve aspects of civil governance, social design, and education, among other?

KY: Effective healthcare system cannot exist without taking into account the social design, civil governance, education and socio-economic status of the population. However the key is to acknowledge health as a fundamental right, ensure universal coverage based on equity and adequate resources for the same, with the government playing a central role in providing them.

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