What the doctor ordered for 2021: Public-oriented health systems

post-Covid health system

A resident of a containment area being tested for COVID-19 in a fever clinic. Pic: BBMP Commissioner/Facebook
Authorities scrambled to organise resources to test and direct people to appropriate levels of care. File Pic: BBMP Commissioner/Facebook

The Covid-19 pandemic put to test the capacity and resilience of health systems across the globe. Public health systems in countries witnessing widespread virus transmission (USA, western European countries, Iran and India) were overwhelmed, leading to higher mortality. Despite lower disease incidence when compared to western countries, major cities of India witnessed significant Covid-19 related mortality. Various shades of lockdowns and civilian restrictions aided containment efforts, but caused severe socio-economic distress.  

In India, the pandemic response relied on tertiary hospitals with intensive care units and ventilators to treat Covid-19 and prevent deaths. Expectedly, the technocratic part of health systems led by medical academicians swiftly responded to emerging needs.

Evidence based national testing and treatment protocols took effect in record time. Laboratory capacity expanded rapidly with adoption of four major methods of testing. Quarantine and isolation facilities of varying quality mushroomed in cities. Yet, several communities experienced rapid transmission of the virus with avoidable mortality. 

When things fell apart

Indian cities scrambled to organise resources to test and direct people to appropriate levels of care. Hospitals and health care workers were often short of equipment, drugs and needed commodities. Repeated changes in technical protocols (expected while battling a new disease) and advisories added to the confusion among health care workers and the public at large.

Working conditions of health care workers deteriorated leading to protests alleging exploitation by government and private managements. Health systems, at all levels, were short of health workers due to absenteeism related to sickness (with Covid-19 spreading among health workers) and fear. Across cities, primary level health systems nearly collapsed or faced severe disruption. 

This situation was compounded by widespread public stigma against the disease; fuelled by misinformation and fake news. People feared Covid-19 testing and preferred to avoid hospital admissions. Public mistrust and resentment against the health system was apparent.

The health system appeared to falter in actions that could have decreased overcrowding of tertiary hospitals by slowing transmission and channelising patient flow. Much of the responsibility to slow transmission (bending the curve) was upon law enforcement agencies and the public at large. 

In summary, it appears that Indian health systems lacked the response and implementation capacity despite possessing requisite technical knowledge. Perhaps our health systems warrant a sector-wide reorganisation to respond to epidemics and other endemic health issues. However, this reorganization can only happen by:

  1. Primary health care towards community needs,  
  2. Health system geared towards public health stewardship
  3. Health policy focus on greater control on health resources and services 

Community-centric model

Since 1952, India has been pursuing establishment and strengthening of primary health care. Since the launch of the national rural health mission, primary care has attempted to include community participation. However, the prevailing bureaucratic approach to primary health care has lived its course, largely failing to address community needs. 

There is growing evidence that a community-centric model of primary health care, owned by the community is more effective.. While this approach is participatory, the model includes management of other social determinants of health like water, sanitation, food security and nutrition. It provides an effective platform to plan for health locally, considering context specific resources and issues. 

Rather than technocrats, this model relies on community health workers – who as first responders, provide basic relief and appropriately channelize referrals to higher care centers. Community health workers play a key role in integrating population groups with the health system by being the means of health communication.

These models have worked best in managing stigmatizing diseases like HIV/AIDS. There is global evidence that areas with communitised primary health care has better managed dangerous epidemics like Ebola (and perhaps even Covid-19).

Public health cadre as stewards

In India, clinical specialists have led the organic growth of health systems. However, emerging challenges have precipitated the need for a ‘systems approach’ to organise and deliver health care. With increasing complexities, many countries have developed public health specialists to lead, manage and organize health systems.

Modern public health is an umbrella specialty of epidemiologists, health planners, program managers and social health professionals. Public health specialists plan and manage health programmes based on hard data, factoring socio-economic realities. Although India has nurtured many public health institutions, most function in isolation even while aiding national health programs.

But the academic space of public health remains primitive, relying mostly on foreign educated professionals. This was evident in the archaic response of the Central and state governments, when they appointed a variety of clinical specialists to lead Covid-19 task forces. This misalignment of specialities contributed to the liabilities in  Covid-19 response.

Indian health systems require a mature public health cadre to lead and manage health systems at all levels. States like Kerala and Tamil Nadu, having adopted this paradigm, stand testimony to the success of this strategy.

Regulating private sector

Goals of the private health sector are at variance with national and social health goals due to slack regulation and profit orientation. Moreover, this sector concentrates a significant proportion of the country’s health resources (human, technology and monetary) which seldom benefit public health causes. Consequently, the government health system shouldered the burden of Covid-19 response, vastly stretching its resources..

Private hospitals often resort to financial exploitation of patients, as evidenced by recent Covid-19 related court rulings. With the exception of states like Delhi, Kerala and Tamil Nadu, most governments, including the Center failed to mobilise private health care resources effectively. 

The complex health care challenges that India faces require focus of all resources towards a common health goal. Moreover, health is a fundamental right and provision of the same is the duty of governments. Thus, government control and regulation of the private health sector to work towards social goals is imperative. There exists global evidence to this effect. 

Structuring efficient health systems is complex and requires multi-sectoral reforms. The aforementioned reforms can create an equitable health system, resilient to cope with challenges like the Covid-19 pandemic. The dividends of such reforms are non-tangible and hence may not be initiated from power centers.

However, in the Indian system of governance, health remains a state subject, with the possibility of intervention even by gram panchayats. Hence, faith should be placed on people’s health movements, however small, to induce primary level reforms that can lead to reforms in the larger context. 

About Himanshu M 1 Article
Dr Himanshu is a physician and researcher in global health with experience in planning health programs. He is currently engaged with an international medical organisation in New Delhi.