KESHAV DESIRAJU , a 1978-batch Indian Administrative Service officer of the Uttarakhand cadre, will be remembered for the systematic changes he tried to usher in during his short tenure as the Union Health Secretary. He joined the Ministry of Health and Family Welfare as Additional Secretary in 2010 after completing his tenure as Chief Secretary of Uttarakhand. In a message in the first report of the Sector Innovation Council for Health, brought out by the National Health Systems Resource Centre of the Ministry in 2013, he stated: “While India has a tradition of innovation in pharmaceuticals and in health informatics, much more needs to be done for innovation in medical devices and in health systems development and health care delivery. Even in our traditionally strong areas of pharmaceutical and information technology, the emerging challenges cannot be addressed unless continuing innovations are made possible. Making more investments in the health sector without creating a culture that permits innovations would diminish the effectiveness of the additional investments.”
In this interview to Frontline , he talks about the basic issues in the health sector. Excerpts:
Different parts of India suffer from one epidemic outbreak or the other every year. Outbreaks of measles, dengue and malaria are almost a regular feature, and there was SARS (severe acute respiratory syndrome) in 2009 and before that cholera. Now, it is COVID-19. The public health delivery system in India is the aggregate of all State health systems and there are massive differences in the quality of health care available in the States. In this situation, how big a challenge does COVID-19 pose to the people and the public health delivery system?
COVID-19 is a huge challenge because of the infection rate and the lack of a proven treatment. As of now [April 11], Maharashtra [with 1,574 cases] and Tamil Nadu [with 911] have the highest numbers. Fortunately, these are States where, on the whole, the public health system works better. Of course, this presumes that all the States are testing and collecting data in a like manner; this may not actually be the case.
Our systems on the ground are flimsy, despite massive investments since 2005, under the National Rural Health Mission [NRHM], later the National Health Mission [NHM]. Investment in public health is not a one shot operation as some donors and some corporate social responsibility [CSR] activities would have us believe. Unless there is continuous and systematic investment in building both human and physical infrastructure, we will not have a public health system that has the ability to respond quickly and effectively to a crisis. Ideally, every four-bed Primary Health Centre [PHC] should have at least one well-trained doctor, at least two trained nurses, the required complement of allied health staff and a reliable and regular stock of all medicines on the state-approved essential list. In such a PHC, a wide range of complaints would be attended to, both communicable and non-communicable, and normal deliveries would take place. Standard pathology tests would be possible and doctors would have the experience to make correct referrals. In the absence of a system working at this level of efficiency, COVID-19 poses a massive problem.
As investment in primary care needs to be continuous and systematic, only the government can do it, without expectation of returns in the short run. The government has assured us that health and wellness centres [HWCs] are being supported, as the underpinning to hospital-based, insurance-supported secondary and tertiary care. In September 2019, the Government of India said [Preeti Sudan and Indu Bhushan , “ In one year, PM-JAY has created a framework for comprehensive universal health care”, [ The Indian Express , September 23, 2019] that “more than 20,000” HWCs had been set up. Even assuming that they are all fully functional, a dodgy assumption at best, we should remember that there are about 24,000 PHCs and over 1,56,000 subcentres, all of which are potentially HWCs. These broad-brush, macro-level figures need careful scrutiny, a look at State-wise allocations for this purpose, and on-ground verification. I am told, for instance, that the HWCs in Puducherry are working very well. But this will probably not be true of Uttar Pradesh.
In a situation such as the one posed by the rapid spread of COVID-19, what should be the role of the Union government? Should it merely be a facilitator and supporter of State governments’ actions or should it involve itself in all facets of disease management and control, right from procurement of personal protective equipment [PPE] and test kits to directing what tests should be carried out on whom and when? Or, should it only step in in places where the State governments are floundering?
It is not a question of one or the other. A federal setup at its most productive needs both Central and State governments doing what they can do best. The virus does not respect State boundaries and there is no need for anyone else to do so. Traditionally, the Centre has laid down broad policy directives and has coordinated the implementation of, and also significantly funded, disease-oriented programmes. It is the Government of India that is in close and regular touch with the World Health Organisation [WHO] or with agencies such as the Centres for Disease Control and Prevention [CDC], Atlanta, United States. But State governments have to run the hospitals, they have to coordinate with doctors and health personnel on the ground and they have to do the testing. At present, they have to enforce the lockdown.
States can, and do, exercise their right to decide for themselves on a State subject. Take, for instance, Odisha’s unilateral decision to extend the lockdown. Or Tamil Nadu, which has not appointed ASHAs [accredited social health activists] as it has always had village-level health workers. But more often than not, the fact that the Government of India provides the funds means that the States fall in line. If States develop the ability to find budgetary resources for health care, they can show more independence in decision-making. The often-cited figure of 3 per cent of gross domestic product [GDP] for health care includes both Central and State allocations. States must begin to allocate more for health care.
Clearly, procurement-related matters should be left to the States but it depends on who is paying, and, sadly, we know from experience that medical procurements can lead to big corruption. I would say that we should leave it to whoever can do it more efficiently. Some years ago, Tamil Nadu and Rajasthan had well-structured procurement corporations. These were held up as an example for all States. I do not know if they have retained their reputation for efficiency and integrity.
The involvement of a research body, the Indian Council of Medical Research [ICMR) in all aspects of handling the coronavirus disease pandemic raises questions such as where are the infectious diseases experts in the country and what should be the role of institutions such as the National Institute of Communicable Diseases? Is there a protocol in place in the event of an epidemic? If not, why is there none?
The ICMR is a natural choice to provide technical leadership at this time. The National Institute of Epidemiology, Chennai; the National Institute of Virology, Pune; and the National Centre for Disease Informatics and Research, Bengaluru; are all ICMR-affiliated institutions. There is also the National Centre for Disease Control [until July 2009 called National Institute of Communicable Diseases] under the direct control of the Central Department of Health and Family Welfare, which is responsible for the Integrated Disease Surveillance Programme [IDSP] with the objective “To strengthen/maintain decentralised laboratory-based IT-enabled disease surveillance system for epidemic-prone diseases to monitor disease trends and to detect and respond to outbreaks in early rising phase through trained Rapid Response Team (RRTs)”.
I cannot immediately say if there is an up-to-date, technically valid protocol with the Ministry of Health but I am well aware of the WHO “Pandemic influenza preparedness Framework for the sharing of influenza viruses and access to vaccines and other benefits”, approved at the World Health Assembly [WHA] in 2011, which in itself is following a WHA resolution of 2007. [https://www.who.int/influenza/resources/pip_framework/en/]. This has much detail on how national institutes and laboratories need to coordinate with the [six] WHO National Collaborating Centres on Influenza, etc., but, of course, it won’t help if one looks at the document for the first time when the pandemic is upon us. Systematic investment in surveillance and response systems over the years would have enabled better compliance with what the WHO Framework advises. I am somewhat struck by the fact that in all the relentless editorialising about COVID-19, no one is talking about this.
There is another point here. The ICMR need not have been the focal point for the COVID-19 response if the Directorate General of Health Services [DGHS] had been more effective. The DGHS has its origins in India’s pioneering work in communicable disease control, and was a great organisation. It is still described as the technical arm of the Department of Health and Family Welfare but simply does not pull its own weight. The head of the DGHS should have been the face of the government response in this crisis. I remember commissioning a detailed report by one of my predecessors on the revitalisation of the DGHS, but the report, with readily implementable suggestions, has been buried, with the active support of the DGHS.
As the DGHS was not playing its public health role, the Public Health Foundation of India [PHFI] was set up, with strong commitment from the government and the private sector. The PHFI was expected to set up a chain of Indian Institutes of Public Health to train public health cadres at all levels in the States. This did not happen as quickly as was desirable. The PHFI was not allowed to function and there were also serious problems with its governance structures. It is only now that things are changing. Hopefully, when this crisis has passed, the government will find a way to strengthen the DGHS and the PHFI.
Perhaps, the best experience we had in preventing and treating infectious diseases was in the National AIDS Control Organisation [NACO]. But NACO has been effectively shut down on the grounds that the prevalence of AIDS has come down, even if there are still large numbers living with the disease. We have lost the enormous experience gained in civil society participation in disease control.
In 2012, the Government of India constituted the Epidemic Intelligence Service on the lines of a similar organisation in the U.S. It appears that nothing has happened since the on-paper approvals were made. During your tenure as Union Health Secretary, was there any move towards reviving this or making this part of some other organisation?
You are quite right. The National Centre for Disease Control [NCDC] began training programmes as well, but my understanding is that they have all wound up basically because State governments showed no interest in sending people for training. It is all down-to-earth, hard-to-do, solid public health work. No one wants to do it. Maybe after the present scare things will change.
On the basis of this experience, would it be prudent to invest in a communicable diseases hospital-chain infrastructure, on the lines of, say, the Employees State Insurance (ESI) hospitals? What are the other options available for a country like India, which cannot spare massive resources for a dedicated chain, which might be of use, say, once in a decade or so?
There is no need for a chain of communicable disease hospitals. There is no need to recommend new construction activity because then that will become the objective of the activity itself. Every district hospital [there are about 750 across the country] should be fully geared to handle epidemics, sudden increase in number of patients, etc. A district hospital is where a person goes or ought to be able to go with any complaint, with communicable or non-communicable disease, for delivery, during an emergency, after an accident, for elective surgery, for eye and dental care and for routine check-ups. A good district hospital is also one where difficult surgeries can take place; this means surgeons and anaesthetists are needed, and there is a functioning blood bank. It will also need a qualified nursing team, with specific categories such as intensive care unit [ICU] nurses. There are quite a few across the country that meet these standards. If a district hospital is well staffed and well run, it will develop the capacity to convert its wards into isolation wards when called upon to do so.
I think there is a standing decision that district hospitals will be converted into medical colleges. This is not a bad thing if it will increase bed strength and increase the facilities available. But there is also a talk that these hospitals will be handed over to the private sector, which will invest in upgrading the facility to a teaching college and, presumably, collect the profits raised from fee collection. The immediate consequences of this for the general health care seeking public are unclear and probably bad. If this is done, then the hospital will not be available to you in an emergency.
We see a lot of health versus economy debates happening in the country. The argument is that the economy should not be allowed to be on a free fall until such time the public health issue is fixed. Is there a way to strike a compromise or is there a middle path?
A lockdown situation cannot be indefinite. It is not just a question of losses on account of reduced economic activity. The consequences of being thrown out of work and being forced to leave the cities for “home” can be ruinous from the point of view of the health and well-being of thousands of workers, in both formal and informal sectors, and of their families. We do not willingly recognise that substantial numbers of those suddenly laid off work belong to the backward and Scheduled Castes. We do not know enough about how the threat of disease, the loss of family income and the return home of migrant men has affected women in rural India. There are already reports of increased domestic violence and the real possibility of unwanted pregnancies.
Clearly, people are going to have to return to work, but this raises a huge ethical dilemma. The urban middle class can probably continue to “work from home” or “work flexi-hours”; with some minimal adjustments, ensure that food and security are not a problem; and continue to self-isolate. The more vulnerable working class person, who has to go back to work because he/she needs to earn and whose daily work is not such that can be done from home, is going to have to break isolation and expose himself/herself to infection.
You talk of a middle path, but it is quite unacceptable if the middle path is one where people like us continue to protect ourselves from the risk of infection and the less privileged have to expose themselves to infection “because the economy has to be kept moving". If there is a risk, all citizens should share it.
Clearly, governments have to spend money on food and wage subsidies, paid to people at the place where they have isolated themselves. Several experts have called for Food Corporation of India [FCI] surpluses to be distributed; for MGNREGA wages to be paid out even if there is no work; and for efforts to be made to keep workers from migrating by setting up large camps in cities using public lands and buildings for the purpose or by requisitioning private spaces, if necessary.
When the threat of infection has abated, then all workplaces can start functioning. All this will cost money, but if the government does not spend now, when will it?
From a public health standpoint, as well as from the standpoint of society, what lessons can we draw from the events that have unfolded so far, across the world and in India? Does the force of this pandemic finally settle the public sector versus private sector health care debate in favour of the public sector?
The world has been transformed, and significantly for the good, by advancements in technology, information technology, and human ingenuity as manifested in the marvels of the modern world. The possibilities of AI [artificial intelligence] and advancements in scientific research are breathtaking. But what the present crisis has taught us, in our hubris, is that everything can be thwarted by pestilence and disease. Like the plagues of old, COVID-19 has brought the world to its knees. This is a lesson we should never forget.
A second lesson is that when a disease strikes it does not recognise religion, class, caste, income or nationality. It is tragic that this lesson needs to be repeated.
We are also learning at this time that we do not necessarily get from all our citizens the degree of responsible cooperation that is wanted at a time of national crisis. It is true that for a naturally undisciplined people, the urban middle class has observed, or has been forced to observe, lockdown reasonably well; but the newspapers regularly report disgusting, reprehensible behaviour by persons in authority and other citizens. This may not change even after the crisis has passed but we may hope that we will learn some lessons in collective well-being.
I hope we learn that India has to invest in the training of doctors, nurses and public health workers such as auxiliary nurse midwives [ANMs], ASHAs and Anganwadi workers. For 30 years we have believed that the private sector will take care of medical, nursing and dental education, with calamitous results for public health and the availability of qualified health personnel in public services.
The Central and State governments should invest in medical and nursing colleges, and take the lead from States such as Tamil Nadu. The Allied and Healthcare Professions Bill, 2018, pending in Parliament needs to be passed at the earliest and mechanisms put in place to systematically train young people in the recognised allied health professions and make them fit for service. A similar exercise is required for the range of public health services.
Tough decisions will be needed on how best to use the existing army of front-line workers, how they should be trained, how they should be supervised and how they can be absorbed into government service.
The present situation has also taught us something that we should never have forgotten. When it is the government’s responsibility to handle a crisis, it is government institutions that come to the front. It is for this reason that the government must invest in its institutions and not seek to outsource its responsibilities. We have had enough of the tedious differentiation between "providing" and "provisioning for" health care. No one disputes the fact that some degree of tertiary care can be insurance funded, but to pretend that the substantial responsibility for health care can be so funded reveals a fundamental lack of understanding of India’s public health realities. If this lesson is learnt from the COVID- 19 pandemic, it would be, even at a high price, a lesson well learnt.
