Covid-19 lessons: Public health system must offer free drugs, diagnostics

Ayushman Bharat scheme
The Ayushman Bharat scheme, aimed at reducing out-of-pocket healthcare expenses, is facing challenges due to fraudulent practices by some practitioners.

By Yogesh Jain

India’s public health system failed the Covid challenge: As a public health practitioner from rural Chhattisgarh, I would talk a bit about the various components of the health system – space, skills, and systems. I would explain why these are important. From what I gather from media coverage, India is preparing for the third wave of the Covid-19 pandemic. Are we preparing also for future pandemics if there is such an eventuality? India needs to build a robust public health system to tackle all challenges in the future by taking cognizance of the fact that we failed during the second wave of Covid-19 pandemic.

The impending third wave is reason enough to build a resilient public health system. Thai model of healthcare shows that if you want to get universal healthcare, then we need to channelise people’s demand. We say there’s a need for healthcare because health is a human right. When people are sick, they can’t ask for it. And when they are not sick, they don’t feel the need for it. Here we discuss how public health systems need to be developed to be able to deliver universal health coverage. For this, there has to be a political commitment which is missing at the moment. This is something that has to fight for.

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Needed: A robust public health system

If I talk about staff specific issues, I would say we need a public health cadre. This is a necessity for developing the right type of health systems. I would rather focus on non-physician health staff as there has been a lot of discussions around physicians and nurses. The issue of non-physician health staff has not been given importance even though it was recommended 10 years ago by the MCI. The rural health practitioner course has been implemented in a timid way. It needs more investment in training and mentoring. The ASHAs have been lauded for their work during the pandemic. They need to be supported more.

I would also like to speak about the conflict of interest in allowing private practice by public system physicians. Banning of private practice by government doctors is one bullet we need to bite. Without this we are unlikely to get systems that would work. This needs to be done even if some people will leave as the need of the hour is people committed to public systems.

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ASHA workers need support

ASHA and other non-physician health workers have to be supported. For chronic illnesses you need to transfer power and responsibility to support the peer groups that can be formed for chronic illnesses. That way you can reduce the burden on the system. Using information technology to support, not police, peripheral health workers is something that we need to do.

The ASHAs need to be paid full wages from an increased pool of funding that goes into human resources. That would be one way to improve the absorptive capacity of the system. Even physicians are not mentored in this country, forget about other non-physician health workers. So, a formal programme of mentoring, not only for individuals, but also for teams at primary healthcare level is needed. Quality issues have been already flagged, and to address them I recommended knowledge centres based at district hospitals to serve the entire state.

When it comes to staff, there are two things — both drugs and diagnostics need to be made available free of cost if we want to strengthen the public health systems and improve its footfall. Without this building a robust public health system is impossible. The that Tamil Nadu Medical Services Corporation leads by example. I know that the other states have not warmed up to this model.

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An essential diagnostics list must be made for free services, as some states are already planning. There should also be more medical colleges. Physicians, it seems, are not willing to go to rural India or a marginalized India. We should have those practices in place before we open more medical schools.

What about pediatric beds? That pediatric problems may occur during the third wave of the Covid-19 pandemic is actually a bogey. But, if that gets some services for the children in the near future, it would be useful to get some beds for sick children. Setting up regional virology research centres and vaccine production facilities in every state would be the way forward. Medical oxygen factories in each and every state with required tankers for immediate supply to hospitals, and a centre for communicable disease control would be necessary. LMO generation plants of 150 tonne capacity in every district hospital is a clear way going forward.

And we need isolation wards for ICU beds with minimum five ventilator beds in district hospitals. Even though ventilators are often not used, they are useful for snake bites and other illnesses. We know that cities have failed the people during the Covid-19 pandemic. There is a need to develop multi-use community centers that can be used during natural disasters as well as during pandemics. There will offer water, sanitation, and clean night shelter. We also need a surveillance system that is clearly lacking. Its absence was felt during the pandemic.

Something we missed during the second wave of the pandemic is medical audits of all practices, including prescriptions. A formal program needs to be put in place and monitored. Another thing that was sorely missed was a regulatory body, which is separate from the line departments of health. And we need to think about universal healthcare sort of paradigm, not an insurance-based model that has been offered.

We need to think out of the box and really start thinking about UHC. Immobile resources should be built and strengthened, but there should also be mobile resources like skilled medical teams, technicians, and, machinery. And finally, I would say that the most important thing is a regulator to oversee quality, rationality and pricing by the private sector.

(Dr Yogesh Jain is primary healthcare expert at Jan Swasthya Sahyog, New Delhi. This article is the reproduction of a speech at a webinar organised by Policy Circle. )