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Vital lessons for India from the second wave and way forward

Covid-19 is perhaps the only health emergency that has put to test the four fundamental health systems pillars: promotive, preventive, curative, and rehabilitative. India has laid an exclusive focus on the ‘curative’ pillar largely neglecting the rest over the last 50 years. Any curative-care dominant health system will struggle with a pandemic because hospitals should be the last line of defence, and not the only one. There is a dire need for us to align the four pillars to mitigate the chinks in the proverbial armour of our healthcare system. 

Classical Interventions

Institute a command-and-control centre 

The second wave bears testimony to the fact that a vast nation like ours requires strategizing and coordinating with a high degree of precision at all institutional and community levels simultaneously. A single national level war-room comprising the best and brightest minds, analysing, publishing data, and coordinating with local state government machinery would have yielded better results. This must aid unfettered decision making as close to the ground as possible. Furthermore, we must institutionalize a rigorous metric system continuously monitored for outcome and where good practices are shared and replicated rapidly. 

Test, Track, and Trace 

The methodology used in public health crises to understand where the virus is present, the extent of its spread, and its expected progression.  For a complicated system like ours, where several contravening extraneous factors, data deficiency is rampant. Scholarship, therefore, assumes a larger margin of error in their work. Serological and rapid antigen testing needs to be used as a surveillance measure for faster, accurate results. RTPCR should be the gold standard of clinical assessment.

Expand healthcare infrastructure and decongest hospitals 

In the absence of a promotive and preventive healthcare system, pressure shifts to expensive, hard-to-quickly scale curative systems.  But we need to move beyond expansion of basic hospital capacity and work on staffing these expanded facilities with skilled doctors, nurses, healthcare workers, critical medical supplies, and oxygen.  Gradation of requirement is a prerequisite to efficient care.  A vast majority of Covid-19 patients can be treated at home and quarantine centres.   A judicious use of hospital infrastructure while we continue to build additional infrastructure is critical to providing appropriate care requirements.

Encourage Pandemic Appropriate Behaviour 

The ‘promotive’ pillar would focus on three fundamental behavioural changes of washing hands, wearing masks, and social distancing. These inherently contradict India’s social norms. Therefore, a high-octane awareness campaign would drive and reinforce these much-needed changes.

Way Forward

Vaccinations in the shortest possible time

Drawing insights from the first wave, a disproportionate focus of vaccinating the large 20 cities which are the typical hotspots should have been laid followed by transit corridors. While vaccinating the vulnerable aged 45 and above seemed imminent, logic warranted vaccinating the age groups which were majorly spreading the virus much earlier. While our execution machinery may get stretched in the process, it possesses the capacity to vaccinate by 10X through smarter supplemental methods such as neighbourhood vaccination camps, allowing private hospitals and corporates to vaccinate, turbocharging the rural health missions with a new vaccination agenda, and giving people incentives to get vaccinated. 

Genome Sequencing 

INSACOG, a country-wide consortium was established to help identify new and circulating variants by genome sequencing across multiple states last year. One of its main goals is to sequence 5% of all Covid-19 positive cases in India. A mutating virus needs gene sequencing surveillance at war footing to understand the virus and thereby, devise effective treatment protocols to prevent further mutations. 

Critical medicines and related supplies

The shortages of critical medicines or equipment results from inherent lags in the supply chain or distribution inefficiencies. With the government dependent on private manufacturers, supply chain parameters, including quantity, delivery schedule, etc. are agreed upon preemptively. The government could purchase production options and pay for them upfront to incentivize private manufacturers to produce critical supplies over others. Visibility of the supply chain is similarly critical to redeem the population’s agony. 

Alternate oxygen capabilities 

Many hospitals view capex on setting up oxygen plants as an unprofitable venture.  However, incentive alignments such as interest free loans or tax benefits, can be instrumental in motivating hospitals to set up plants as opposed to taking oxygen off the grid. Fortunately, exercise is already underway with plans to set up 551 oxygen plants in district hospitals.x We also need to augment the grid oxygen supplies including containers, concentrators, among others. 

Motivation for frontline workers 

The mental and physical well-being of our fatigued and helpless doctors and nurses is in a rut as they continue to work in high pressure situations with scarce resources. The expression of our gratitude needs to manifest in the form of financial incentives. Private and public sector frontline staff should be given short-term and long-term incentives, even if these incentives do not reduce fatigue or pressure.  At the very least, these incentives can provide a little bit of succour in these trying times. 

Develop the future arsenal

If Covid continues to appear in this sinusoidal wave pattern with localized ebbs and flows over the next 3-5 years, we need to develop and ramp up our promotive and preventive health systems. Continued innovation is needed to assuage the burden of the disease. Both private and public sectors need to find new ways to promote Covid appropriate behaviour. We will need on-demand detection kits, oxygen kits, oral therapies, nasal sprays, and automatic sanitization. The time to start is now!



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Disclaimer

Views expressed above are the author’s own.



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