Dr. Srinath Reddy discusses how the big takeaway from the COVID-19 pandemic should be the critical importance of building broad based and accessible primary health care across geographic and urban-rural divides. This interview was originally published in Pandemic Discourses.
This is part one of the Interview with Dr. K. Srinath Reddy.
Mahajan: Thank you for speaking to Pandemic Discourses. In the context of the devastating second wave of COVID-19 India is experiencing, you have noted a few times in your articles and interviews that COVID-19 can serve as a “wake up call” for India because the crisis could be used as a way to rethink and rebuild public health systems. This is relevant not only for India but for many countries. So I was hoping we could start by outlining what you see as the big pillars of public health that India should focus on.
Reddy: Firstly, I believe we do need a fairly well structured and well resourced health system in each and every part of the country. There is a huge asymmetry in the level of health system capacity and efficiency across the country, between various states, and within each state’s urban and rural areas. Sometimes you find district to district differences as well. There is much difference between a tribal pocket and a non-tribal area. We need to talk about the geographic diversity that exists. We need to recognize that the availability of efficient and equitable health services is not a given in every part of the country. And that is what we need to correct first.
Even as policy makers provide some degree of attention, if not adequate resources, to the health system, their focus is mostly on curative high-end care. And quite often, policy makers and even the media see tertiary care and to some extent, secondary care as the symbols of the health system, which they judge and grade. On the other hand, primary health care has generally been neglected.
Even as policy makers provide some degree of attention, if not adequate resources, to the health system, their focus is mostly on curative high-end care. And quite often, policy makers and even the media see tertiary care and to some extent, secondary care as the symbols of the health system, which they judge and grade. On the other hand, primary health care has generally been neglected. And it is a paradox that urban primary health care particularly has been neglected because rural primary health care at least has been designed, even if not efficiently delivered. But right from the beginning, policymakers assumed that there’ll be enough doctors and hospitals to take care of people in cities, and therefore urban primary care was never really prioritized. That was a misconception. Urban primary health care is absolutely important and if efficiently functioning, it can reduce the huge pressure of unnecessary cases self-referring to more advanced tertiary care institutions. So we must recognize that we pay a huge price for neglecting primary care.
Let us say you take universal health coverage as your ultimate goal. Take the WHO cube, which is conveniently framed in three dimensions of population coverage, service coverage and cost coverage, and say that this cube should be progressively filled based upon the availability of resources. We recognize that with respect to the first dimension, that is population coverage, it is primary care that’s truly universal. Everybody needs some type of primary care some time in life, whether it is immunization or whether it is even normal delivery care or whatever. There are so many things that come under primary care. Then, if you take service coverage, the largest package of services will be under primary care because virtually most conditions are covered there. And if you take cost coverage, primary care is the most cost efficient way of delivering services. And they’re mostly going to be very resource conserving in terms of avoiding unnecessary advanced care by prioritizing early prevention and care. So, the neglect of primary care, in many states of India, has actually cost India quite a lot.
But outpatient care and medicines, which contribute to the larger fraction of out-of-pocket expenditure, and which contribute to healthcare-related impoverishment over time, have not been really addressed in any of these schemes, till very recently. So as a result, you have a very weak health system in terms of both efficiency and equity, and that has cost us.
And of course, the very low level of public financing, the great shortage of skilled health workforce across various categories, and the highly asymmetric distribution across the country — all of these have been huge challenges. The high out-of-pocket expenditures because of low levels of public financing is a big problem. Even where some degree of government-funded schemes operate, they have mainly covered secondary and tertiary care. But outpatient care and medicines, which contribute to the larger fraction of out-of-pocket expenditure, and which contribute to healthcare-related impoverishment over time, have not been really addressed in any of these schemes, till very recently. So as a result, you have a very weak health system in terms of both efficiency and equity, and that has cost us.
Mahajan: Ironically, what you describe about India sounds very similar to the United States. Even though the two countries are at very different economic levels, there’s a similar pattern of mistakes – of a long term under-investment in primary care and public health systems.
But I wanted to follow up about the government financing schemes you mention. In recent years, much has been made out of what have been some of the world’s largest health coverage schemes that the Indian government has rolled out. There has been RSBY and then PM-JAY, with striking features such as their digitally mediated biometric databases, a focus on the poorest sections of the population, and service provision both from the private and public sectors. In light of India’s experience in the pandemic, what would be the lessons for redesigning such schemes that are getting the bulk of health financing from the government?
Reddy: Well, firstly, whether it was RSBY, or the expanded version of the program under PM-JAY, which has a higher level of financial coverage, they both have essentially focused on tertiary care and secondary care in hospitals. Moreover, they have covered certain procedures and not others. In fact, it was a bit amusing… in the initial stages of the PM-JAY rollout, there were a lot of questions in many government offices about why they were getting so many claims for cataract surgery and dental procedures, when the scheme was actually meant for cardiac surgery, renal transplantation, and so on. So the government wasn’t expecting claims for primary care, or even secondary care to that extent. Everybody was flocking to advance care institutions even for relatively minor complaints which could have been tended to at other levels. The government has tried to restrict admissions to hospitals to a select set of procedures, but has realized that there are many other health conditions that need to be cared for and they are not being covered by the list that was prepared for the so-called health coverage and insurance schemes.
So you have tremendous and continuous challenges in deciding the ambit of these health coverage programs, which are very restricted. They don’t anticipate all the needs of the people. So I believe having universal health coverage, which does not necessarily have a very restricted package of services, is going to be absolutely important.
Take COVID-19 as an example. We haven’t seen much of COVID-19 care being covered. But let us assume that COVID-19 care gets covered with some recent government announcements. Then suddenly we have a big spate of the fungal infection mucormycosis, which just today was declared as a notifiable condition under the National Epidemic Act, because all states are reporting cases of mucormycosis as a result of extensive use of steroids to treat COVID-19. So now the question becomes: who is covering the cost of treating mucormycosis with Amphotericin B? Suddenly, that drug has gone out of the market, or it’s very highly priced, which was the same with drugs for COVID-19. So you have tremendous and continuous challenges in deciding the ambit of these health coverage programs, which are very restricted. They don’t anticipate all the needs of the people. So I believe having universal health coverage, which does not necessarily have a very restricted package of services, is going to be absolutely important.
Mahajan: In the history of many countries, crises – and health crises in particular – have been used as a crucible for forging new compacts and for reconfiguring health systems. SARS in Vietnam and China, or AIDS in South Africa, come to mind. But there’s always the danger of taking the wrong lessons from a pandemic and applying them.
For instance, in the preparations for the anticipated third wave, there have been government announcements for the need to have oxygen compression plants, extra ICU beds, and other emergency resources. However, what you are saying is that the longer term lesson should not be merely to bolster emergency measures and surveillance, which is very much in line with a larger global health security paradigm. Rather you are actually emphasizing the need for building primary healthcare, or maybe integrating emergency services and primary healthcare.
Reddy: Absolutely, you need both. But in a judicious mix. I mean, you do need fire engines to put out the fires, right? But you’re not going to have every street with fire engines parked in front of every house. You have to take other measures to prevent fires from happening in the first place, or to put out fires very early before they really become conflagrations. So, that is why primary healthcare is key. You do require some advanced care and you do need anticipatory preparation for some public health emergencies. And certainly no hospital should run short of oxygen. And secondly, you do prepare for certain additional anticipated rises in demand and build in an additional cushion, so that you do not fall short of absolutely essential medicines and equipment if an emergency were to grow to a size that was not originally anticipated. So I think we do need to plan, but you don’t only plan for the big fires, you have to try and prevent small fires.
Mahajan: Do you see a challenge in establishing narratives that emphasize this kind of a judicious balance between primary health and emergency preparation – or do you think that, especially in light of the devastating toll that the pandemic has taken recently in urban areas, there will be an uncritical embrace within policy realms of building mainly emergency measures?
Reddy: Well, actually, there was a ray of hope. Last year, before the COVID-19 pandemic, the Fifteenth Finance Commission determined that Indian health services were not in any commendable shape. So they decided to constitute a committee, which was called the high level group, to give them advice on how best to strengthen the health system. Credit must be given to them. In a departure from past traditions of finance commissions, they decided they must have a special dedicated chapter for health. That’s not usual. And it so happened that just as that particular report was being prepared – in which they talked about primary health care, allied health professional training, and district hospitals – COVID-19 struck.
And having watched COVID-19 roll through the first wave, the Finance Commission again reconvened the group, and said, “What more can we do?” So, some more sections were added, but interestingly, they still maintained primary care. They said urban primary care was neglected, and that must be attended to. They said, the funds must flow directly for primary care to local bodies, such as the panchayats and the urban local bodies. Otherwise, they do not get adequate allocations and primary care will continue to get neglected. They also asked for strengthening disease surveillance systems, because we learnt from COVID-19 that we need stronger surveillance systems. They also wanted more critical care centers to be built, which was expected, of course, after COVID-19. But crucially they also said district hospitals must be strengthened and allied health professionals must be trained in larger numbers. Now, these were elements that were incorporated into the union budget of early 2021. And the budget was presented, I think, on the first of February. But then the second wave of COVID-19 really ramped up. And now we do not know what’s going to happen. Some of these recommendations will wait for quite a while now. It’s possible that the government or some of the planners might say, “Okay, the Finance Commission has submitted its report, lets work with it.” Alternatively, they may have to prepare for the third wave, which might demand a lot more intensive care units, a lot more pediatric intensive care units, and so on. So it is possible that there could be some reprioritization and primary health care may again go on the back burner. We do not know, but we should not let it happen.
Prof. K. Srinath Reddy is President of the Public Health Foundation of India. A cardiologist and epidemiologist by training, he is a Foreign Associate Member of the National Academy of Medicine, USA.