2020 was a terrible year, especially for India. Covid-19 had a devastating impact on people’s health and healthcare, and the economy took a beating. India finished the year with the second highest number of Covid-19 cases (currently over 10.5 million reported cases, with over 152,000 deaths, which is likely to be an under-estimate). With the Covid-19 incidence declining over the past few weeks, and with the launch of an ambitious vaccination campaign, 2021 could, hopefully, be a better year. But only if the country learnt from the experience of Covid-19 and rebuilt the foundations of it’s public health system.
I asked 35 Indian experts (17 men and 18 women) from diverse fields (clinical medicine, public health, media, administration and academia) what they wished India had done better during 2020, and what they would like to see India do during this year and in the future, to better handle health crises. Nearly everyone said India should have done a more thoughtfully planned lockdown and mitigated the humanitarian crisis among migrant workers. And nearly everyone wishes that India will learn from Covid-19, invest more in health, and build a universal and comprehensive healthcare system.
Looking back, what could India have done better during 2020?
India could have planned the lockdown better and avoided the massive internal migration crisis that followed. Nearly every Indian expert I interviewed emphasized this as the single biggest failure.
“India has over 100 million circular migrant workers,” said Chinmay Tumbe, author of India Moving: a history of migration and The Age of Pandemics. “Any lockdown strategy has to have clear communication to internal migrant workers. By not doing this, we ended up creating an unprecedented migration crisis with millions hitting the road to walk back home (after the lockdown was imposed),” he added.
“In dealing with the migrants, the government not only displayed a total lack of compassion and the lack of planning ability, it also allowed the virus to travel from urban pockets into the countryside,” said Keshav Desiraju, a former Health Secretary and co-editor of Healers or Predators: Healthcare Corruption in India.
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A stringent lockdown, enforced within a few hours effectively “converted a health disaster into a humanitarian crisis whose cost was paid mostly by the poor migrant families,” said Nidhi Jamwal, an editor with Gaon Connection, which has been tracking the impact of the pandemic on rural India.
India could have done more to support over 50 million people who live in extreme poverty. “This is perhaps for the first time in the independent India everyone, including the media, had forgotten the miserable plight of the poor,” said PV Ramesh, former Principal Health Secretary of Andhra Pradesh state. Lack of social solidarity with the migrants and the poor might be due to the caste system in the country, according to Awanish Kumar, a development studies expert at the Azim Premji University. “In Indian society, populated by a grand multitude of castes, restricting access to good quality public systems is a form of exercise of social control over subordinate castes,” he argued.
“India should have attempted to put more money in the hands of the poor and middle class, through expanded safety nets or a near-universal stimulus,” said S Rukmini, an independent data journalist. “It would have been good to provide more financial compensation through direct benefit transfers to citizens for the entire duration of all the phases of the lockdown,” said Soumyadeep Bhaumik, a researcher at the George Institute for Global Health in India.
Poor communication and lack of transparency by the government created tremendous confusion, panic, stigma and distress. “The government could have been far more transparent and less patronizing in their communication,” said Priyanka Pulla, an independent journalist. “They should have given people accurate and honest assessments of the situation, instead of simplistic versions aimed at preventing panic,” she added. “We had conflicting and often jingoistic messaging about how we’re doing well as compared to other countries and how good our “recovery rate” is,” said Sandhya Ramesh, a science editor at The Print.
“We could have created a single scientific source of updates and evidence that was then distilled and translated effectively by popular voices across the states,” said Indira Behara, a public health physician at Global Health Strategies, India. “Better communication would have improved official and public understanding of the evolving and mixed effects of the pandemic, improved the response, and established more trust,” said Divya Nair, a Director at IDinsight.
India could have let science, not populist politics guide the response. “The government responded to an infectious disease outbreak like it was a law & order issue. With this flaw at its root, the pandemic response went on to spread misinformation, trigger a humanitarian crisis, and blame minorities as the virus spread from urban to rural India,” said Vidya Krishnan, a health journalist, currently a Neiman Foundation Fellow. “India should have focused on evidence in its response, and ensured transparency,” said Anant Bhan, a global health ethics expert.
“The government followed the typical ‘command and control’ norms of the bureaucracy that came a complete cropper with the poor,” said Gopi Gopalakrishnan, founder of World Health Partners. “We should have had public health experts advise the government and used data to come up with the strategies required to contain the epidemic,” said Sujatha Rao, former Health Secretary and author of Do We Care: India’s Health System.
With politics driving the response, evidence-based healthcare became a casualty. “The government promoted clinical options which were lacking in rigorous research- from hydroxychloroquine to traditional medicine,” said Anoo Bhuyan, a journalist with IndiaSpend. This created distrust and confusion among healthcare workers and the public alike. This confusion continues into 2021 with the ongoing vaccination rollout.
Lack of community engagement and a decentralized response was another big gap. “The government could have partnered better with civil society organizations in responding to people’s needs and strengthening accountability of various kinds of services. Civil society was largely relegated to the margins in policy response, even though it took on much of the task of relief work,” said Inayat Singh Kakar, a health expert with the People’s Health Movement and Medical Support Group.
“We did not sufficiently decentralize our response despite a history of decentralized governance in many states. This also increased reliance on “experts” at too high a level to make an impact,” said NS Prashanth, a public health expert at Institute of Public Health.
“People sensitive and citizen participatory planning and implementation of the Covid-19 response could have avoided problems like the migrant misery, fear and stigma that marked the initial months of the response and the super spreader events that followed after the lockdown eased,” said Srinath Reddy, president of the Public Health Foundation of India, and author of Make Health in India.
Lack of access to Covid-19 testing was another bottleneck in India’s response. For many months in 2020, India struggled to scale-up diagnostic testing in the public health sector and failed to effectively leverage and regulate the large private health sector. “There was confusion around diagnostics and it took some time to figure out who gives approval for kits and who provides support for diagnostic tests,” said Kamini Walia, a scientist at the Indian Council of Medical Research.
Disruption of general health services was a huge gap in the pandemic response. Millions of people failed to receive adequate healthcare and all areas of non-Covid-19 care was severely disrupted, from basic immunization to treatment of common conditions such as tuberculosis.
“India let the fear of Covid-19 disrupt general healthcare services in a way that was avoidable,” said Oommen Kurian, a health expert with the Observer Research Foundation. “India’s preparedness could have been significantly boosted had the foundation of a robust public health system existed,” said Urvashi Prasad, a public policy expert at Niti Aayog.
“The widely prevalent fear, stigma and paranoia associated with Covid-19 is likely to have long-term psychological sequelae,” said Lance Pinto, a pulmonologist at the Hinduja Hospital. Stigma also reduced testing for other diseases such as TB. “A plan to run non-Covid clinics would have helped people to a great extent,” said Vijayashree Yellappa, a public health expert, and fellow at Niti Aayog.
India also failed to tap and effectively regulate the massive private health sector during the crisis. With the public health sector swamped with Covid-19 patients, private health care became scarce and expensive for the public. “What stood out is the stark lack of compassion which permitted widespread profiteering in Covid-19 treatment and the government’s refusal to regulate effectively,” said Malini Aisola, a Co-convenor of the All India Drug Action Network.
“During the lockdown, state governments failed to either use private resources sensibly or regulate private services. If done properly, this could have taken some pressure away from public services,” said Keshav Desiraju. Vijayashree Yellappa concurs. “We needed clear policies to involve private hospitals for diagnosis and management of cases,” she said.
Looking forward, what should India do to tackle Covid-19 and future health crises?
“Increase the investment in health and strengthen the public health system” was the single most important recommendation from nearly every Indian expert I interviewed.
“There’s no alternative to a strong public health core,” said Anoo Bhuyan. “We need to build up the tattered public health system at the state and national levels,” said Sujatha Rao. “India must invest in building resilient, strong health systems- both at the center and state level- to be able to better and effectively respond to such health crises,” said Anant Bhan.
“Instead of a disproportionate focus on curative care, India must prioritize health promotion as well as prevention and early detection of diseases. This requires a significant increase in the levels of government spending on public health as well as building a well-trained and motivated public health cadre in states across India, said Urvashi Prasad. Divya Nair concurs. “At less than 1% of GDP, India’s overall government health expenditure is currently very low by global standards,” she said.
Indians relied heavily on the public health system for Covid-19, but found the system under-resourced and overwhelmed. “There is no doubt that public hospitals are invaluable for the safety net they offer the poor, but there has developed a certain blindness to the huge deficits in quality – some explained by lack of funds, and some not – in many of them,” said S Rukmini. So, it is important to improve quality of care delivered in public facilities. This, in turn, requires a strong work force in the health sector. “It’s high time for the government to realize we need a resilient work force,” said Soumyadeep Bhaumik. “India should strengthen front-line workers, and formalize the millions of accredited social health activists (ASHA) and Anganwadi workers whose efforts were invaluable during the pandemic,” argued Nair.
Quality healthcare must include mental health. “We absolutely must include a robust mental health component in our national responses to such public health crises. And it should be focused on the long term, since mental health implications of such crises tend not to be restricted to the near term,” said Tanmoy Goswami, who runs an independent platform dedicated to mental health.
Although India has historically acknowledged the importance of primary healthcare, it has steadily focused more and more on tertiary care. “Our country’s primary health delivery is in shambles,” said Gopi Gopalakrishnan. “The government believes that insurance-funded, hospital-based care is the answer. This mindset has to change,” said Keshav Desiraju. “We need to shift focus from sickness to wellness of the whole of society. This can be done by focusing on determinants of health and prioritizing service delivery to the poor, women and marginalized communities,” said Giridhar Babu, a professor at the Public Health Foundation of India.
One way to strengthen primary care is to strengthening local governance. “Local governments are the first responders in this kind of crisis. Local governments can also play a critical role in addressing exclusion from social welfare services, which makes people very vulnerable; and they can take convergent action to address the social determinants of malnutrition and poor health,” said Uma Mahadevan, Principal Secretary, Panchayat Raj, Government of Karnataka. NS Prashanth concurs. “I wish we could strengthen grassroots leadership,” he said.
“We need to really ramp up social protection to address food and nutrition security for the poorest and amplify efforts to create more jobs and income security across the board,” said Purnima Menon, a senior research fellow at the International Food Policy Research Institute. The latest NFHS-5 data show a worrisome trend of worsening nutritional status in many states in the country.
There is no getting around the reality that a majority of Indians currently seek private health services. “We must stop the endless debate about the virtues of private versus public health care and affirm that ‘quality health care for all’ is a public good and must be publicly provisioned,” said PV Ramesh.
Better governance of the private health system, therefore, is critical. Although many states tried to regulate cost of private care for Covid-19, enforcement was a big challenge. “The pandemic has shown us that implementation of ‘regulated rates’ is a huge challenge, especially given the lack of political will or inclination to regulate private healthcare service providers in general,” said Inayat Singh Kakar.
“Indian states must institutionalize better working relationships with the private sector whether offering just out-patient services or hospital care,” said Shailaja Chandra, a former Health Secretary in the Ministry of Health.
India needs much better disease surveillance system than what exists today. “Indian epidemiologists cannot work with a blindfold on,” said Vidya Krishnan, arguing for timely, reliable data from the government. “We need to develop surveillance systems that can provide early alerts and enable rapid decentralized data driven responses to public health emergencies,” said Srinath Reddy.
“India must work to build stronger active surveillance and really focus on removing the scourge of TB and some of the other ancient diseases (such as malaria, lymphatic filariasis, and visceral leishmaniasis) though both good public-health policy as well as healthy public policy,” said Nachiket Mor, a Commissioner on the upcoming Lancet Commission on Reimagining Healthcare in India.
“To prevent and deal with such crises, India clearly needs to separate the public health functions from healthcare delivery at central and state levels, to invest in a cadre of public health epidemiologists, health administrators trained to deal with such crises, and develop a robust disease surveillance system with strengthened laboratory capacity,” said Anurag Bhargava, a professor at Yenepoya Medical College. To strengthen laboratory capacity, India needs to come up with a “clear framework for diagnostics R&D and approval,” said Kamini Walia.
“As a country, we need to invest in and harness the scientific potential we have more effectively,” said Indira Behera. India is widely recognized as the world’s pharmacy, and it now has the unique opportunity to deliver affordable Covid-19 vaccines for the whole world, and help overcome the current vaccine scarcity and excessive reliance of the ‘trickle-down’ model where products and innovations developed in the Global North slowly trickle down to the Global South.
But even though India has developed indigenous Covid-19 vaccines, it is clear that the government needs to build trust, improve transparency, and strengthen regulatory processes to ensure quality. “The government has an opportunity to take steps to overcome the recent regulatory lapses and follow instead regulatory processes that favor scientific integrity and transparency,” said Malini Aisola.
“India must prioritize is trust-building,” said Patralekha Chatterjee an independent journalist. “Without openness and transparency, trust can’t be built, and trust is key to effective management of a health crisis, now and in the future,” she added. Priyanka Pulla concurs. “India can’t justify opacity in government functioning anymore, especially it comes to things like drug and vaccine approvals,” she said. Several Indian groups and scientists have expressed concern about the government rushing to approve a Covid-19 vaccine without efficacy data. This could result in erosion of public trust in domestic vaccination campaigns, and reduce uptake of Indian vaccines by other countries.
“It is imperative to build more trust in scientifically sound public health. Conflating untested Ayurveda, homeopathy, and other harmful alternative “medicines” with evidence-based medicine will continue to be a big problem, and our health agencies have to urgently stop incorporating pseudoscience within our health systems, said Sandhya Ramesh.
“India must rebuild trust and communication between the government, policy makers, regulatory bodies, civil servants, health professionals, scientists, journalists and public,” argued Shriprakash Kalantri, a professor at the Mahatma Gandhi Institute of Medical Sciences.
Every society needs the media to hold the government accountable. Kiran Kumbhar, a doctoral student at Harvard University studying the history of medicine in post-independence India, is concerned that the Indian media is not playing this role effectively “because it has become an extended propagandist arm of the Government of India.” He believes there is still some “hope in the independent media outlets and in independent experts and influencers on social media,” he said.
In conclusion, the Covid-19 pandemic is the biggest stress test of modern India’s health system. Predictably, it has revealed huge cracks in the foundation which need to be rebuilt and perhaps reimagined. As Oommen Kurian put it, “this is a rare point in history when economists and health experts agree on the need of additional resources for the health system.” India must therefore not waste this crisis, and build a comprehensive and equitable health system that will serve all Indians. If this dream were to be realized, history will mark the 2020 mahamari (plague) as the singular inflection point in India’s progress towards a healthier nation state.
Acknowledgements: I am most grateful to all the Indian experts who generously shared their insight and expertise, and trusted me to elevate their voices. They make me hopeful about India’s future.