The sheer panic of the second wave of COVID-19 generated unprecedented interest from donors both based in India as well as worldwide. Almost overnight, we witnessed individual and established donors rapidly raise and deploy large amounts of funds. Among other things, they provided PPEs, ventilators, oxygen cylinders, and oxygen concentrators to enhance the ability of Indian healthcare providers to serve more patients.
Swasth Digital Health Foundation for example was able to deploy more than 25,000 Oxygen Concentrators to over 600 districts across India within a short period of 8 weeks. The Swasth Science Alliance similarly assembled a large coalition of, among others, local and global clinicians, academics, graphic designers, and large field level organisations to ensure that the benefits of rapidly emerging scientific knowledge were getting to the furthest reaches of the country.
Now that the second wave of COVID-19 has started to recede in most parts of the country, it is important to reflect on what needs to be done to prepare the health system for any future waves as well as to make it stronger and where well-meaning philanthropy can have the greatest impact as we move forward.
We already know that the progression of COVID-19 is such that early action ends up saving the most lives. Unlike several other diseases, COVID-19 does not yet have any effective medical treatment and the only real strategy available, like in the case of other viral infections, is to allow the body the best possible opportunity to fight it off. This is done ideally by keeping the initial infection load low through the active use of masks but if the infection does take hold, which it could in about 20 percent of the people, keeping the body well oxygenated through the early use of low-flow oxygen and medicines to avoid the clotting of blood.
While, with what we know, it is impossible to predict the course of the disease for any one individual, we do know that close to 80 percent of those who develop mild to moderate COVID-19 recover using this approach, leaving a very small proportion with a serious disease requiring both high-flow oxygen and, on occasion, even ventilator support, needing to be hospitalised.
However, during the second wave, the response was principally focussed on hospitalisation with the inaccurate presumption that we had effective treatments on hand and all we had to was to get the patient to the hospital. This led to a massive, and potentially unsustainable, over-investment in hospital focussed equipment, including by donors.
The hospitals were nevertheless overwhelmed and a number of lives were lost because the required close-to-patient rapid-oxygen-response was strongly discouraged and remained underdeveloped. This, sadly, was not a surprise because, as the Italian experience had made very clear in March 2020 itself, not even the best health systems can cope with the deluge, without appropriate primary care to manage most cases outside of the hospital.
As a result, even at the end of the second wave, despite the massive amounts of external investments that took place, primary care remains as weak as ever in most of India. Beyond COVID-19, comprehensive primary care should include the provision of antenatal care, access to services during pregnancy and after the birth of a child, and screening and early treatment for chronic diseases to all adults.
Unfortunately, no state, not even Kerala, is able to deliver even the minimal four antenatal check-ups to all the expectant mothers. Coverage of just this basic service is less than 50 percent in several of the larger northern and eastern states, despite maternal and child health currently being almost the sole focus of government community health workers.
And, while in primary care the deficiencies are uniformly high across the country, as the C-section map of India shows, the hospital system is unable to provide adequate emergency or surgical care for mothers in the northern and eastern parts of the country. The consequences of this enormous under-provision are reflected almost directly in the neonatal mortality map of India, which illustrates the extent of the loss of life in those regions.
Urban areas and the western and southern parts of the country on the other hand—towards which much of the COVID-19 hospital investments were directed—not only have adequate hospital capacity but as can be seen from the C-Section map, use it to heavily over-provide these services.
What do these realities mean for how new philanthropic investments can support a sustained response to COVID-19 that also strengthens the health system in the long run? Among others, three specific areas jump out which could benefit from such investments.
1. Public Health:
While India has made progress in areas such as vector control and vaccinations, we require much stronger disease surveillance to track outbreaks to inform responses, which could avoid the over-use of blunt instruments like total lockdowns during COVID-19. In particular directing investments towards developing durable solutions to the recording of births and deaths, aggregation and analysis of already available diagnostic and insurance claim records, and development of sentinel sites in each block, could prove to be very valuable.
2. Primary Care: The pandemic laid bare multiple weaknesses and pre-existing challenges of the primary healthcare system that need to be addressed in the long run. More immediately, however, there are several non-governmental providers such as pharmacies, individual doctors, and small clinics and nursing homes, particularly those who serve the most remote parts of the country, which have, if suitably strengthened, the potential to offer a much higher quality of comprehensive primary care. Supporting, among other things, the development of digital backbones which aspire to connect with these different providers and enhance their response capacity could go a long way towards building up a strong comprehensive primary care infrastructure in India.
3. Hospital Care: As discussed earlier, while there is a surfeit of this capacity in urban areas and in the southern and western parts of India, there are clear challenges in the availability of emergency care in the northern and eastern states. While physical infrastructure has been possible to build, the absence of specialised capability is the biggest challenge. Fortunately, most cities and towns even in these states have an adequate number of basic undergraduate doctors and nurses, but it has been difficult for them to attract and retain specialists. While continuing with efforts to recruit and retain specialists, helping scale up remote services which offer advanced specialist support via telephone and video to existing primary and secondary care providers and enhance the capacity of on-ground personnel to respond to emergencies becomes very important.
Strengthening a health system as large and as complex as India’s is a gargantuan task that is likely to take many years. In the meanwhile, however, the three areas of disease surveillance, a digital backbone for primary care, and remote specialist support for primary and secondary care particularly in the northern and eastern parts of India, could be actioned quickly and would go a long way in both preparing India for any future COVID-19 waves as well as help strengthen the core of its health system.
—The authors, Nachiket Mor, PhD, Visiting Scientist, The Banyan Academy of Leadership in Mental Health; Sapna Desai, PhD, Public Health Specialist, Population Council. Views expressed are personal