ACCESS Health India Country director Dr. N. Krishna Reddy recently appeared on US Pharmacopeia India’s “USP COVID-Connect” series, an online live interview series with experts and health systems stakeholders. The idea behind the series is to generate insight into how various healthcare businesses are adapting to the dynamics of the COVID-19 pandemic.

The topic of the discussion was ‘What needs to change to strengthen India’s health systems and infrastructure?’ The interview was moderated by Ms. Sireesha Yadlapalli, Regional General Manger, USP-South Asia. Dr. Reddy spoke about the challenges of the health system and infrastructure in both the public and private sector in responding the COVID-19 pandemic.

Dr Reddy spoke about the challenges around financing in dealing with the Covid crisis. He eluded to existing healthcare funds being diverted for Covid, leaving a direct impact on other diseases and verticals. He spoke of the challenges faced by the private sector in training and securing their staff, especially at the time of decreased footfalls. He also spoke about the lack of quality, despite access to medical care for Covid.

Dr Reddy pointed to the need for the regulatory environment to be nimble and agile in terms of evaluation and approval processes. This will ensure that quality products such as diagnostic tests, drugs, vaccines are available.

Read the experts from the interview below:

The pandemic has exposed vulnerabilities in health systems throughout the globe. From the governance point of view, what has worked well and what could have been done better to deal with the Covid crisis? Has evidence played a role in policy and decision making?

The initial response was as is usually expected in the initial stages of an epidemic. Based on some of the models, it can be said that if lockdown and social distancing would not have been imposed, the expected infection rate would have been much higher, running into millions. I feel the governance system has come under stress because the focus has now shifted from the central government to the states as we are a federal structure and health is a state subject. The response has to be planned according to the given state structure and its ministry of health. Not just state, but it also needs to percolate to the district level. This is where the public health expertise in handling an epidemic through the science of epidemiology can guide decision makers in the planning process. This is where we are seeing the stress being faced by different states because each state has a different capacity. As per WHO notification released in May, the testing rate has to be in accordance with the positivity rate of the infection. We were seeing hiccups in this coordination between the local development, the regulatory authorities, approval process, validation of test sensitivity and specificity. As different types of tests started being available, it was important it to be communicated effectively. 

How much financing is available with the government and the private sector to deal with the Covid crisis and from the standpoint of regulation and emergency approval of drugs for use and repurposing. How is that going from the governance perspective?

We have not heard much about any additional budget being allocated for the public health delivery system. When an epidemic or pandemic occurs, the existing limited budget gets diverted to dealing with the unforeseen crisis. This has a direct impact on other areas, verticals and diseases, especially chronic conditions that depend on the continuous supply of drugs and diagnostics. Some examples are diabetes, hypertension, TB, HIV. The budget falls short for meeting the requirement of these diseases. Our fear is that a similar problem may occur during the current Covid crisis, unless there is ring fencing of the existing budget. The third area of financing is the private healthcare provider financing. If this is not robust, they will not be in a position to pay their staff adequately, or provide them with personal protection equipment and training to prevent transmission of infection.

Most private healthcare providers are struggling because their non-Covid patient footfalls have dropped by almost 50 percent. There was no readiness on dealing with a crisis like this. A simple measure like the public payer system such as Central Government Health Scheme and Employees’ State Insurance Corporation releasing all the outstanding dues to the empanelled hospitals can help the private sector at this time. The amount is running into thousand of crores of rupees. This amount will be very handy to private hospitals in the current times of crisis.

This is the time when our regulatory environment needs to be a lot more nimble to ensure that there are quality products whether it is a diagnostic test or a repurposed drug or emerging vaccines. The need is for a lot more agile and nimble regulatory system, in terms of evaluation and approval processes.

What has been the case so far on access and what is the role of primary healthcare? Is there anything the pandemic has brought out?

In terms of geographic access, people have their access, even in remote villages. In terms of access to physicians, pharmacy, and diagnostic facilities, this has improved significantly in the past few years, both in the public and private healthcare system. The problem however is the highly variable quality, cost, and appropriateness of care that is being delivered. A study revealed that for someone to come to a correct diagnosis for tuberculosis when someone develops fever and cough, they go through six providers before he/she gets the correct diagnosis of tuberculosis. In short, people have the access but the access is not to good quality, reliable and safe healthcare.

In terms of the current pandemic, the same situation persisted. This means that access to a doctor was not so much of a problem, especially due to our extensive use of telephonic consultation. Unlike in the west, physicians in India give out their personal phone number. That gives tremendous comfort to the people.

During this crises when resources are short and everything is needed urgently and approvals  are given quickly, is there a chance of compromise on quality?

The lack of focus on quality is a big challenge. We have focused on access and were able to improve access. We are trying to give financial protection against catastrophic health expenditure. But we are not focussing enough on quality. A culture of infection prevention control system is not present, because of a lack of mandate and regulation especially in the provider system. The clinical establishment system is not adequate. Same thing applies to drugs and diagnostics and monitoring systems. The current pandemic has brought out these gaps very clearly. “We should take this opportunity to learn from what we are seeing so openly. We need to realize that health is not an expense but is in fact the bedrock of the economy.