Country Director of ACCESS Health India, Dr. N. Krishna Reddy recently appeared on two interviews on Doordarshan News. DD News is among India’s oldest and highly respected news channels. In one, he spoke about the response of the Indian health system to the novel coronavirus pandemic. In another show called Mask Up India, Dr Reddy spoke about the importance of wearing masks and handwashing.
Asked about his evaluation of the response of the Indian health system, Dr Reddy highlighted the early need of stewardship by the government over the private sector in treating Covid cases which unfortunately did not happen in the initial weeks of the pandemic. He appreciated the government’s decision to issue a lockdown that helped reduce the reproduction rate of the virus but hindrances to strict observance of social distancing subsequently prevented it from falling below the containment rate of 1.
He highlighted the need for the public and the private sector to work together till the country reaches a level of immunity. He emphasized the trust deficit in public healthcare facilities that have resulted in under utilization of public health facilities and over burdening of private facilities. Moreover, a lack of culture of quality of care has resulted in inadequate emphasis on infection prevention and control system and proper training of frontline workers.
He spoke of the possibility of government contracting out Covid services to private hospitals designed for intensive care. Dr Reddy spoke about leveraging the power of digital health, in the form of an online platform where hospitals can upload basic information such as their bed position, whether or not they are taking Covid patients etc to eliminate the prevalent confusion in the mind of the general public seeking Covid care.
Alluding to the huge gaps in health systems laid bare by Covid-19, Dr Reddy reiterated the need for every country to reinvest in public health, especially disease control, disease prevention, social determinants of health, and qualified healthcare workforce.
In Mask Up India, Dr Reddy highlighted the importance of handwashing from the perspective of the healthcare worker and how Covid has made handwashing critical outside the hospital setting too. He alluded to the doctors’ responsibility of sanitizing hands before and after touching a patient and how that can prevent many deaths that occur when infections pass from one patient to another. “Most of the bugs we carry are multidrug resistant. The spread of anti microbial drug resistance can be prevented with the simple technique of handwashing and facemask,” Dr. Reddy said.
Dr Reddy stressed the need to identify diligent handwashing as the responsibility of not just every organization but every individual. He spoke of how simple social determinants such as clean cooking gas and clean water can have a significant impact on population health outcomes.
The other speakers on the show included Dr Yasmin Ali Haque, UNICEF India representative, Ms Naina Lal Kidwai, Chair of the India Sanitation Coalition, and Mr. Rajesh Bhushan, Secretary, Health and Family Welfare. Dr. Reddy emphasized the need for clear and strong messaging by opinion leaders and politicians and how a small mistake like a leader removing his mask in public can influence the behaviour of people. He is of the opinion that masks will become a part of the culture the way seatbelts and helmets did. This will be for both infection prevention and guarding from pollution. “In countries that were exposed to SARS 1, wearing a mask has become a culture during the flu season or when the pollution goes up. Innovations in making the masks more comfortable will help people overcome the barrier of discomfort associated with wearing a mask and in making it people’s second nature,” Dr. Reddy said.
- How would you evaluate the response of the government in dealing with Covid-19?
In the beginning, the dominant response was seen by the public health sector in terms of surveillance, product controls, case retention, isolation and tracking. That was most effective in the beginning of the pandemic. Subsequent lockdown helped reduce reproduction rate from 2.8 to 1.3. Before it could touch 1 and below 1 where the virus can be contained, unfortunately the migration issue came up that compromised social distancing to a great extent.
Given the relaxations in the lockdown, the pandemic will continue to grow, as we are seeing each day. This is because we did not manage to bring the reproduction rate down to 1. There is a need for the entire private and public system to work together and jointly respond to the rising pandemic till we reach a level of immunity.
Private sector response in terms of the material resources has been good. For example, we did not have much capacity for personal protective equipment (PPE). But recently India became the second largest producer of PPE in the world. From a stage of nothing to a stage of surplus shows the resilience of the private sector to respond to a public crisis.
But a similar collaboration and cooperation is not observed in the private delivery healthcare system that is the hospital delivery system. This is because there was more focus on strengthening the public delivery systems. This included increasing the beds and ventilator capacity in government hospitals. But given the public perception and the trust deficit towards the public sector, there has been a reluctance to seek healthcare from public facilities. Public hospitals were converted into Covid hospitals with surplus bed capacity but unfortunately are running at just fifty percent capacity.
So if the planning had taken place from the very beginning, from the moment we started to realize that we may not be able to continue the lockdown till the stage of containment of the virus, we required a joint response by the private and the public. Joint planning was needed from day one. Private sector should have been involved much earlier, identifying which facility is Covid ready, pooling resources from both the public and private sectors. Clear public messaging on where they need to go for testing and treatment is equally important. Despite the gaps though, we have been trying our best to respond to the crisis and have created a lot of capacity in this short time.
- India produces the bulk of vaccines for viral infections. Do you see India becoming an important part of Covid 19 solutions as well?
This pandemic presents a silver lining for India, giving us an opportunity to rise to the occasion to meet not just our but also global health needs in terms of providing vaccines and drugs. We may not be involved in cutting edge research but a great development that took place is that most of the public research and development units, including the Council of Scientific and Industrial Research, have been opened up for public private partnership to jointly work on the development of vaccines and drugs. Most of our capacity has been already partnering with global universities including Oxford University wherein we will be in a position to manufacture to meet the needs of the public.
So we have ramped up our capacity even before we have the evidence that this vaccine will work. I think we are in a good position to be able to manufacture vaccines and drugs when they are ready. We will be in a position definitely to meet our own requirements but also meet the requirements of some the underserved regions such as Africa, South Asia and other Asian countries as well.
- How do you see India’s testing strategy for Covid 19 evolve over the past four to five months?
India has adopted a scientific and epidemiological response as far as the testing is concerned. It started scaling it up as per the requirement of the epidemic. An indicator of the adequacy of testing is the positivity rate. That is in 100 tests, how many are positive. If the positive rate does not exceed five percent, as per WHO stipulation from May, it means that testing is adequate. Since June however, the positivity rate has been climbing up, more so in metro cities such as Delhi Chennai and Mumbai and Hyderabad. This indicates that the testing is not adequate and needs to be ramped up, as the number of cases are doubling every 18 to 20 days. So testing needs to be further increased. The present capacity is about 5 lakh tests per day but given the rise in cases observed every day, we may need to recalibrate so that the positivity rate does not exceed five percent.
- The National Institute of Virology has come up with three types of testing kits, RT-PCR, IDG Eliza and Virus Neutralization Assay. What factors need to be kept in mind while interpreting these test results?
Broadly, there are two methods of testing. One, where you are testing for the presence of the virus and two, where you are testing for the immune response, i.e. the anti body response of the patient. So the two types of viral testing are where you amplify the RNA using the PCR methodology, and the other is the antigen based testing where you develop and detect antibodies in the nasal swab, no amplification. Sometimes PCR, being very sensitive, can give false positive due to contamination. The antigen testing is less sensitive, which means you may miss some cases. But it is less specific. This is an easier, safer, and quicker form.
- WHO says this is second peak of first wave, not the second wave. Does this put to rest the speculation of a second wave of Covid 19? How do we prepare for the second peak of the first wave?
The second wave means the peak shifts to the south of the globe, that is Asia, Africa, and Latin America. These countries resorted to rigorous lockdowns in the early part of the epidemic. That explains the delayed peaking in the southern region of the world. ICMR has published the zero conversion rate in April wherein the zero conversion rate was 0.8 percent of the population. This means still 99 percent of the population are vulnerable for infection. So unless the zero conversion rate reaches the herd immunity level, we cannot be safe. Herd immunity means 64 percent of the population needs to be infected.
So our response till a proven vaccine comes out will be to continue rigorous social distancing, personal protection, isolation and testing measures. We should not relax yet till we reach herd immunity, or till we have an effective drug or vaccine.
- How do we ensure that non Covid 19 healthcare needs of people are not ignored in the current times?
Non Covid needs are as important as Covid needs, especially things that we cannot avoid. Example vaccinations, ante natal care, care of TB and HIV, dialysis patients, chemo therapy, and other medical emergencies such as heart attacks and strokes. To meet these non Covid health needs, there has to be meticulous planning for resource allocation, assessment of whether these needs can be met at home except for people coming to hospitals for emergencies. Today, consultation, diagnostics and drugs are all delivered at home, through online services. Mobile clinics are also well placed to deliver healthcare at homes. This challenge is being felt across the globe, and not just in India. Fortunately in India, we have been used to telemedicine and platforms like Whatsapp to access our physicians and specialists. As a clinician, my patients reach out to me any time they want.
- What do you have to say about instances of hospitals turning away Covid 19 patients, non Covid patients, and pregnant mothers in labour. They say they don’t have beds.
A glaring instance being seen in both public and private hospitals is the lack of culture of quality. Similarly, there is a lack of infection prevention and control system and training of frontline workers. This is resulting in hospitals that are not prepared to handle suspected Covid positive cases. They are getting afraid to admit these people. The reason is that frontline health workers such as nursing staff are continuously exposed to Covid positive patients. Despite providing PPE, these workers are not well trained to handle use and dispose PPE effectively. Lot of FLHWs getting infected is becoming evident. They are suddenly resigning and leaving their jobs because of pressure from families. This is where the hospitals need to rapidly train the staff and triage patients within limited resources to segregate into Covid and non Covid. The best scenario is where the government contracts out a private hospital designed for intensive care. This may eliminate some of the current confusion. It is a real challenge. If there is an online platform can be helpful, where hospitals can upload their bed position, whether they are taking Covid patients or not. This basic information can be quickly made available on an app and be linked to say Aarogyasetu app, where people can be guided. We need to fill the public communication gap. The need of the hour is clear and coherent public communication.
Precautions are important but we must keep in mind that the fatality rate is 0.3 pc , 3 out of 1000. Therefore one must not spread fear. The fatality rate of Covid is as much as the risk one faces while travelling by road. Risk and fatality rates differ in different demographic sections like old and young. These need to be communicated effectively. People should not fear that their lives are at a risk but at the same time those who are vulnerable should be clear that they need to be protected from contracting the infection. We may create new hospitals, beds and ventilators, but what about the additional medical staff, nurses trained in intensive care, ventilator management? We do not have enough people trained in critical care. So the real shortfall is of human resources, not beds or ventilators. We need to be conscious about this and protect our medical staff and give them assurance. This the only way we can handle this crisis despite the relaxations from the lockdown.
8) What is your driving force as you work towards reforming health systems and last mile delivery of health services?
Covid 19 has laid bare the huge gaps in health systems even of the best of the health systems. Every country has to reinvest in public health measures such as disease control, disease prevention, and social determinants of health.
We do not have enough qualified public health professionals required up to the district level or even the Community Health Centre level. Our primary health care is not robust enough. Need to strengthen this. Formal, informal, AYUSH professionals need to be better organized and people need to know how to navigate this complex primary healthcare system.
Financial protection has to be expanded. We have seen many efforts towards this at state level and the Pradhan Mantri Jan Aaroygya Yojana at the central level in the recent years. This may not be sufficient, especially for the missing middle like the informal labour who are neither protected by social insurance nor by state sponsored health insurance which is meant for poor people. PMJAY has announced coverage for this section of the population but states have not announced it yet under their programs. Two thirds of our population still meets its healthcare needs through out of pocket expenses. There is an immediate need to expand the number of people covered and the percentage of illnesses and health needs covered (primary and hospital level) and what portion of their healthcare expenses are covered. Despite 60 percent coverage by PMJAY and Employee State Insurance, only a third of the total healthcare expense is covered.
We also need to strengthen the public healthcare system. Enough infrastructure is created. What is required is autonomy, different mode of financing these healthcare systems. Today we finance them through a supply based model, not demand based or performance based. The latter will make them accountable and there will be a motivation to do better.
So when you strengthen the public health care system, you create a competition to private healthcare . This is important because if there is no competition, public will get less value of services, because the ever rising cost in the private healthcare system.