The COVID-19 pandemic is sign of how vulnerable and fragile our world is. The virus has upended societies, put world’s population in grave danger and exposed deep inequalities. COVID-19 pandemic is the worst combined health and socioeconomic crisis in living memory and a catastrophe at every level. In India, public health has been given important place in public policy and National health policies are formed to prevent and protect citizens and be prepared for any health emergencies.
National Health Policies of India
Health policies of Government of India (GOI) started with establishment of Bhore Committee in 1946 (Peters, Rao &Fryatt. 2003). To provide preventive and curative healthcare systems, Bhore Committee made three important recommendations in three-tiered model: public healthcare system, healthcare workers on government payroll and limiting need for private practitioners.
First National Health Policy of India
First National Health Policy (NHP) of India was formulated in 1983 to provide primary healthcare access for all Indian citizens by 2000 (Maulik et al., 2013). It is based on suggestions made by Bhore Committee. It prioritised establishment of primary healthcare service networks by using health volunteers and technology that has created referral networks and integrated network of specialist facilities. Since mid-nineties, private health sector has expanded rapidly and public health system has been reformed to suit private model by implementing user charges and outsourcing of services (Duggal, 2004).
Second National Health Policy of India
Second NHP formulated in 2002 with goals of delivering health services to general population through decentralisation, private sector’s use and increase in public healthcare spending (Singh, 2008). It emphasised use of non-allopathic medicines such as Ayurveda, Unani, Siddha and reinforced decentralised decision-making processes by providing more autonomy to states.
National Health Policy 2017: “Health in All” Approach
GOI restructured and conceptualised its health policy – NHP-2017 which is based on WHO’s “Health in All Policies” (Javed&Chattu, 2020). Main objectives of NHP-2017 included reinforcing people’s trust in public healthcare system, aligning private healthcare sector’s growth with public health goals and progressively achieving universal health coverage (UHC). In 2018 NITI Aayog released five year strategic plan (2018-22) which had four dedicated chapters on health. Both documents identified challenges in Indian healthcare system. GOI acknowledged issues such as low government funding for health, shortage of health workforce, focus on curative services, limited provision for preventive and promotive services, suboptimal functioning of primary healthcare system, weak disease surveillance systems and insufficient urban primary care systems (Lahariya, Kang, &Guleria, 2020). To check policy’s successful implementation, set targets are to be achieved in time-bound manner, such as increase of life expectancy at birth from 67.5 to 70 by 2025; reduce under-five mortality to 23 by 2025; reduce infant mortality rate to 28 by 2019. to ensure availability of paramedics and doctors in high priority districts by 2020; increase community health volunteers to population ratio in high priority districts by 2025. Most important highlight of NHP-2017 is SwasthNagrikAbhiyan or “Health in All” approach to providing “assured healthcare for all at affordable cost” (Sundararaman, 2017). NHP-2017 shows India’s commitment to achieving 3rd Sustainable Development Goal (SDG) of United Nations and recommends time bound rise in public health spending to 2.5 per cent of GDP. Ayushman Bharat was launched as suggested by NHP-2017 to achieve universal health coverage (UHC). This project was planned to achieve SDGs and its underlining pledge, which is to “leave no one behind” (National Health Authority, 2018). It is essentially designed to provide health insurance to poor, lower sections of society. It is considered one of world’s biggest schemes as it aims to cover more than 50 crores citizens. This scheme comprises two interrelated components—health and wellness centers (HWCs) and PradhanMantri Jan ArogyaYojana (PM-JAY). HWCs aim to deliver comprehensive primary healthcare (CPHC) and provide free essential drugs and diagnostic services. PM-JAY aims to provide health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalisation across public- and private-empaneled hospitals in India for 10.74 crores poor and vulnerable families.
Health Security and Healthcare investment
Health security is fundamental right under Article 21 of the Indian Constitution that deals with the “right to life”. However, healthcare expenditure in India is low. According to WHO Expenditure Database 2016, India ranks 170 out of 188 countries in domestic general government spending on health as percentage of GDP (Sharma, S., 2020). Although post-liberalised Indian economy has been growing exponentially, healthcare investment is around 1.6 percent of GDP in financial year 2020 (Pilla, 2020). Though NHP-2017 is primarily aligned with UN SDGs, due to low expenditure on health budget, India can still not meet set SDGs targets, which ensure “healthy living and well-being for all”. India’s health expenditure includes established expenditure comprising of salaries, gross budgetary support to various institutions and hospitals, and transfers to states under centrally sponsored schemes, such as “Ayushman Bharat” set under NHP-2017 (MoHFW, 2017). NHP-2017 has set its objective to “improve health status through concerted policy action in all sectors and to expand preventive, promotive, curative, palliative and rehabilitative services provided through public health sector with focus on quality” (MoHFW, 2017). The question is how government would achieve these objectives with expenditure of 2.5 percent of GDP and also without additional methods of funding as preferred method of funding healthcare is limited to way of general taxation (MoHFW, 2017).
Today there is freedom, hope and self-respect for the people in the two Union Territories. There are no deprived classes. Ethnic security one of the 16 elements of national security (Paleri, 2002) has been optimised by governance by national security (GBNS). The two Union Territories are on the fast track to maximum well-being. But will it all last? The anteforce is working overtime in perfect unison to pull the forward surge back. That is where the biggest trial of national governance lie—recycling the energy hidden in the anteforce towards proforce (Paleri, 2002). It is still a topic in infancy in national security governance. Contrasting may not be the only solution. A perfect government is the only hope even for those who oppose it unwittingly.
Existing healthcare system in context of COVID – 19
COVID-19 pandemic has challenged India. Since December 2019, more than 182 million people have been infected by the Coronavirus worldwide, and close to four million people have lost their lives (WHO, 2021). India rapidly ramped up its diagnostic capabilities and aligned its digital technology expertise. This ensured that there was comprehensive tracking of the pandemic. India rapidly instituted both case-based (Trace, Test, Treat) and population-based measures (wear masks, wash hands, maintain distance, avoid crowding and closed spaces) for COVID-19 prevention, management, containment, and control. The Center for Disease Dynamics, Economics and Policy (CDDEP) and Princeton University have estimated existing state-wise availability of hospital beds, intensive care units (ICUs), beds, and ventilators across India based on data available on website of Central Bureau of Health Intelligence (CBHI) under title “National Health Profile 2019” (The Central Bureau of Health Intelligence. MoHFW, 2019). According to CDDEP report published on 20 April 2020 and National Health Profile 2019, (i) the total hospitals in India are 69,265, i.e., (public hospitals—25,778 and private hospitals—43,487); (ii) the total hospital beds—1,899,228 (Public sector-7, 13,986; and Private sector—1,185,242); (iii) the total number of ICU beds—94,961 (Public sector—35,699 and Private sector 59,262); (iv) total ventilators—47,481 (public sector—17,850; private sector—29,631). Data indicates most of healthcare facilities in India lie in private sector and available government hospital beds and ICU beds are 0.51 and 0.025 per 1000 population, respectively; whereas available private hospital beds and ICU beds are 0.85 and 0.04 percent per 1000 population, respectively. Total number of public hospital beds, ICU beds, and ventilators in India are 713,986; 35,699; and 17,850, respectively Healthcare facilities have not been congruent to size of Indian population. Health care in India was in need of reform long before COVID-19 pandemic (The World Bank, 2020). Despite considerable progress across health indicators such as maternal and infant mortality, disease burden in India is disproportionately high, less than two-thirds of children were fully immunised in 2017–18 (Ministry of Statistics and Programme Implementation, 2020) Implementation of National Health Mission (NHM) brought some focus on social determinants of health and encouraged development of health system based on primary health care (National Health Mission. MoHFW). GOI expanded its investment to ramp up country’s healthcare infrastructure which led to improvement in health services and had impact on health indicators which have been gradually improving in India, but health for all is yet to be achieved. Life expectancy is 68.7 years, infant mortality rate is 33/1000 live births, maternal mortality ratio is 130/100,000 live births and total fertility rate is 2.3 children/woman; however inequities by geography, gender, caste and region are seen (Office of Registrar General of India, 2020).
Ayushman Bharat Mission (ABM) has started insurance coverage for medical and surgical procedures for hospitalised patients belonging to socioeconomically vulnerable families similar to RashtriyaSwasthyaBimaYojna (MoHFW. 2019). Development of subcenters into health and wellness centers is under NHM. NHM and ABM deal with primary and secondary care, respectively, should advocate for comprehensive public health-oriented intersectoral health promotion initiative. Amid COVID-19 pandemic times, 41,000 Ayushman Bharat Centers have been providing healthcare services to 8.8 crore people (Kumar, Thakker&Arora, 2020).
Actions Initiated to stop spread of pandemic / mitigate hardship caused due to pandemic
Lockdown
Lockdown is most preventive measure to stop spread of novel coronaviruses by GOI. On 24th March 2020, Prime Minister Narendra Modi announced nationwide lockdown for 21 days from 25th March 2020. Several preventive measures were instituted, including travel restrictions, closure of educational establishments, theatres, banning of mass social, religious, political ceremonies. On 4th April 2020, GOI extended lockdown to 3rd May 2020. Lockdown 3.0 was announced by GOI to further extend same until 17th May 2020. The pandemic affected areas were divided into three zones, namely green zone, orange zone, and red zone, where red zone falls under category of most affected and has strict regulations. On 12th May 2020, lockdown was further extended from 17th May to 31st May with new guidelines for lockdown 4.0. In lockdown 4.0, Ministry of Home Affairs (MHA) allowed salons, barbershops, shopping complexes, sports complexes, except in containment zones, to be opened from 18th May 2020 with staggered timings. In June, MHA had released fresh guidelines stating that reopening phases will “have an economic orientation” (Sharma, N., 2020). Lockdown restrictions have been continued in containment zones, while operations would be permitted in other regions in phased manner. This first reopening phase was called “unlock 1” and was allowed to reopen shopping malls, religious sites, hotels, and restaurants from 8th June 2020 (Sharma, N., 2020). Large social and political ceremonies/activities were still forbidden, but inter-state travel ban was lifted. Night curfew was, in effect from 9 PM to 5 AM. GOI had authorised states to place necessary restrictions on all social, religious, and political activities (ET Bureau, 2020). On 1st July 2020, GOI announced new guidelines for “unlock 2.0”, which started from 1st July 2020 that included opening of training institutes, no restrictions on interstate and intra-state movements of persons and goods (except in containment zones), night curfew relaxation, etc. (ET Bureau, 2020). GOI has issued guidelines for unlock 3 and 4; however, ban continues on large gatherings.
National Task Force for COVID-19
Indian Council of Medical Research (ICMR) has constituted National Task Force (NTF) for COVID-19 to effectively and systematically contribute to ongoing pandemic’s scientific and technical responsibility. Main objectives of NTF are to immediately initiate research studies and identify research priorities for clinical research, diagnostics and biomarkers, epidemiology and surveillance, and vaccines and drug development (Hindustan Times, 2020).
COVID-19 Protective Kits
Personal protective equipment (PPEs) is protective device designed to protect workers’ health by reducing exposure to biological agents. PPE kits include goggles, face-shields, gloves, masks, gowns / coverall, headcovers, In initial days of coronavirus outbreak, India has imported PPE kits from various countries like Singapore, South Korea, and China. India has imported nearly 17 lakh kits from China on 5th April 2020, out of which 50,000 kits had failed quality test based on Indian standards (Sindwani, 2020). Against backdrop of poor quality of imported PPEs, India started producing and manufacturing same. India became world’s second-largest PPE kit manufacturer in just two months, with average production of 1.7 lakh PPE kits per day (Swarajya, 2020). This initiative results from joint efforts made by various government institutes like Defence Research Development Organisation (DRDO), Ministry of Textiles, along some private manufacturers (Economic Times,2020).
Vaccines
As novel coronavirus continues to play havoc with lives and livelihoods worldwide, scientists have been making efforts to find a vaccine that could combat the coronavirus, Several research institutes in India have been working on separate programs to find coronavirus vaccine. The Serum Institute of India (SII) has been producing the Oxford-AstraZeneca vaccine, named ‘Covishield’, for domestic use and exports. Another Indian bio-pharma company, Bharat Biotech, together with the Indian Council of Medical Research (ICMR), developed ‘Covaxin’ (Dhar, 2021), which is India’s indigenous COVID-19 vaccine. Covaxin is an inactivated vaccine developed from an infectious SARS-CoV-2 virus strain, which has shown extensive safety and effective immune responses (Kumar, 2020). In initial days of coronavirus outbreak in India, Ministry of AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy) recommended some immunity-boosting measures, particularly for respiratory health that includes intake of warm water and “kadha,” use of Ayurveda herbs in cooking and doing Yoga (AYUSH, 2020).
Economic Packages
For boosting economy and industrial sectors, strengthening country’s health infrastructure and for treatment of COVID-19-infected people, GOI provided financial package of Rs 15,000 crores (Outlook India, 2020). The fund’s value is equal to 0.1 percent of India’s GDP and was devoted to improving health facilities including testing facilities for COVID-19, isolation beds, PPE, ICU beds, ventilators, etc. India’s finance minister announced stimulus package of 1.7 lakh crores valued at 0.8 percent of GDP. Key elements of package included provision of food, cooking gas and cash transfers to lower income households; wage support to low-wage workers; insurance coverage for workers in healthcare sector (Business Insider, 2020). Keeping in mind need for dedicated national fund with primary objective of coping with any kind of emergency or disaster situation, public charitable trust was formed under name “PM CARES, i.e., Prime Minister’s Citizen Assistance and Relief in Emergency Situation Fund” (National Portal of India, 2020). GOI declared economic package worth Rs. 2,097,053 crores under scheme of “Atma-Nirbhar Bharat” as post-pandemic economy plan aimed at helping economy to recover from loss caused by COVID-19 (Ohri&Palepu, 2020).
Innovations to ensure availability of health services
Innovations have been put into practice to ensure availability of health services, which include providing legal status for teleconsultation for medical care, home delivery of medicines and engagement of AYUSH providers for preventive and promotive health services. Number of regulatory measures such as capping price of laboratory tests and charges for hospital beds in private sector have been initiated to ensure access to care (Lahariya, Kang &Guleria, 2020).
Actions to be taken immediately as well as from long term perspectives
References
Global times (June 6, 2018) Unmanned ‘shark swarms’ to be used in sea battles, Global Times, Retrieved from- http://en.people.cn/n3/2018/0606/c90000-9467892.html.
Gupta, S (Oct 27, 2020) India to get 5 military theatre commands, one each for China and Pakistan, Hindustan Times, Retrieved from- https://www.hindustantimes.com/india-news/india-to-get-5-military-theatre-commands-one-each-for-china-and-pak/story-UzFJNollsvpj3tcUetWVNM.html.
Malhotra, R (February 2021) Artificial Intelligence and the future of power, New Delhi, India, Rupa.
Morgan, F (March 2020) Military applications of Artificial Intelligence, Santa Monica, US, Rand Corporation.
Tewari, S (June 2019) Disruptive Technologies, Pune, India, Madhavi.
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