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. COVID19 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 Swasth Nagrik Abhiyan 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 Pradhan Mantri Jan Arogya Yojana (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).

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 Rashtriya Swasthya Bima Yojna (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 interstate 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 postpandemic 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 perspective

• To prepare India for new phases of COVID-19 pandemic and to respond effectively, comprehensive strategy with clear goals, milestones and priority actions is needed. India should apply public health measures systematically, consistently and rigorously in every state at the scale epidemiological situation requires.

• All states to have explicit evidence-based strategy to curb COVID-19 transmission.

• Vaccination must be combined with testing, contact-tracing, isolation, quarantine, masking, physical distancing, hand hygiene and effective communication with public.

• Production of and access to COVID-19 tests and therapeutics, including oxygen, should be scaled up in India with full funding for procuring tests, strengthening laboratories and running surveillance and tests.

• Vaccine rollout needs to be scaled up urgently and equitably in India and vaccines be delivered across all states in India. Virus is also mutating and creating new challenges. Variants may still emerge that our vaccines cannot manage. More quickly we vaccinate now, less likelihood there is of ever more variants emerging.

• India recognises WHO COVID-19 Strategic Preparedness and Response Plan for 2021 provides useful technical guidance but there is need for higher level roadmap for ending pandemic with clear targets, milestones and dates to guide and monitor implementation of efforts towards ending COVID-19 pandemic..

Capacity Building

India spends around 1.28 percent of its GDP on health, there is just one bed per 1844 patients in government hospitals and doctor-patient ratio is 1:1445, far from WHO recommended one doctor per 1000 patients. There is urgent need to make sizeable allocations to annual health budget to build capacities to allow for rapid response to public health emergency. Areas that require focus include creation of hospitals; creation of reserves of personal protective equipment, testing kits and masks; enhancing supply chain of critical health related products; scaling up testing abilities of labs across India; strengthening R&D for vaccine development. While ‘flattening the curve’ through social distancing and hygiene has been at forefront of all government initiatives, we must enhance capacity of healthcare systems. (Sharma, M., 2020).

Public Private Partnership

Private hospitals accounted for 55 per cent of all in-patient hospitalisation according to 2017 -18 National Sample Survey on household social consumption related to health. GOI needs to strengthen medical infrastructure through private sector partnerships. Ayushman Bharat Pradhan Mantri Jan Arogya Yojana has laid down blueprint for such engagement. Pooling resources of private healthcare establishments would prevent overstretching public health infrastructure when dealing with public health emergency of COVID – 19 in India (Sharma, M., 2020).

Community level preparedness

GOI should utilise existing service model at local level from districts to villages in its pandemic response. Devolution of powers to village panchayats to manage primary health centres would bring in ownership and accountability. Pandemic response measures such as lockdowns and social distancing can be better implemented by involving villages.

Rapid response teams

Outbreaks will emerge and need speedy containment. Rapidly deployable surveillance teams comprising of public health experts, virologists, epidemiologists and frontline health workers that can gather epidemiological evidence can help arrest spread transmission of virus.

Leveraging technology

Employing Artificial Intelligence and Data Analytics to predict extent of spread of virus outbreak has many benefits. GOI must foster innovation and engage with tech firms to scale up disease surveillance capabilities which will provide inputs for swift response. Mobile based applications, such as ‘Arogya Setu’, and other state-specific applications were effectively used for contact tracing and to deliver public health messages. CoWIN app is used for facilitating vaccinations.

Non pharmacological interventions are equally important and effective

War against COVID – 19 has been fought by people adhering to non- pharmacological interventions or ‘social vaccines’ of wearing face mask, handwashing and physical distancing. Till effective therapies or vaccines become available and even thereafter, these non- pharmacological interventions will continue to play key role in decreasing disease burden (Lahariya, Kang & Guleria, 2020).

Decentralised Health Services

The organisation of essential health services must be decentralised. One-size-fits-all approach is untenable since numbers of COVID-19 cases and health services differ substantially from district to district (COVID- 19 India, 2021). District-level groups that have autonomy to respond to rapidly changing local situations must be empowered to receive funds and resources to coordinate efforts across all sectors of health system, from front-line workers to tertiary care.

Multi-sectoral collaboration is essential for preventive and curative health

Keeping people safe and healthy requires interventions across broad range of services, including testing for identification of those with infection, tracing the healthy who have been exposed and are at risk of falling sick, isolating those who are sick and can transmit infection, treatment for those who need medical care. Pandemic health issues can be tackled by taking non silo approach with teamwork between health and non-health contributors (Lahariya, Kang & Guleria, 2020).

National Pricing Policy and Cap on Health services prices

Transparent national pricing policy and cap on prices of all essential health services— ambulances, oxygen, essential medicines and hospital care are must. Hospital care should not require out-of-pocket expenditure and costs should be covered by health insurance schemes for all people (FE Bureau, 2021). Fifteenth Finance Commission constituted high-level health expert committee, which recommended increasing government funding for health to 2.1 per cent of GDP. In wake of pandemic, it has been revised to 2.5 per cent for health, to align it with recommendation of NHP 2017 (Lahariya, Kang & Guleria, 2020).

Dissemination of Evidence-based information on management of COVID – 19

Evidence-based information on management of COVID-19 must be widely disseminated. This should include suitably adapted international guidelines for home care and treatment, primary care and district hospital care in local languages that incorporate local circumstances and clinical practice (WHO, 2021). Guidance should be offered by government on appropriate use of Indian systems of medicine, especially for prevention and health promotion interventions (Ministry of AYUSH, 2021).

Human Resource in Health Sector

All available human resources of health system, must be marshalled for COVID-19 response and adequately resourced, including recalling retired medical professionals, with sufficient personal protective equipment, guidance on use of clinical interventions, insurance and mental health support. Implementation of decision to deploy final-year medical students and AYUSH students in COVID-19 response should be extended to nursing and paramedical students (ET Bureau, 2021).

National Health Threats Council

National Health Threats Council is vital to success in future which would help secure highlevel political leadership and ensure attention to pandemic prevention, preparedness and response is sustained over time. The Council should be inclusive and legitimate voice of authority with ability to utilise both accountability mechanisms and provide access to financing to ensure preparedness as well as response at national level.

Vaccines

Central systems to procure and distribute COVID-19 vaccines free of cost should be established in departure from current policy of decentralised procurement through state governments (Lahariya, 2021). Such approach would optimise prices and minimise inequities that may result from differential fiscal and capacity contexts. State governments must decide on priority groups for vaccination to optimise use of vaccine doses, which can be expanded as supplies improve.

Community Engagement and Public Participation

Community engagement and public participation must lie at heart of India’s COVID-19 response. Grassroots civil society has historically had crucial role in people’s participation in health care and other activities, such as in strengthening COVID-19 response in Mumbai (Golechha, 2020). Active collaboration between government and civil society organisations is necessary to create and disseminate accurate information, enabling home-based care, emphasising prevention, helping access to life-saving treatment and promoting vaccination.

Transparency in Data Collection

There must be transparency in data collection to enable districts to proactively prepare for likely caseloads in future. Health system personnel require data on age and sex disaggregated COVID-19 cases, hospitalisations, mortality rates, community-level coverage of vaccination etc.

Promulgate Indian Public Health Act

Parliament should promulgate Indian Public Health Act with mandate to protect health of people as fundamental right to health and health care. Public Health Commission should be established to implement provisions of the Act and achieve coordination of various initiatives in Ministry of Health and Family Welfare.

Strengthen Health System in India

Health system needs to be strengthened in systematic and comprehensive way. It is worthwhile to carry out situation analysis of challenges, prioritise interventions and prepare detailed plan for action, engaging policy makers, decision makers taking input from technical and subject experts. All interventions are done to ensure that intermediate objectives of health systems such as access and quality are fully achieved. Final end goals are to ensure equitable health outcomes for all people, ensure financial protection, improve responsiveness and bring efficiency. The pandemic should be viewed as an opportunity to improve and strengthen health system in India (Lahariya, Kang, & Guleria, 2020).

India’s engagement with other countries in combating COVID – 19 pandemic

Medical and COVID - 19 related supplies to other countries

India helped several countries by providing medical and other COVID-19 related supplies. Under Mission SAGAR (Security and Growth for all in the Region), Indian naval ship Kesari delivered food and medical assistance to island nations of Maldives, Madagascar, Mauritius, Seychelles in May 2020 (Roche, 2020). Similar assistance was given to neighbouring countries like Bangladesh, Nepal and Bhutan. India sent essential medicines to around 150 countries to tackle COVID – 19, 82 of them were sent as grants (Economic Times, 2021).

Vaccine Maitri

Under Vaccine Maitri initiative, India has sent 6.6 crores of vaccines to 95 countries in Asia, Africa, South America and Caribbean (MEA, 2021).of which, more than one crore vaccine doses were given as grants and about two crores supplied as part of COVID-19 Vaccines Global Access (COVAX) facility.

Tech assistance in apps to other countries for COVID – 19 applications

India as Tech leader has offered technical assistance in apps like CoWin to other countries for facilitating vaccinations.

World Community support to India in fight against COVID – 19

The constructive role played by India during this difficult time has created immense goodwill especially among smaller countries in immediate and extended neighborhood. It has helped India during its crisis situation. In India’s fight against deadly second wave of COVID – 19, entire world community supported India, as aid and supplies poured in from all directions which played important role in India’s fight against the Coronavirus. It received around 50 oxygen plants, about 20000 ventilators and thousands of oxygen cylinders, oxygen concentrators, drugs and other medical supplies from across the world (MEA, 2021).

Conclusion

COVID-19 can be characterised as global health crisis having multidimensional implications on all facets of life like health, economy, education for entire world. GOI had taken several curative measures like lockdown, quarantine, social distancing, etc. to combat COVID-19. India needs to expand public healthcare system and enhance expenditure as per set goals in NHP-17 and WHO standards. The constructive role played by India during this difficult time has created immense goodwill especially among smaller countries in immediate and extended neighborhood. It has helped India during its crisis situation. There is need to craft robust health response system, employing entire government approach. GOI should lay greater emphasis enhancing healthcare capacities, epidemiological survelliance, health technologies, community readiness and integrated response from all stakeholders to build resilience needed to address future health emergencies.

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