Recommendations by experts fail to impress

Though aptly titled, India’s resurgence of COVID-19: urgent actions needed,^[1] the article authored by several eminent Indian personalities under the umbrella of Lancet Citizens’ Commission on Reimagining India’s Health System, fails to capture or address the exigency of India’s serious predicament. In fact, the article is a rambling document that enumerates a laundry list of to dos, most of which are outdated, irrelevant or long-term solutions inapplicable to an acute crisis. More importantly the document overlooks what measures have been taken so far and thus projects a skewed perspective.

The authors list eight broad set of recommendations.

The first recommendation is that “the organization of essential health services must be decentralized.” Decentralization is an attractive buzzword universally parroted during the current crisis. The call for decentralization is redundant as health is a state subject under the Indian Constitution and therefore decentralized.

The process of decentralization of health care services began in India in the mid-1990’s. The 73^rd Amendment to the Constitution of India (1993) provided the legal framework for decentralization; a series of systemic reforms were introduced that delegated administrative and financial responsibilities to the districts in the management of health care institutions.^[2] Subsequently, the National Rural Health Mission (NRHM) introduced in 2005 bolstered this concept.^[3]

However, there does exist “a substantial gap between the spirit of the NRHM guidelines on decentralization and the actual implementation on the ground. There is a need for substantial capacity building at all levels of the health system to genuinely empower functionaries, particularly at the district level, to translate the benefits of decentralization into reality.”^[3]

Decentralization is a work in progress that is not ready for prime time yet. Its role in the management of an acute crisis like Covid-19 in the context of the current health infrastructure is limited without expert medical guidance from the state or the center to tackle this novel disease.

When the entire country is engulfed by the same problem a centralized approach may offer more benefits especially with regards to planning, strategy and management guidance as the Central government has access to more resources both medical (several advisory bodies) and financial. District specific modifications could then be adapted.

Examples of decentralized success stories like Nandurbar, a tribal district in Maharashtra where a far-sighted district collector Dr. Rajendra Bharud was able to effectively plan for the second wave is a unique situation: ^[4] The medical background of the chief local administrator was crucial to the outcome and not reproducible in other districts.

A price cap on essential health services such as ambulances, oxygen, and hospital beds is a welcome suggestion as is the recommendation to have health insurances cover the entire cost of hospital stay for Covid patients. (Recommendation 2).

On April 3, 2021 Union Minister of Home Affairs sanctioned the release of ₹11,092 crore under the State Disaster Risk Management Fund to all States to aid in tackling the COVID-19 pandemic.^[5] Therefore, for the authors to reiterate this point in their May 25 article is superfluous (Recommendation 2).

The recommendation that “clear, evidence-based information,” that incorporates “suitably adapted international guidelines” must be widely circulated is based on an old references^[6] (a reference from February).

The AIIMS/ICMR- Covid-19 Task force has guidelines that are available online^[7] and are continuously being revised for latest developments. On May 17, the guidelines excluded the off-label use of convalescent plasma. With regard to drugs such as Ivermectin and HCQ the guidelines clearly state that they are therapies based on low certainty of evidence^[7] in keeping with scientific practice.

It is commendable that the article refers to the health benefits of Indian system of medicines and yoga but these measures can hardly be called acute interventions.

Coming to the question of marshalling health care providers for this crisis, Dr Devi Shetty one of the authors highlighted this issue at a virtual conference in late April.^[8] The government responded promptly and on May 3 and agreed to deploy final-year MBBS students, BSc and qualified nurses for Covid duties. In addition, it announced incentives in future recruitments for medical personnel completing 100 days of Covid duties.^[8]

The government of India introduced its telemedicine service, eSanjeevani, on August 9, 2020 in line with its “Digital India” initiative.^[9] The system which provides both doctor to doctor and doctor to patient interactions has been effectively used to diagnose and treat patients in remote areas. As of December 2020, the service had logged in more than 1 million consultations,^[10] is being used in more than 550 districts and is being expanded rapidly

The suggestion that “central systems to procure and distribute COVID-19 vaccines free of cost should be established in a departure from the current policy of decentralized procurement through state governments” is only half the truth. India’s entire vaccination program from its inception in January till April was entirely managed by the Center right from procurement to supply. Dr Vinod Paul, chairman of the National Expert Group on Vaccine Administration for Covid-19 has clarified the misperception that is being disseminated: “The Centre ran the entire vaccine program from January to April and it was quite well-administrated compared to the situation in May. But states that had not even achieved good coverage of healthcare workers and frontline workers in 3 months wanted to open up the process of vaccination and wanted more decentralization. Health is a state subject. The liberalized vaccine policy emerged from constant requests made by the states to give states more power. The fact that global tenders have not given any results only reaffirms what we have been telling the states from day 1: those vaccines are in short supply globally, and it is not easy to procure them at short notice.”^[11]

The vaccination program exemplifies how decentralization can be counterproductive. The decentralized vaccine policy introduced in May 2021 proved to be a disaster. On June 7, accordingly the Prime Minister announced that the Center would retake charge from June 21 and that procurement will be at the central level.

As of May 30, India had administered 208 million doses and stands second only to the United States (294 million). These numbers are quite impressive when analyzed within the framework of effective targeting. Of the 270 million people in the vulnerable age group (45 plus), 113 million (41%) have received one dose and another 27 million (10%) have received both doses as of May 19.^[12]

Furthermore, the government has made arrangements with 8 vaccine manufacturers to acquire more than 2 billion doses by year end which would cover the entire population.^[13] Finally, the authors recommend cash transfers to those affected to alleviate the “profound suffering and risk to health caused by loss of livelihoods.” The Government of India has been conscientious about of its fiscal and welfare responsibilities toward its citizens. During the first wave on March 26, 2020, the Finance Minister announced an INR 1.7 trillion (22 billion USD) relief package to help India’s poor tackle the crisis. The relief package included free food grains for 3 months (later extended to 6 months) and direct cash transfers to over 800 million people via direct benefits transfer-a digitalized cash transfer process popularized by the Modi government which allows instant cash transfer into a beneficiary’s account.^[14,15]

Likewise, during this second wave, despite a Covid sensitive budget just announced on February 1, 2021 the government is contemplating a fresh Covid relief package to tackle the economic fallout of the second wave and has already announced free food grains for the poor till November of this year.^[16,17]

In conclusion, the expert report disappoints. It proves to be a pedestrian document that lacks the insight of expertise or the diligence of meticulous groundwork. It fails to provide any additional or robust solutions to deal with the second wave. Indian experts writing in the Western media should attempt to post an authentic picture from the ground instead of feeding into the cliched stereotypes of India as a dysfunctional inept nation that the Western media would like to perpetuate.