Swine flu is a wake-up call for the health system

Every time a disease outbreak is reported, the government swings into action. High level review meetings are held in the health ministry and the cabinet secretariat, guidelines are issued for states, health minister visits hospitals and makes reassuring statements that  there is ‘no shortage of drugs and vaccines’. On the ground, however, government hospitals are crowded with patients complaining about lack of proper care, confusion prevails on diagnostic tests and medicines, and generally there is an atmosphere of panic among the general public. This is pretty much the picture whenever a disease outbreak occurs in India or there is a threat of a pandemic touching Indian shores. We have had a series of them in the past decade – Severe Acute Respiratory Syndrome (SARS), Avian influenza (bird flu), swine flu, Ebola and so on. The current outbreak of Influenza A (H1N1) -- popularly called swine flu because it originally got transmitted to humans from swine -- is no different. The last major outbreak of this flu in India was in 2009 when Influenza A (H1N1) was declared a pandemic by the World Health Organisation. 

Has anything changed in our preparedness to address such outbreaks in the past 10 years? The good news is that India has developed a national disease surveillance system with help from external agencies like the World Bank and the US Center for Disease Control. Under the Integrated Disease Surveillance Project, disease surveillance units have been established in all the states and they have been networked via satellite and computer links. Inter-disciplinary rapid response teams with experts from various sectors like epidemiology, entomology and microbiology have been trained in each state so that they can investigate outbreaks locally and suggest measures for containment, if necessary. A dozen influenza surveillance labs have also been established across the country. At the national level, the erstwhile National Institute for Communicable Diseases is being transformed into a more modern outfit called the National Centre for Disease Control (NCDC). Guidelines relating to patient categorisation, hospitalisation, clinical management, infection control and laboratory testing for influenza have been developed and shared with states. An outbreak monitoring cell to provide timely information about various epidemic-prone diseases is also functional.

While all this is praiseworthy and should ideally help us address outbreaks reasonably well, the problem lies in actual implementation and the capacity of the state-funded health systems to handle epidemics and emergencies. Advances made in satellite technology and cyclone warning models could not save lives in coastal states like Odisha till the time local administration in cyclone-prone districts developed the capacity to act on early warnings. Much the same way, surveillance systems however robust they may be would be of little use until our public health system is able to act on information coming from surveillance labs and is capable of taking necessary steps. The number of public health and infectious disease experts both in central and state health departments is woefully inadequate. Manpower in other tiers of the health system, too, is inadequate.

Merely having a surveillance mechanism is not going to produce the desired results, especially when we have a weak public health system and an unregulated private health system. The private sector today provides nearly 80 per cent of outpatient care and about 60 per cent of inpatient care. However, when outbreaks like swine flu or SARS occur private sector draws into a shell. Patients are denied admission on the pretext of private hospitals not having isolation wards or the fear of losing medical tourists. Pathological labs start charging exorbitant fees for conducting diagnostic tests, as has been happening in the case of the current outbreak. Chemists begin hoarding or black marketing essential drugs like oseltamivir (trade name Tamiflu), working in tandem with private doctors and hospitals. As a result, all the burden of handling an outbreak falls on the already-overburdened public health system. Specific executive orders have to be issued to discipline private sector during outbreaks but all such measures are short-term. 

The situation is all set to worsen during future outbreaks, because the present government has made it clear that it neither plans to increase investment in the public healthcare system and strengthen it nor wishes to regulate private sector. The government (central and states together) currently spends 1.04 per cent of its GDP on health. The National Health Policy of 2002 had targeted to increase it to 2 per cent of GDP. The National Health Policy 2015 draft issued by the Modi government proposes “a potentially achievable target” of 2.5 per cent of GDP but says that since this target “represents an almost four fold increase in five years, a longer time frame may be appropriate to even reach this modest target”. In effect, no clear commitment has been made to increase public investment in health over the next five years. While this is so, the demand for regulating fee structure in private sector has been rejected because this smacks of the return of “license raj” and “unnecessary and inefficient government interference in private health sector growth”, according to the policy draft. The central government had enacted the Clinical Establishments Act 2010 to regulate private sector, but only a few states have adopted it. Corporate hospital lobbies as well as medical bodies like the Indian Medical Association are opposed to any regulation. Instead of regulation of fees and quality, the new policy emphasises the route of accreditation and self-regulation. This approach ignores the havoc played by self-regulatory bodies like the Medical Council of India in the field of medical education.

Moreover, the health policy draft envisages the public health system to eventually become a “purchaser” of care from the commercial private sector. The private sector engagement, according to the policy draft, would largely take the form of purchasing care from private hospitals on a reimbursement basis against cashless services provided by them. Purchase of care from private sector would be both for secondary care hospitalisation and for tertiary care. “Such extensive use of purchasing as a means of financing would require the creation of special institutional mechanisms at the national and state level – in the forms of trusts or registered societies”, the policy says. An unregulated or poorly regulated private sector and a weak public system are sure recipe for disaster. One shudders to think of the consequences of such a policy during a pandemic or health emergency in the future.

The writer is a columnist and author based in New Delhi