The global pandemic is marching on. As I had said at the JRD Tata Oration , hosted by the Population Foundation of India on its 50th anniversary, of the lessons I have learned over the last nine or 10 months, the most important one is the significance of investing in public health and primary healthcare. Countries that invested in primary healthcare over the past decade or two are reaping the benefits now. Another lesson is the positive role of science and scientists. The global collaboration between scientists to take forward advances in knowledge so that science is continuously informing our response to the pandemic has been encouraging.
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Gendered impact
In India, the pandemic has had a differential impact on women. Despite gaps, India had seen progress in maternal mortality. There have been significant gains in infant mortality, institutional births and replacement level fertility. However, there is still a high unmet need for family planning and improved access is required to contraceptive services and safe abortions. A recent modelling study showed that because of the reduction in coverage of essential services, the prevalence of wasting in children could increase by 10% to 50%. There could also be 60% more maternal deaths because interventions like the administration of uterotonics and antibiotics, and clean birth environments, are no longer available.
COVID-19 has also disrupted the education system. It has also adversely affected access to nutritious food as a huge number of children depend on school meals.
Another worrying development is the surge in domestic violence. In India, a third of women said that they had previously experienced domestic violence, but less than 1% sought help from the police. Governments can include response to violence against women in the package of essential services.
Many women have lost their work and livelihoods. More women than men work in the informal economy and therefore their income fell by over 60% during the first month of the pandemic. In India, the number of women and girls living in extreme poverty is expected to increase from 87 million to 100 million.
A few months ago, the World Health Organization (WHO) emphasised the importance of gender analysis and gender-responsive public health policies. One of the major issues is the lack of availability of data that is disaggregated by sex and age. We also do not have data on violence against women and children. We have urged WHO Member States to collect data, report and analyse it, disaggregated by sex, and include responses to violence against women as an essential service.
Over 70% of countries reported partial or complete disruption of immunisation services. Other services disrupted include diagnosis and treatment of non-communicable diseases, cancer diagnosis and treatment, family planning, contraception, antenatal care, malaria and TB case detection, treatment facility-based births, and urgent blood transfusions, as well as emergency surgery. This will have a huge impact. On the one hand, essential services have to be provided; on the other hand, we must ensure financial protection. This can be guaranteed only if there is either a health coverage scheme, like Ayushman Bharat, or through private health insurance.
Out-of-pocket payments cause about 100 million to fall into extreme poverty every year, and 800 million globally spend more than 10% of their household budget on healthcare. The World Health Organization has been urging countries to ensure financial protection and effective coverage of health services.
The effective coverage index is a useful measure of the quality of health services — it looks at the provision and efficacy of services in terms of health outcomes. This metric suggests that 3.1 billion people worldwide would still not be covered if we continue to do what we’re doing. The index enables us to move away from just measuring process towards measuring outcomes. Many countries do not have the data systems to be able to accurately measure both mortality and the incidence of certain diseases. India needs to invest more in its vital registration system.
What can we do better?
Many countries have moved to digital technology, especially using platforms to provide telemedicine, for example, to overcome the problem that people could not meet physically. Platforms like ECHO have been used in many States to train healthcare workers and the government’s e-Sanjeevani platform is enabling telemedicine appointments.
We now have a national digital health blueprint and a road map. We want to move towards electronic and portable health records. It is important to think about not only data governance principles, but also new ways of collecting, using and sharing data, enabling local, contextualised decision-making.
We also need to think about working with the private sector, which is already playing a very big role in technology. But we need to think about technologies that are considered public health goods. At the Aravind Eye Hospital in Puducherry, for example, they did an experiment with shared medical appointments. This seemed to result in better health outcomes as well as higher productivity, apart from reducing costs and saving a lot of time for doctors.
We need to further integrate social protection systems, food systems and health systems in order to really have an impact on nutrition. India has done much to ensure these services, but it needs to expand these to protect its most vulnerable population groups. We must ensure that the pandemic does not further increase food insecurity.
False or misleading information leads to harmful behaviours, and mistrust in governments and the public health response. In the last eight months we have done an incredible amount of work with many tech companies. But infodemic management is not straightforward; it is linked to people’s beliefs and behaviour. Therefore, we’ve set up a behavioural insights group to provide advice on behaviour change.
We often think about health as purely as delivery of services to take care of the sick. The risk factors and the social and environmental determinants of health, such as the quality of water and air impact our health. But investments here are much more difficult as they lie outside the health sector. It is a question of all arms of the government looking at the impact of their policies on health.
Empowering our frontline health workers will yield rich dividends. We need to invest in them to ensure that they have the tools they need, receive regular training and mentoring, and are well paid.
We need to invest in strong institutional mechanisms and capacities in our regulatory bodies, research centres and public health institutions. We have seen so much fear, stigma and discrimination circulated on social media. This must be countered by health literacy.
India is on the path to investing in Universal Health Coverage. Financial resources are very important for this, but we also need investment in human resources and to engage and empower communities. A health system cannot only be about the supply side. It has to keep in mind how to involve citizens and the people it is trying to serve and have them involved in developing the services that we are bringing to them.
Soumya Swaminathan is Chief Scientist at WHO
