The year 2020, defined as it is by the COVID-19 pandemic, has shown us more clearly than ever that public health facilities are the first and arguably only responders during a time of dire need. Consider this: Karnataka started its combat against the pandemic with the government-run Victoria Hospital catering to all victims as the designated hospital, and it remained so for the longest time.
Fighting against the disease has its share of lessons. These include strengthening the surveillance system for early detection and isolation, increased manpower and logistics for contact tracing and control measures and better information management and communication for managing the crisis. Mortality reduction was possible in Karnataka only by strengthening the public health facilities in terms of infrastructure and better clinical management protocols. All these efforts were done primarily by protecting vulnerable communities and preventing stigmatization.
These lessons necessitate a booster of what I call ‘3As’ to public health systems: allocations, autonomy and accountability.
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The coronavirus has dramatically changed the health sector landscape with the public sector severely drained of its resources. This constraint is artificial as the government allocates less than 2% of the State's GDP, with a significant proportion, to manage the curative illness. Greater allocations are needed for several reasons.
Public health efforts involve evidence-based, multidisciplinary measures to assure that people of Karnataka are healthy. While medicine and reimbursements mainly focus on treating illness in individuals, public health activities ensure that societies remain healthy. Increased allocation to preventive and rehabilitative action is necessary by ensuring equity, partnerships, and social justice through organized efforts of society. A competent and well-oriented public health cadre is essential to steer the changes towards healthy Karnataka.
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More allocation is also necessary to ensure that salaries for doctors and healthcare professionals are comparable to that of the Union government. This will ensure that vacancies are filled with high quality, qualified and competent manpower. Greater financial allocation is needed for addressing the dynamic need of shortage in drug supplies, diagnostics, beds and other resources. The Health Department did a phenomenal job in responding to the crisis in 2020. However, sustained efforts in ensuring infrastructure and trained manpower in healthcare facilities can attract the patients to the public sector.
It should be noted that urban areas are the worst hit during a pandemic and generally have deficient health workforce. There are only 135 health centres for 198 wards in Bengaluru with one health centre for 90,000 people. The city recruited 1,786 ASHA workers during the pandemic. The health manpower in urban areas needs to be strengthened to offer primary health care services.
The State needs more resources to ensure that people with comorbidities, the most vulnerable, and their families are diagnosed and treated. The State should strengthen the Non-Communicable Diseases Registry, by registering every person with hypertension, high glucose levels and cancer. Early diagnosis and adequate treatment can reduce the costs of reimbursements and strain on the budget. Otherwise, we will very soon be spending greater allocation on reimbursements.
Autonomy
The public health system needs to be sensitive to citizens’ needs and changing realities. Autonomous institutions, modelled on the Jayadeva Institute, can ensure that efficient public institutions can be created to serve the community and respond quickly.
Autonomous institutions can efficiently coordinate and communicate for rapidly deploying people and resources. Autonomy for the government functionaries can help efficiently run the health system, especially in a crisis such as a pandemic.
Accountability
The public health systems should also be held accountable for their performance in ensuring adequate services of reasonable quality, and continuity of care. The goal should be to create inter-connected systems incorporating early warning systems and information sharing in real-time to manage routine functioning and contain the crises. Greater accountability is needed to ensure that funds and power allotted are subjected to proper checks and balances and audits.
With increased allocations, autonomy and greater accountability, the public health system can be reconfigured to ensure healthier, resilient societies with proactive measures to tackle future pandemics. COVID-19 is a reminder to invest in public health. We can only ignore this call at the cost of another looming pandemic.
(The author is professor, Head-Lifecourse Epidemiology, Indian Institute of Public Health-Bengaluru. He is a member of State’s COVID-19 Technical Advisory Committee.)