Gaps in India's preparedness for COVID-19 control

Abstract

Under-investment in public health-care system poses a challenge to India's COVID 19 containment plans. Patralekha Chatterje reports. The death toll due to the coronavirus virus disease 2019 (COVID-19) in India was of 356 as of Apr 14, 2020. Since Mar 24, 2020, India has been under a nation-wide lockdown, now extended by the Government to at least May 3, to curb the spread of the new virus. India is not among the worst-hit countries, but its grossly under-funded and patchy public health system, with huge variations between different states, poses special challenges for the country's disease containment strategy. Over the past few weeks, there have been several reported instances of patients trying to flee isolation wards in government hospitals and hide travel history. Many with exposure to suspected cases of COVID-19 and infected persons have also tried to dodge the mandatory home quarantine. These are worrying developments in the backdrop of India's latest containment plan, a 20-page document, which specifically talks about “non-pharmaceutical interventions”. “Quarantine and isolation are important mainstay of ‘cluster containment,” the document states. Quarantine refers to separation of individuals who are not yet ill but have been exposed to COVID-19 and therefore have a potential to become ill. Isolation refers to separation of individuals who are ill, suspected, or confirmed COVID-19 cases. There have been repeated reports of people escaping hospitals or quarantine in the past week. How can this impact the ongoing control measures for COVID 19? One key issue is the trust deficit in the public health system in many parts of the country. Other important factors include fear of isolation and stigma attached to those who are being quarantined and isolated. Epidemiologists and public health experts say that increasing expenditure in the public health system is key to building trust. “[Escaping quarantine] is mostly out of fear and stigma, and wanting to be with one's family since it is for a prolonged time as well as lack of income. It is difficult for people in India to understand the importance of isolation and quarantine, even though it is a response to a pandemic. The faith in the public health system cannot emerge immediately as a response to the pandemic” said Giridhara Babu, Head-Lifecourse Epidemiology at the Public Health Foundation of India. An overstretched public health-care system forces millions of Indians to turn to the unregulated private health-care sector. The Indian government's expenditure on health as a percentage of GDP still hovers around 1·5%, one of the lowest in the world. For around 52% of households in urban areas, and 44% of households in rural areas, the private sector is the main source of health care when they are sick, according to government data. “Infectious disease surveillance and in particular, the timely detection and early warning of disease outbreaks are a function of strength and capacity of the health system. This is the time to win the trust of people with a thoughtful approach. This can only be done by increasing the health expenditure by government as a percentage of GDP compared to what it is now and not just through health insurance. Creating a reliable system with a public health cadre will address these problems”, Babu told The Lancet Infectious Diseases. Stigma has aggravated the problem. Thiagarajan Sundararaman, a global coordinator of the Peoples' Health Movement—a worldwide network of grassroots health activists, points out that fear-based messaging can make a person feel that he or she is responsible for his and her disease. “Stigmatisation hampers persons from coming forward. The messaging should be emphasising that most persons would recover, but since there is a small risk, one should take some extra precautions to keep safe. Those who recover would be the greatest corona-warriors for the community”, Sundararaman told The Lancet Infectious Diseases. The state of Kerala, which successfully dealt with a Nipah outbreak 2 years ago, offers useful lessons. “COVID 19 treatment is currently focused in government hospitals. In most parts of the country, these hospitals have been underfunded, not patronised by the rich and powerful; their staff are demoralised. This does not change overnight. Trust in government is an important component in an emergency health response. We saw what trust can do when we managed the Nipah response. Kerala has always been proud of the technical quality of its government hospitals. Since 2005, the state government investment has gone up considerably. Kerala government's The Aardram project has further raised the profile of government hospitals; substantial investments have been made“. Rajeev Sadanandan, Chief Executive Officer, Health Systems Transformation Platform, told The Lancet Infectious Diseases. With limited information coming from the rural parts of the country, only the coming weeks will show the real impact of the current measures. © 2020 Flickr - Bill Bourne 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.