The impact of the pandemic on world is not only on lives but also on the economy that would inflict all who are alive. Any sector that suffered the most is healthcare, across the board, across the globe. In addition to over 3.5 million lives lost, the dent in GDP growth is massive, and the COVID-19 global triggered recession is the deepest since the end of World War II. It is, therefore, essential to have an integrated view on the situation of the healthcare system, a huge challenge faced due to inequity or accessibility to healthcare including vaccines, and way forward bring the economy on track and ensure better recovery post-Covid 19 pandemic.
After World Health Organization (WHO) declared the outbreak a Public Health Emergency of International Concern on 30 January 2020, and a pandemic after good 40 doomsdays, all the scary events covered by media about Covid 19, then named 2019 novel coronavirus (2019-nCoV), ran fast-forward the Contagion movie in our thoughts. Since then, we have not come out of some of the fear or worries, even until we, fortunately, are fully vaccinated. Total of over 18 months of the ordeal, losing millions of precious lives, having seen way too many sufferings, and way way too many thrown into financial jeopardy, we are faced with the biggest question after the extinction of dinosaurs, that whether our future of humanity is independent and safe? Since the core of this global problem is science, and like science fiction, we would want to go in the future and see if our future is better than today. Not sure, if it looks that way anymore! At present, this problem falls in the ambit of healthcare and has deep implications for regional and global economic wellbeing. The Contagion movie did one thing that it set a primer for deadly outbreaks, but it did not prime us on how to prepare for the future. Of course, a movie ticket cannot buy more than that for us. So here we stand, we took that sci-fi movie just as entertainment, and since none of any generation alive did experience the last pandemic, the Spanish Flu of 1918, we got trapped humbly unprepared, scrambling to deal with chaos and patching the cosmic gaps in healthcare with any and many ad hoc arrangements.
Not that it was possible to fully prepare for such a cataclysmic event, but it was at least possible to have fewer regrets for not preparing what was possible. It is not Christian to play passing the parcel of blames, but certainly, a conscious call to learn a lesson two. It is more relevant for India, as for first it got lucky that it got few extra weeks before Sars-Cov-2 got an opportunity to spread, and well-wishers of India alerted key offices that gave a knee-jerk right in time before spread got into exponential phase. Since timely nation-wide lockdown flattened the first wave, a general misconception crept in that Indian have some sort of resistance to Sars-Cov-2 and people of India and healthcare system has defeated Covid pandemic. This misinformation instilled complacency and left India vulnerable to the second wave. We do understand the subscription of that misconception by the general public, but the complacency of the scientific and medical community worries us more than it astonishes us! Though some random unfounded discussion or communications were offered by those who were accountable and responsible in the scientific and medical community as to substantiate the role they played, none of those can qualify as a scientific and systematic approach. The second wave claimed way too many precious lives (no point throwing numbers as those numbers are incorrect and on the top situation stays unusually dynamic), the sheer unaccountability, at least of those who were supposed to gather intelligence, set alert about the second wave, and propose mitigation plans, is unacceptable! We have the burden of so many lives lost so it is unethical not to say that they let us down as it was the case that the defense ministry misinformed the prime minister of India about an aggressive move of PLA and the country’s defense caught sleeping when PLA attacked India in 1962 and faced most humiliating defeat!
Like many countries, India too lacks medical supplies and care facilities, inequalities in the delivery of quality healthcare services. No one on this planet can come up with a pragmatic solution as to how to get everyone vaccinated of a population of over 1.4 billion, and that too in a year’s preparation time. Another problem that a country of 37 states, with a mind-boggling number of variations, lackadaisical and non-cooperative approach of states when it comes to a collective initiative. This a sure-shot recipe for creating inefficiency and widening equity gaps.
The most pertinent question is what lessons are learned, what metamorphosis is envisioned in the scientific/medical set up and what reform is strategized for healthcare?
It is extremely critical to translate the tough lessons learned during the pandemic into the future of medicine, and healthcare. It is important to bring innovation at an accelerated pace, improve logistics for public health, the creation of an efficient manufacturing and distribution system for critical supplies, and revamp the scientific and medical frameworks.
Healthcare systems across the world faced challenges
Pandemic is beyond any healthcare system and hence COVID-19 exposed weaknesses in almost all health systems, whether it was from rich and poor countries. No one around the world would disagree that the healthcare system needs overhauling and strengthening. Health ministers from the 20 most advanced economies (G20) gave a joint statement in a virtual meeting hosted by the group’s current president Saudi Arabia, “the COVID-19 pandemic has highlighted systemic weaknesses in health systems.”
The healthcare system of New York City, which boasts about its outreach, modernization, and sophistication, the decimation of the financial model of the healthcare in a matter of 2-3 weeks after the Covid peak went exponential. But soon after, medical professionals and experts started to provide expert insights on major flaws in the healthcare system and how to patch some gaps in the near future and long term. Would they able to fix those issues completely? No one can tell but, they have launched a process of identification of the issues and building strategies to reform the healthcare system so that it is better to prepare in the future with the same or more resources.
It may sound not the right time to have an evaluation, but then we run into the risk of ignoring it once we are out of the pandemic. When it is difficult to assess when time is ripe, it is better to do it when it has the potential to get the highest attention. Therefore, we need to evaluate, identify, address the weakness, and advocate for change in weak health systems.
The Healthcare of India got many things right
The healthcare of India is better than what it was before the onset of the Covid pandemic, and we can enlist the following: re-inculcation of Covid-appropriate behaviour, telemedicine, ICU bed ratio to population, high rate of vaccine production, and most importantly improvisation of the vaccination program.
With various awareness programs ran by healthcare departments and media on personal hygiene and prevention measures for contagious diseases. This is the long run takes off some burden of contagious disease from healthcare and also decreases hospital-acquired infections. Together, a decent amount of relief on the cost burden. Visit of patients to healthcare facility incur some cost and with telemedicine, that got strengthen during the COVID-19 pandemic, would in addition increase effectiveness in the healthcare system as it would be better for patients and for providers for the subset of visitors where you don’t really need to physically come in to see your doctor. To meet with an exponential need for medical supplies, medicines, ICU beds, oxygen, and PPE, manufacturing capabilities increased unprecedently, and these with improved supply chain logistics strengthen the healthcare tremendously. The most striking aspect of all is the development and manufacturing capabilities of vaccines.
There are many reckless reporting about vaccination program in India, and all that just manifest incapable or prejudiced biased journalism flared by racial fever. Those from places where 10%-17% GDP is spent on healthcare would have no idea about the inadequacy of healthcare with only 038% of GDP bankruptcies are obvious that vaccination in a country with a big population and inadequate infrastructure would take time, and taking that as news headlines only means too many intellectual bankruptcy if not blatant apathy.
Not that all executed well as it was planned in the health ministry. Not all states took stewardship and to an extent went with undesirable and untimed agendas which neither were in favor of the people of those states nor the favor of the nation. There were not only many reports unearthed planned and deliberate wastage of vaccines, misinformation, various kinds of hindrances, and non-cooperation, but also very systematic media/Social Media-based (national and international) propaganda about central government to establish a narrative that central government failing in vaccination program. We can’t deny that due to this vicious agenda, many additional lives have been lost!
Fortunately, the biggest respite so far India going through the second wave over 8 weeks, Prime Minister Narendra Modi in his addresses to the Nation announced that “Govt of India to provide free vaccine to all Indian citizens above 18 years of age, and 25% vaccination that was with states will now be undertaken by Government of India: PM. In addition, the Government of India will buy 75 percent of the total production of the vaccine producers and provide to the states free of cost.” This is a very bold and need-of-the-hour move by the Govt of India to tackle inefficiency and inequity in vaccination programs. Centralization offers the benefit of taking control and streamlining operation with unified objectives, however on the other hand it takes away the level of penetration of deliverables. But, this move is very well thought out and it leverages the power of decentralization of operation. This move is certainly provides impetus to the vaccination program, but it still does not address the question of inefficiency and inequity, which are complex issues and affect nearly all healthcare systems of the world. Healthcare systems administrators’ top agenda is to address inefficiency and inequity in healthcare access. India has more reason to do the same, and rather urgently. If we just do not force ourselves to focus only on what percentage of the population is vaccinated, the vaccination program of India is coming along quite well.
Equity = accessibility: Challenges for the healthcare system have gone up
However, given the socioeconomic disparity across various states, India has one added significant challenge. Certain groups in India have been experiencing the impact of the pandemic more severely, right from the onset of the Pandemic. Those unfortunate ones were from an unstructured economy and lived primarily on daily wages or short-term contracts. They faced a certainly provides double whammy, as they completely lost their earning as their jobs needed to be done in person. More vulnerable ones were who due to sudden loss of earning had to migrate to their native place to get support from family or to get government assistance. The condition of those and certain other native communities living on the daily wages of few states has become extremely measurable. Thousands while uprooted from their livelihood had to go through the humiliation of standing in line to get grains and few other things for mere sustenance. These moral annihilating conditions have damaged the confidence of people in the system, and they have become more prone to misinformation and propaganda. Undeniably, crores of such Indian citizens have become fodder for agenda-driven anti-national and anti-government activists, and it’s a serious concern if the government is oblivious of it. A time bomb is ticking! Various observations have been made that points to a fact that the key agenda of such activists have been to artificially increase the damage of the Covid pandemic so that it creates more fear, chaos, loss of trust in the government, and eventually lead to civil unrest disrupting ongoing government programs. Intuitively, vaccination program has seen by those anti-national activists as an antagonistic activity to their agenda, and thus they have come most strongly and systematically to hinder the vaccination program. Some reports have pointed out that the social media (ToolKit) budget of anti-national activists has gone historically up to ensure that their propaganda against the vaccine program reaches far and wide, and to the grassroot level. It is nothing surprising that not only misinformed masses became reluctant or averse to vaccines but also some state machinery have allowed slackness (or disruption) of vaccines of the supply chain. Taken together, the level of inefficiency and inequity has amounted to quite a significant level, resulting in serious dampening of the vaccination program. It is important to revisit the key aspects of the pandemic. Mainly it has three parts and is based on scientific logic first is the spread of infection (epidemiology and R-naught), the virus (Virology), and disease in humans (contagious disease and disease etiology). Mitigation strategies must address all three and in this sequence of events, say if the spread of infection is contained and prevented (we may say lockdown did during the first wave), strong chances are that the rest of the two would be manageable. But if the spread of infection has already happened (we may say as happened in the second wave), then finding a way to counter the virus, by the combination of therapy and covid-appropriate behavior, as well as enhancing capabilities to provide healthcare services are done. However, in this scenario, neither armament to combat the virus can be built that fast nor healthcare capacity can be increased to cover the explosion of infected cases, therefore, the “ULTIMATE” and the most critical goal is to achieving herd immunity. And surely ASAP! For this ultimate objective, an “Effective” vaccination program is the main leverage a healthcare system has, and effectiveness depends on how smart strategies are and how efficiently they are executed. Equity=Access plays the most important role in achieving “Effectiveness” as it helps to tune the vaccination program to target high risk (spreading) on a priority basis. Leveraging this has the potential to achieve herd immunity faster than a uniform and unadjusted program can achieve. Since we now kind of awake and have started talking about third/fourth waves, we need to do anything to increase the effectiveness of the vaccination program. The Central Government Officials tried to run the vaccine drive as efficiently as possible but relied on state machinery for its effective execution. So far about 15-17% of adults have gotten at least one covid-19 shot, which does not align with the urgency India has given the third/fourth waves. This undeniably warrants an overhaul in the vaccine program strategies, implementation plans, tactics, risk evaluation, and mitigation, a highly creative and comprehensive solution. Local reports have highlighted the in some states many people in hard-hit communities still have not received effective communication about vaccines, and even those who are not misinformed and want vaccines may continue to face practical barriers to getting shots. As a result, those communities are still more severely affected, screaming loud about inequity.
The strategy to increase equity=accessibility must be adjusted to the demography and risk of spread of the place and with innovative solutions (Big data analytics/Artificial Intelligence (AI)/Machine Learning (ML) in vaccine logistics, a better outcome can be achieved. Just for a context, when such situation was identified in Mississippi, USA where a larger percentage of low-income demography initially faced stark vaccination disparities, local social and religious groups step in and help remove misinformation and encouraged people to get vaccinated. That helped healthcare in a big way in achieving parity in vaccine access. Otherwise, a proportion of the population of that region would still have left with a significant spreader mass. Ever since the Covid pandemic set its foot in India, propaganda and misinformation skyrocketed, which, as per various reports, were well planned and executed through Toolkits. People facing issues due to the oversubscribed healthcare the stem were very prone to such exploitation and malice perpetration, and they got looped out of vaccine program. The Healthcare system is not equipped with logistics, tools, and mechanisms to counter misinformation or mismanagement of vaccine stocks by state healthcare machinery. Achieving equity is often a question of accessibility, and many things prevent getting a vaccine, including inconveniently located vaccination sites with limited hours, the need for transportation to those sites, and the difficulty of taking time off work. Public health and equity researchers predict a disparate effect on certain communities, therefore, there is an urgent need to mitigate risk due to the health disparities along regional and economic lines.
Prioritizing equity is difficult for India, but by adjusting the strategy especially for the regions like Bihar, Jharkhand, Odisha, and UP, where likely a smaller portion of the population is in the pipeline to be vaccinated.
“It’s the old public health trick: you make it easy for people to say yes”
It is important to keep in touch with hesitant communities to know if there is a surge in interest so that vaccinators can quickly meet the demand. Have a mechanism to continue the surveillance and monitoring and get the best data you can on vaccination and combine it with tactics to increase cooperation of the community. Many states of the USA have launched various incentive programs. In addition, healthcare systems incorporate such tactics employed for covid-19 vaccinations in other conversations about health needs that are going unaddressed, such as diabetes, malnutrition, maternal health, women’s hygiene, etc.
Impact on economy and way forward with smarter moves
Though it is not easy to estimate economic damage by the COVID-19 pandemic, economists predicted that most majories will lose at least 2.9% of their gross domestic product (GDP) over 2020, which actually surpassed, and GDP lost 4.5%, and that spells to whooping 3.94 trillion U.S. dollars (global GDP around 87.55 trillion U.S. dollars in 2019). In major economy close to 40% of responders in a survey reported loss of income. There is an optimism that once an adequate population is vaccinated, economic recovery may ensue, but it would vary globally. It is therefore critical to have a systematic evaluation and charting out future plans, given that only powerful but less bulky engines would gain momentum. For others, innovative solutions would be needed. In the US, a systematic and serious effort is already underway. The census bureau has launched an interim survey to capture demography’s altered characteristics in terms of vaccination, income loss, past/present/upcoming unemployment, any ongoing health issues, bankruptcy, and spending/saving/investment behavior to name some. Everyone guesses that while in the grind of the Covid 19 pandemic, plan to deal with what’s eminent and have a deep impact. If such planning has not been initiated in India, then, it is to be noted that there’s no time to lose, rather efforts should be to catch up.
Healthcare is intricately linked to the economic framework of a country. The economic researcher Janvier Mwisha-Kasiwa, “Health is both a direct component of human well-being and a form of human capital that increases an individual’s capabilities and opportunities to generate income and reduce vulnerability”. It is, therefore, critical to invest in healthcare in India, especially due to Covid 19 pandemic country is bound to face the social and economic aftermath and which may lead to a health crisis in the long term. Across the world, the healthcare system is undergoing a forced metamorphosis by utilizing lessons learned.
Here are a few worth considering, tailoring, and effectively implementing. There would likely be many discussions, and some may lead to planning, and of them some may lead to implementation, and therefore keeping these in discussion might have value.
Good governance and capacity-building
Despite efforts by the central government to enhance and improve the performance of healthcare systems, bad governance and corruption seem to be an issue in many states and in some central offices. This is plain like vanilla, an overhauled better system needed to be built by weeding out inefficient, incompetent, or non-dedicated people, and non-pragmatic processes. Without this nothing much can be achieved for sure. Right replacement of defunct pieces with aided healthcare capacity is the key. Social welfare programs should be designed to support the most vulnerable segments (demography) of the population. An emergency package with adequate investment is needed to ensure accelerated response by healthcare.
Innovation and diversification
It is beneficial to improve infrastructure, supply chains and also motivate healthcare providers and insurers to adopt automation, artificial intelligence, and cloud delivery of services. Given how information was unavailable or mismanaged, for the healthcare system which is digitized, Covid 19 pandemic can also be called Data Pandemic. Despite having National Digital Health Mission (NDHM), when reliable data was needed to be collected data from disparate sources and analyzed to track COVID-19 prevalence, the nation’s data handling came completely belly up. The role of states in collecting and providing COVID-19 diagnostic testing, cases, recovery, deaths, and post-infection antibody testing, was far less adequate. As a result, hardly any effective and meaningful epidemiological research is possible. That means hardly any learning which is data and science-based—No intellectual progress!
In other parts of the world, Artificial intelligence (AI) and machine learning are meaningfully playing a key role in better understanding and addressing the COVID-19 crisis. These are not some random research that is done with no outcome (innovative problem-solving products) accountability. The innovations made in the USA with AI are enabling organizations to scale and adjust and help solve healthcare problems. Application of machine is helping in analyzing large volumes of data to forecast the spread of COVID-19, and that is critical to use it in setting up early warning systems for future pandemics as well as identifying vulnerable populations. If AIs were used and the prediction was made well in time, the second wave in India perhaps could have been managed better. If a scientific community of India was aware and accountable, they could have simply utilized Biohub (California, USA) innovation that devised a model to estimate the number of COVID-19 infections that go undetected and cause silent spread. Since this innovative method helps quantify undetected infections – analyzing how the virus mutates as it spreads through the population, it would have helped India in a big way. Is it not too much to expect that the scientific community of India could have nudged a bit out of their complacency and ignorance, and have utilized the innovation of BlueDot, (Canadian start-up) and could have made some prediction of the second wave? It is worrisome for our future if scientists of India did not use BlueDot, which was one of the first to raise the alarm about a worrisome outbreak of a respiratory illness in Wuhan, China. BlueDot enables the scientist to provide analysis information to epidemiologists to verify that the conclusions confound the scientific standpoint. Another useful one is launched by AWS launched called CORD-19 Search, which is a new search website powered by ML and helps in searching for research papers and get answer questions related to COVID-19. Another innovative ML solution helps in extract relevant medical information from unstructured text and using natural-language capabilities provides answers. BenevolentAI, a UK and Closedloop, an AI start-up and many alike have provided a various solution that is aiding to the combat against COVID-19 pandemic.
Finance and resources to improve health infrastructure and working conditions
Beds not available taught us one simple thing that measurably increases hospital ratio to people by forging many transparent and non-corrupt public-private partnerships. It is unacceptable that the education that can build the right workforce is so lagging. Policy change must start from the education sector to develop a skilled workforce to effectively manage improved healthcare systems. Mechanisms for the change needed to be implemented urgently and rigorously and such measures needed to be sustainable and aimed at addressing existing healthcare needs, as well as building tensile strength to absorb shocks such as the COVID-19 pandemic.
Scientific insight-driven and data-based decision-making are the keys to increasing the effectiveness of healthcare operations. Preparedness with excess capacity, national-level infrastructure to support the efficient distribution of supplies. Not that India needs to copy, but India does not have to reinvent the wheel either. While India is in a long haul trying to make the most of the healthcare system that has been built so far and combatting the second wave of Covid 19, that has hit hard across all states regardless of their level of awareness, preparedness, prudence, or responsiveness. The struggles of few states are grave due to even weaker infrastructure and disaster management acumen, and the result that those states are faced with disparity. When we zoom in, we witness further disparity at the district and village levels. The issue is not just one way; it is in the other way as well. Varied level of awareness marred by misinformation and unwarranted chaos and confusion an unacceptable level of inefficiency and widening of the equity gap in healthcare access, in particular vaccination.
About the Author
Rudra Dubey is a professional with Ph.D., MBA, MS, BS degrees. He provides advisory and consultancy to academia (technology transfer offices), incubators, economic development agencies for states, incubators, early to commercial stage start-ups from biotechnology, pharmaceutical and healthcare industries. He also has a broad-base experience in multi-functional areas of healthcare, biotechnology and pharmaceutical industry.