Indian Confederation for Healthcare Accreditation (ICHA) has launched the ICHA MITRA a portal to support all front line health workers during the Covid 19 epidemic.
The august fraternity of ICHA is collectively capable of addressing issues faced by Corona warriors through appropriate interventions is the main thought process behind the project.
“ICHA MITRA – From Fear to Care” Implementation Steps
a. An access platform has beencreated https://www.icha.in/mitra/ where presently, for one week only volunteer enrolment is being undertaken.
b. Constituent Associations are requested to disseminate the information and link https://www.icha.in/mitra/ to their respective members to enrol as volunteers.
The aim is to generate a city wise and region wise database of volunteers / Nodal coordinators who would be able to render help to any Corona Warrior seeking help and support.
c. All members of your Association requested to share and disseminate ICHA Mitra information on their social media through WhatsApp, Facebook, Twitter, Linkedin among others.
d. The request for support/help received from Corona Warriors will be redirected to the respective city /area Nodal coordinator. (S)he in turn, through a local WhatsApp group or other such means redirect to the Registered Volunteersor assign the issue to a particular volunteer on phone.
e. The volunteer after determining the veracity of issue received will start resolving the issue on phone or escalation to appropriate levels – Regional/ State / National level. This will be done in a time bound manner with information to ICHA Team.
f. An online briefing / training will be done to equip the volunteers and clear all doubts.
g. The entire records and summary will be visible on a dashboard on the platform and the progress of each submission will be continuously monitored by the ICHA Team.
h. This will be a yeoman service to our Covid warriors and build a credible connect amongst them – from fear to care and a feeling that they have support to bank upon – ICHA being “Main Hoon Na”.
Considering the situation this is a step in the right direction and hopefully, ICHA MITRA would support many health workers during this epidemic.
Covid-19 pandemic has brought vaccines under limelight once again. Research laboratories and pharma/biotech companies are working overtime to develop a vaccine against coronavirus at the earliest. As of July 31st, 2020, more than 100 efforts to develop a vaccine for Covid-19 are underway in different parts of the world, and at least four of these are in phase III trials – three in China and one in the UK. As per some unverified reports, some phase III trials are underway in Russia also, but not much is known about these trials at the moment.
We have two promising candidate vaccines here in India also – one at Bharat Biotech in collaboration with ICMR and the other at Zydus Cadila. The Drugs Controller General of India (DCGI) has allowed both of them to start human clinical trials. Besides the early stage trials of these two indigenous candidate vaccines, Serum Institute of India received the regulatory approval on July 31st, 2020 to conduct a large multicentric phase III trial for the AstraZeneca/Oxford vaccine in India.
Every small or big news coming out of the laboratories is getting dissected endlessly – not always in the most logical manner and often with more political rather than scientific context. For example, there have been claims by eminent people in India, US and other countries that a vaccine for Covid-19 could be available by or before the last quarter of 2020. In fact, just this week Russian news agencies announced that two candidate vaccines there are in the last phase of development and that Russia will launch a vaccine by August 12th itself.
I have discussed this in a detailed point of view here.
We need to be careful while setting any timelines for Covid-19 vaccine. Going by the history of vaccine development, this seems a rather aggressive timeline. Till date, Mumps vaccine is the fastest developed vaccine, which took four years in development – from the time of initial sample collection in 1963 to its licensing for mass consumption in 1967. Despite all the scientific advancements since then, Mumps vaccine remains the only vaccine ever to be developed in less than five years. So, to have a vaccine for Covid-19 thoroughly tested, approved and readied within under one year may actually be a wee bit too ambitious a goal.
By Dr Lalit Singh , Managing Director – McGraw Hill Education, India
While COVID rages on globally and across India a more spirited debate ranges in my mind. Was there a way to anticipate and proactively move on infectious and non infectious conditions in India?
One thing that COVID has exposed is the gross unpreparedness of the Indian healthcare system to deal with pandemics. But it also exposed how little we knew about the situation on the ground. Data available is inadequate and most of the data especially from the villages and districts is not captured.
At the front line for the fight against disease and other illnesses is the Indian Primary Care system. This system is mostly run by ASHA (Accredited Social Health Activists) If something is coming our way, they are the first to know. And while they have been around since the recommendations of the Bhore Committee recommendations were given in 1943, it is easy to see how they are ill-prepared to deal with anything.
This is some data that I have been able to ascertain from public sources.
Number of ASHA Workers
9,00,000
Number of primary health centers
25,000
Average Salaries of ASHA Workers
INR 2,000/PM
Average costs incurred by ASHA WOrkers
INR 800/PM
So this is the on-ground scenario. These workers have to fill multiple forms for child care, maternal care among others, and then they have made 10-15 home visits per day. There are key reasons why ASHA workers are important.
They are local to an area, they understand the local customs and traditions
They have the trust of the community, communitites in rural India do not like to discuss their health with strangers
While are part timers, going from home to home makes them the best eyes and ears for the healthcare system
But given their situation and low pay, would it be interesting to see what we can do to help their situation. The government is spending close to INR 5000 Crore on the Ayushman Bharat Program. Next year the outlay is close to 10,000 Crore. But at a fraction of this cost, we can increase the pay for the ASHA workers and get much better coverage to prevent patients from getting hospitalized.
In the coming days, I would be focusing on how we can strengthen the primary care system and improve the overall effectiveness of the ASHA workers while providing them better remuneration for their tasks.
We did this video to talk about the challenges of the primary healthcare system. Below is the recording for the same.
As always we look forward to your comments and suggestions on the same.
Recently, Dr Devi Shetty, the founder of Narayana Hrudayalaya, authored an article in the Times of India Sunday Edition where he said that healthcare will become a poll issue in the future. Given the historically low percentage of budget allocated to public health in India, can Covid19 realistically push the government to prioritise this area?
An analysis[1] of select 2014 election manifestos indicates that we may be woefully behind on the path to a more comprehensive health plan for citizens.
India spends about 1.2% of its GDP on health services and in 2018 this number went up to 1.4%. However, this is still significantly lower than the time and efforts allocated to areas like physical infrastructure development and jobs.
Women Led parties had more space dedicated to healthcare in their election manifestos (AIADMK – 6% and TMC – 5%). AAP follows closely with 4%, whereas national parties BJP and Indian National Congress (INC) dedicated around 2.3% and 2.1%, respectively. Interestingly, the AIADMK appears to have been implemented given that Tamilnadu leads on several health parameters, the TMC in West Bengal needs a stronger implementation policy to suitably action on its promise.
Most parties tend to pay little attention to preventive health. There is almost no mention of areas like nutrition in election manifestos and while the BJP manifesto does talk about Swachh Bharat, there is no mention of ways to tie that back to measuring health outcomes. The INC manifesto talks about malnutrition and mentions Anaemia and HIV but does not spell out anything concrete in terms of action plans to prevent or tackle the disease.
All election manifestos considered for analysis missed addressing non-communicable diseases and the measures to tackle them. Given the high incidence of non-communicable diseases such as diabetes and hypertension in India, this is a glaring miss.
Most of the focus on health in manifestos is on building hospitals – more beds and more clinics and so on. But there is no focus on the quality of care provided at these centres or the variety of ailments they can treat. One cannot provide hospitalisation and expect improvement in the state of health without tackling the underlying social and sanitation causes for the ailments.
Strangely, while the focus remains on building new facilities, there is no mention of improving existing primary health centres and community health centres that have suffered from decades of neglect. Even in Ayushman Bharat these have not been addressed. While the insurance part of Ayushman Bharat is doing well, the wellness program can be significantly improved.
There is no mention of disease surveillance in any manifesto. This is surprising considering most developing countries in the world have some semblance of proactive disease surveillance to curb the spread of disease and manage its citizens’ health.
In summary, even if all that has been promised in the election manifesto is delivered, it would not even make a dent in the state of health in the country.
Why is this so?
Historically India missed the boat in prioritising healthcare reforms recommended by the Bhore committee in 1946 (See box in the next page), particularly the delivery of health at the grass root levels through primary health centres (PHCs).
Further, religious beliefs that tie poor health to karma and a generally fatalistic outlook have ensured hospitals and external care providers are seen as the last resort for patients. Preventive healthcare was largely provided at home. In line with this, the government has not undertaken research connecting the health of its citizens to their productivity. For instance, a study in the UK found that those who smoked were twice as likely to take time off work. Another study found that workers with obesity (BMI over 30) annually took an average of three sick days more than those with normal weight (BMI less than 25), and those with severe obesity (BMI over 35) took six days more. In India, a large population and limited availability of jobs means employment remains a bigger issue than health for the government.
The relatively affordable cost of healthcare so far has also meant citizens have remained negligent about lifestyle diseases. Until recently health insurance wasn’t understood and perhaps without the tax exemption many citizens may not opt for it.
Until the time healthcare is viewed as a discretionary spend, political parties may see no value in contesting elections on the plank of better healthcare for citizens. Citizens themselves need to demand for better health from its government for parties to take the issue seriously. A possible reason why some of the Southern states have overall better health indicators is the relatively high proportion of senior citizen population that resides alone, without support from younger people who tend to live outside the state/ country. This changing demographic of voters may have prompted political parties in the region to place greater emphasis on public health and deliver results.
In addition states like Karnataka and Kerala have prospered from the investments from the princely states. Tamilnadu alone benefitted by keeping public health distinct from Health Services, this is one of the few states that implemented this recommendation from the Bhore Committee recommendations.
The following part manifestos were considered for the analysis – Bhartiya Janata Party (BJP), Indian National Congress (INC), All India Anna Dravida Munnetra Kazhagam (AIADMK), Trinamool Congress (TMC) and Aam Aadmi Party (AAP). The rationale was to consider national level parties and those led by women, as it is widely acknowledged that women tend to prioritise health. (We wanted to include the Bahujan Samaj Party (BSP) but we couldn’t find the manifesto in the public domain). AAP was considered in the analysis as it was a recently formed political party that emerged from a citizen movement demanding a corruption free India. All manifestos from 2014 were considered for the analysis.
The following parties have not been considered as their manifestos were unclear on the healthcare aspect – JDS Karnataka, Shiv Sena, Shiromani Akai Dal, and Biju Janata Dal. The communist parties are also missing from our analysis. We are planning a follow up report on the analysis of the 2019 manifestos and we plan to include more parties there.
Late January, a medical student fleeing from Wuhan became the first confirmed cases of SARS-Cov-2 in India.1 Couple of her classmates also contracted the virus and India made its initial entry into a leader board no country wants to lead. The three students largely remained asymptomatic and recovered with a month, ending India’s first tryst with the virus.
The second wave started at the end of February. By now, SARS-Cov-2 had spread to 64 countries / regions across the world, with South Korea and Italy reporting over 1,000 confirmed cases. But it is quite possible there were cases in India long before that. It was only in in May that we found that the virus had already reached France in late December itself.2 It is quite possible that the virus had reached India from Europe long before we started screening the flights coming from Europe.
Nevertheless, as confirmed cases started gradually increasing in India, the Central Government took a bold step in locking the country down for three weeks to prevent the spread of the virus. Many countries were opting for lockdown to tackle the virus, but the step by India was a bold one for two reasons:
Lockdown is a strategy for the rich. It meant many will have to live off their savings and those who can’t will have to be protected by the government. US alone has provided for over 3 million via unemployment benefits.3 India, with perhaps the largest number of poor people in the world, would have struggled to provide for those getting unemployed due to lockdown.
It would have taken a phenomenal effort to enforce the lockdown given the size of the country and population density in certain parts. The only comparable country is China, which can rely on heavier surveillance than India could enforce.
By 14th April, Goa, the North East and East India excluding West Bengal were largely unaffected by the virus and had limited the number of cases to less than 100. States like Haryana, Karnataka and Kerala had managed to control the spread as well and showcasing more than one-fourth recoveries.
But it was already evident by then that many places in the country where the infection had reached the community.
Though India officially denied community reach of the virus, on 10th April, Indian Council of Medical Research (ICMR), which was coordinating India’s Covid19 response (Which in itself was odd since there was already another organization fitted for it – Integrated Diseases Surveillance Programme (IDSP) 4) had recommended 36 districts be prioritized to target Covid-19 containment activities. This was based on the Sentinel Surveillance study done till 2nd April.5
By 3rd April, India recorded a little over 3,000 cases of SARS-Cov-2. This was spread across 255 districts in 30 states and union territories. Incidentally, only 66 districts had reported more than 10 SARS-Cov-2 cases then.
And ICMR was recommending stricter containment in 36 districts.
As the economic cost of the lockdown became more apparent, India went on a period of staggered release of lockdown after 14th April. But as expected from a country with community transmission of a virus, India showed a consistent increase in cases as norms got relaxed. What was 104 districts on 24th March, when lockdown started, it became 379 on 14th April, 489 on 4th May, 564 on 17th May and with the last release on 31st May – 654 districts have seen confirmed cases of SARS-Cov-2 across the country.
The Road Ahead
Image 1 – Italy
Image 2 – India
After a long three month struggle, Europe is finally starting to hope they can move beyond Covid. While most of the European countries peaked in cases late March, they have seen a gradual decline in cases over two months.
This long tail foreshadows what we may see in India. But for that, we have to reach the peak first. So, we can expect considerable pain, both from Covid and the economy, for at least the next two months before things start to get better.
The 66 districts that saw more than 10 cases on 3rd April, now account for 66% of the SARS-Cov-2 cases in the country.
As cases increase, hospitals get stressed and treatment gets delayed. This leads to an increase in fatality rate. While India is doing remarkably well with around 7,500 dead from 267,000 SARS-Cov-2 cases (2.8%), there are over 100 districts with a fatality rate of 3.7% and above. The ones to watch out for over the coming weeks:
All these districts have shown consistent growth the past week and has high fatality rate. With more testing, it may be possible to weed out the SARS-Cov-2 carriers and catch patients early, although districts like Kolkata and Nashik may already be stressed, given the high number of cases there.
Ujjain (Madhya Pradesh), Anand (Gujarat) and Panchmahal (Gujarat) have seen low growth in cases recently, but has an overall high fatality rate. Increasing testing in such places may reveal the extent of the spread, since high fatality rate may be due to late stage discovery of the disease.
On a positive note, there are 48 districts that show a high growth rate in cases with a less than 1% fatality rate. This would indicate better testing and good potential to keep a check on the virus. These include Chennai (Tamil Nadu), Chengalpattu (Tamil Nadu) and Gurugram (Haryana). All of the three districts have recorded over 1,000 SARS-Cov-2 cases
Among the 25 districts that have over 1,000 cases, Indore (Madhya Pradesh) and Jaipur (Rajasthan) have shown the slowest growth rate the past week, indicating a positive road ahead.
Late March, George Gao of the Chinese Center for Disease Control spoke to Science Magazine about the road ahead with SARS-Cov-2 – Trace all SARS-Cov-2 carriers with mass testing, Isolate the carriers and trace out their close contacts, Quarantine and isolate the close contacts.6 As we officially start to slowly unlock our economy in June, despite the numbers on the rise, it will be a difficult road ahead for all of us in India.
A century ago, the Indian subcontinent was the biggest graveyard for the Spanish flu virus. In all probability, we are again headed there and the only way to have some form of control is to trace the infected early by mass testing and ensuring strict quarantine of the infected and their contacts. We also need a workable serological test7 to determine who have already been infected (and not initially traced) so that they can get back to work.
By Ranjith Kollanur
Bout the Author
Ranjith Kollanur is the Managing Parter with the Unseen Ink,
