Health System Response to COVID-19 and Future Pandemics

Abstract

The COVID-19 pandemic is a global health and economic crisis of a scale never witnessed before. Beginning in China, it has within a few months devastated many countries around the globe, requiring an unprecedented mobilisation of health systems. While the disease caused by this novel virus is generally mild and self-limiting, the risk of severe disease is disproportionately high among elderly and those with underlying medical conditions. In the absence of a vaccine or treatment, the public health strategies include: (a) preventing transmission through early detection and isolation, tracing contacts and quarantining them and implementation of measures such as social distancing and hand hygiene and (b) reducing mortality by augmenting clinical management and shielding the most vulnerable populations in the society. The pandemic is yet another reminder that we need to invest in public health, ramp up national capacities to detect a disease early and respond rapidly to emerging infections, strengthen and respect our national institutions and rely on evidence base for policymaking. It is high time that we paid heed to these lessons and strengthened without any further delay our health system capacity, as epidemics and pandemics of this nature will continue to challenge public health well into the future.

Introduction

We are all in the midst of a global public health crisis that is moving at a speed and scale never witnessed before. The story began in Wuhan City of China in December 2019, when a cluster of unusual respiratory cases characterised by pneumonia was reported (Zhou, 2020; Zhu, 2020). This heralded the emergence of a new or novel coronavirus, named by the International Committee on Taxonomy of Viruses as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Gorbalenya et al., 2020) and the disease named by the World Health Organization (WHO) as coronavirus disease (COVID-19) (World Health Organization [WHO], 2019). The cluster was ostensibly linked to a wholesale seafood and wet animal market in Wuhan—as if it was a common source outbreak. Subsequently, it was revealed that many COVID-19 cases in fact had no link with the seafood market and that person-to-person transmission was well underway (Novel Coronavirus Pneumonia Emergency Response Epidemiology Team, 2020). While the origin of outbreak in Wuhan remains obscure, there are anecdotal reports that the cases with severe pneumonia of unknown aetiology were occurring in Wuhan even earlier than December 2019.

On 31 December 2019, China notified the WHO about the new emerging event afoot in China. Soon thereafter and to global concern, many similar cases started to be reported by few countries outside of China and across the world, initiating substantial mortality and morbidity. On 30 January 2020, the WHO declared the coronavirus epidemic or COVID-19 centred in Wuhan City in Hubei Province of China ‘a public health emergency of international concern’ (PHEIC) (WHO, 2020). The WHO explained that the decision to announce a PHEIC was made because of signs of human-to-human transmission outside China and its concern on possible severe consequences if the virus were to spread in countries with a weak health system. On 10 March 2020, the WHO declared this event as a pandemic (WHO, 2020, March 11). Within few weeks, on 16 March 2020, the total number of cases and deaths in China were overtaken by total numbers reported outside of China (WHO, 2020 March 16). As on 27 April 2020, 213 countries had reported 2,858,635 cases with 196,295 deaths to WHO (2020, July 10). Seven countries (Spain, Germany, Italy, UK, France, Turkey and the USA) each had reported more than 100,000 cases, with the USA contributing 899,281 of all cases.

Apart from the disastrous impact on human life and economy, COVID-19 has overwhelmed the health systems across the world.

Health System and Response to COVID-19

A health system can be defined as the organisation of people, institutions and resources that delivers health care services to meet the health needs of the population (Wikipedia). Implicitly, countries design and develop health systems in accordance with their needs and resources available, although common elements in virtually all health systems are primary health care and public health measures including promoting health, preventing diseases and ensuring quality of health service delivery.

The WHO has provided a more comprehensive definition of health system:

A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct health-improving activities. A health system is, therefore, more than the pyramid of publicly owned facilities that deliver personal health services. It includes, for example, a mother caring for a sick child at home; private providers; behaviour change programmes; vector-control campaigns; health insurance organizations; occupational health and safety legislation. It includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well-known determinant of better health. (WHO, 2007)

Health system in a country is managed and directed through a set of policies and plans that are evidence-based and developed by the government, ideally in partnership with other partners. Its implementation is often determined by the availability of resources—both human and financial—of supplies such as essential medicines, technologies and a governance system that is accountable to the population. A responsive health system should be able to address the needs of the country based on epidemiological profile and projected as well as perceived needs of the communities.

In the context of COVID-19, the early experience in countries with large-scale community transmission such as China, Iran, Italy, Spain and USA showed that COVID-19 required unprecedented mobilisation of health systems (WHO EURO, 2020). Countries that have not yet experienced community transmission may by acting urgently and decisively, can slow down the transmission of SARS-CoV-2 and have the time to prepare their health systems to mitigate the impact of the pandemic.

Public Health Strategies in the Face of a Pandemic

Preventing New Infections and Saving Lives

1. Public health surveillance for early detection and rapid response

   Using an infectious disease model, preventing infection involves identifying the individual who is infectious and rendering him or her non-infectious so that they cannot transmit to others, thereby breaking the chain of transmission. Tuberculosis is a case in point. A person harbouring TB bacillus is a reservoir of infection and can spread it to up to 10 people during the course of illness. However, when treated with an anti-TB treatment, that patient becomes free from infection and cannot spread it to others, thus breaking the chain of transmission.

   Coronavirus disease is caused by a novel virus and, at present, there is no treatment or vaccine available to treat it. The strategy here should be to detect someone with the disease on the basis of test results or by virtue of a case definition (based on the cardinal clinical symptoms of fever, dry cough, difficulty breathing, contact with a known case and loss of sense of smell or taste) and quarantine the individual so that he or she cannot spread it to others and at the same time, to trace the contacts and monitor their clinical status and quarantine if asymptomatic or isolate if symptomatic and testing positive. This is an effective way to break the chain of transmission.

   The strategy of course requires a robust surveillance capacity to be able to detect all cases early and take proactive action as already outlined. However, in most of the developing countries including India, the epidemiological and laboratory capacity remains weak and needs to be strengthened urgently. Most of the district epidemiologist posts are lying vacant and there is an overall shortage of skilled human resource to undertake the complex task of tracing the infection. In India, to respond to the pandemic, the government has ordered mobilisation of epidemiologists and other human resource for health on a ‘war footing’. In spite of best efforts of the government, not many qualified personnel may be willing and available to work because of inadequate salaries and poor terms of employment, in spite of several of them holding highest degrees in public health. This must be remedied urgently and the role of public health officials in making the health system strong must be recognised.

2. Implementing key public health measures

   Since droplet infection is the main driver of SARS-CoV-2 transmission, other public health measures recommended are social distancing; frequent and thorough hand washing; cough etiquettes; wearing of masks when going out; and not touching one’s mouth, nose and eyes.

   Why social distancing? It is now well established that many individuals can be the carriers of the novel coronavirus without showing any of the typical symptoms of COVID-19 (Gandhi et al., 2020). But these asymptomatic or presymptomatic individuals or those with only mild illness can still shed virus and infect others.

   To prevent the intense and sustained spread of this new coronavirus, a full implementation of social distancing is necessary. Social distancing means that people stay at home as much as possible, go out only for critical needs like food items and medicines and maintain a distance of at least 1 m or 3 feet from another person. It is also recommended to avoid gatherings of more than 10 people and handshakes (instead use only namaste or any other non-touch greetings), in addition to regular handwashing.

   First, the rationale includes the data which show that for every confirmed case of COVID-19, there are another 5 to10 people with undetected infections (Li et al., 2020). Second, although people with undetected infections are thought to be not as infectious as people with confirmed COVID-19, these individuals are in fact the source of infection for 85 per cent of the cases. Third, when countries established travel restrictions and social distancing, disease transmission slowed down quite considerably. The lockdown in India has also demonstrated an increase in doubling time of the cases of COVID-19. The doubling rate for COVID-19 in India prior to lockdown was 3.4. It improved to 7.5 by 19 April 2020 (Government of India, 2020). Scientific evidence such as these show that social distancing is both a prevention and a mitigation strategy.

   Clearly, lockdown is an extreme form of social distancing which has proven to be effective in flattening the epidemic curve. Otherwise, the sudden large increase in cases would completely overwhelm the existing fragile health system, resulting in a large number of deaths. In India too, the lockdown has already had the desired effect of flattening the epidemic curve (BBC, 2020; The Lancet editorial, 2020). However, before lifting the lockdown, a few conditions must be met. The three most important of these are: (a) to equip the health system in such a way that it has the ability to detect cases, isolate them and trace their contacts, so that the programme is able to snuff the fire in the bud before it can spread or assume the shape of a wildfire (or a cluster containment); (b) to fully prepare the health system to manage the new cases that are likely to occur; and (c) to ensure that the community is fully engaged in preventing the spread of the disease.

3. Risk communication and community engagement

   The role of media cannot be underestimated in ensuring that these public health measures are implemented effectively and people follow the advice given by the government. This includes communicating credible and evidence-based information on a regular basis to the public through daily press briefings about the latest situation update, trends, the associated risks and action being taken. Risk communication is a key aspect in shaping the course of an epidemic and empowering people to take right decisions. To encourage protective behaviour, they need timely, accurate and easy-to-understand information. This can help limit the spread of misinformation which otherwise would lead to panic or hysteria. While social media is a good source of information sharing, its careful use is required so that this medium is not used to spread fake news and cause unnecessary alarm that may harm the society and in fact undermine response to the outbreak. It is essential to have a comprehensive risk communication strategy that is ethical and useful in local context (Bhatia, 2020). This strategy must be developed in collaboration with social scientists and risk communication experts. Psychological impact of pandemic has also been documented (Shigemura et al., 2020). An effective strategy must address this issue too.

Protecting the Vulnerable in the Society

In China, 80 per cent of cases of COVID-19 had a mild disease, 15–20 per cent required hospitalisation and another 5 per cent become critically ill requiring intensive care (acute respiratory distress syndrome and organ failure) (Wu & McGoogan, 2020). In Italy, on the other hand, 40 per cent of patients required hospitalisation (Lazzerini & Ptoto, 2020), with approximately 7 per cent needing care in an intensive care unit. There is a consensus of the opinion that the disease affects all age groups but is disproportionately severe among older people and those with underlying conditions such as hypertension, cardiovascular disease and diabetes. High mortality rates reported in Italy are in part explained as the Italian population is in particularly characterised by older population. There is therefore a clear message that elderly and those with underlying co-morbidities must be protected in the society and in a family environment and not unduly exposed. Within family also, older family members should not interact with young people or children who although looking healthy may be infected.

Recognising the nosocomial spread of COVID-19 virus and health care workers being at a greater risk of infection, we need to improve triage, treatment and infection prevention at the health care settings. Health care workers must be trained urgently on infection control measures including universal precautions and provided with an enabling environment including uninterrupted supply of personal protective equipment (PPE). In Italy, USA and China, thousands of health care workers have become infected and many have died. The number of infected health care workers is increasing daily in India too. Since the health workers are at the frontline of the response in every country, we need to ensure that health care workers are protected at all cost. WHO has recently issued guidelines on ‘Infection Prevention and Control for Novel Coronavirus (COVID-19)’.

Ensuring Surge Capacity in Case ‘Intense and Sustained’ Transmission Occurs

As and when the community transmission commences, there would be large number of cases that may overwhelm the existing health system. The requirement of hospital beds and essential supplies such as PPEs, masks, etc. could go beyond what the governments have planned for. These are all a part of pandemic preparedness and response plan which one must prepare for in advance.

In such an event, countries will need to find ways to increase their surge capacity to treat COVID-19 patients while maintaining essential services in health care facilities. There are large variations in acute care and intensive care capacity in many countries of the world. The number of intensive care beds per 100,000 population ranges from 2.3 in India and 34.7 in the USA, to 3.6 in China, 6.6 in the United Kingdom, 7.3 in Japan, 10.6 in South Korea, 12.5 in Italy and 29.2 in Germany (Forbes, 2020). Sincere efforts are being made to augment hospital bed capacity with the Indian Railways offering to convert its train coaches into hospital beds, thereby increasing the bed availability sufficiently.

With nearly 1.2 million allopathic doctors in the country, the number of doctors per 1000 population in India is 0.75 which is also below the norm of 1 per 1000 population as prescribed by WHO (Medical Dialogues, 2020). Moreover, there is major disparity in distribution with respect to relevant skills, competencies and pandemic training between urban and rural areas. In most remote districts unfortunately, the number of specialists is almost negligible. In spite of the Indian government’s offer of ‘quote your salary and the government will pay’, many states have refused to make use of such an initiative, while their populations continue to suffer without quality and equitable health care.

From the public health point of view, there would be a need for a large number of personnel required for field investigations, contact tracing and outbreak containment. Therefore, mapping of personnel including the existing network of epidemiologists who are already trained in disease surveillance, outbreak investigation and management can be mobilised at a short notice. In addition, services of many public health professionals who are members of various associations can be sought for support in epidemiological work and data analysis.

Unprecedented Opportunities for a Transformational Change

COVID-19 is an unprecedented crisis but also is an opportunity. The current pandemic underscores the need to:

First, invest in public health. The pandemic is a stark reminder that a strong and capable public health system can save lives and offset economic disasters through early detection and rapid response. There is a strong belief that the pandemic will serve as a wake-up call, a trigger mechanism for or a harbinger of change for the better. For too long, health has not been given the priority it deserves—public health has remained chronically underfunded with budget allocation stagnated at around 1.3 per cent of the GDP, leaving primary health care weak. The investment on health, especially at primary care level, must be increased substantially in the near future—much more than 2.5 per cent of GDP that the National Health Policy (2017) has proposed to be achieved by 2022.

Second, ramp up readiness and response capacities at all times. Many countries have prepared pandemic preparedness plans but having a plan alone is not enough. It requires country-level coordination, a strong epidemiology and laboratory capacity including robust surveillance and early warning system, coupled with a network of laboratories, supported in addition by the logistics and supply chain management for life saving medicines and essential technologies. The plan can be fully implemented only if there are enough staff or human resources available and trained in their respective jobs such as contact tracing, case management and infection prevention and control. Such readiness and response capacity are urgently needed to address this pandemic and those that may come our way in the future. Simulation exercises must be done frequently to keep the system fully activated with updated staff and skills.

Third, unleash the enormous potential of national institutions and individual experts such as the National Centre for Disease Control (NCDC) based in Delhi. The mandate of NCDC is to conduct surveillance and outbreak investigation and management in the country, working closely with the states. For an efficient and effective functioning, NCDC needs to be allowed to deliver uninhibitedly on its mandate nationally, and establish effective collaboration with international organisations and associations such as South Asian Association for Regional Cooperation (SAARC) globally. The only way to do it is to grant NCDC an autonomous status. Some of the excellent training courses on field epidemiology such as India Epidemiological Intelligence Services (EIS) being conducted must be expanded so that enough trained epidemiologists are available in the country to tackle problems such as the one we confront now. Such a skill-based programme, if fully supported by the government in both letter and spirit, can ultimately transform public health in the country (Narain, 2018).

The Integrated Disease Surveillance Programme (IDSP) which is a part of NCDC carries out nation-wide disease surveillance. The programme needs to be strengthened urgently at all levels including the district level. Adequate salaries should be offered to epidemiologists so that good quality and trained epidemiologists can be recruited, and they can generate epidemiological evidence essential for policymaking. While the states provide data to IDSP, unfortunately, the data once collated and analysed are stored in a portal and are not accessible to the states, nor to the academic and research institutions or to individuals interested in latest updates, for example, on COVID-19. Such data must be on public domain.

Fourth, ensure self-reliance in diagnostics and medicines. While India is recognised globally as the pharmacy of the world and provides generic drugs for the management of HIV/AIDS, malaria, etc., the COVID-19 pandemic has highlighted the fact that even today, India’s pharmaceutical industry is heavily dependent on other countries. Without active pharmaceutical ingredients, India cannot produce even simple medicines like paracetamol and common antibiotics like azithromycin. Even in the middle of the pandemic, it had to import test kits and PPEs from a neighbouring China. This has to change. The prime minister has also acknowledged the need for India to be self-reliant and self-sufficient including essential diagnostic and medical supplies.

Finally, follow science and evidence-based policymaking with a focus on research and innovation and allocate adequate resources on a sustainable basis for maintaining national capacity for responding to future pandemics. One must never forget that COVID-19 is neither the first nor the last pandemic to hit humanity.