On May 1st, India crossed another grim milestone in the Covid-19 pandemic, with a total of 4 lakh new cases and over 3500 deaths officially recorded on that day. Patients in most major cities and districts are struggling for suitable beds for admission, or oxygen and essential medicines for treatment. Tests reports are hugely delayed and even cremation grounds are overflowing, often with exceptionally long waiting times. in this article, Given this context, Jan Swasthya Abhiyan (JSA), India’s national network of civil society organizations and people’s movements working for health rights has some suggestions about What a government should do in a global pandemic
The central government failed to anticipate this second wave, or make any preparations for it, despite having the clear experience of many countries before it. In November, the 123rd report of the Parliamentary Standing Committee on Health and Family Welfare Committee on “the outbreak of pandemic Covid-19 and its management”, in its detailed report had, warned about it. Allowing large gatherings in the Maha-kumbh and leading huge election rallies, without any concern for physical distancing, rapidly amplified and accelerated the pandemic curve. The government has been evading responsibility for the current crisis including the catastrophic collapse of health care by blaming it on non-observance of Covid-19 behaviour, and on the emergence of mutant strains, implying that this wave could neither have been anticipated nor dealt with. Even now when the wave’s full force is lashing us, the response of the Centre and some states seemed more concerned about managing the media, weakening democratic spaces by shutting down free speech and dissent, and shifting responsibility to the people, while pushing through policies of privatization and profiteering.
Central and State governments must fulfill the following obligations and put in place processes to ensure that these are urgently fulfilled:
Obligation to provide free treatment, ensure transport and prevent denial of care for all patients:
Governments must ensure that all patients who seek admission for moderate or severe COVID in a public hospital or on a help-line must be provided free care. In cases where a Public Health Facility is not able to render needed care for a patient approaching it, it’s the duty of the government to shift the patient to a private hospital and ensure free care. For this purpose, the government must insource private hospital beds as per need, to ensure free treatment to patients by reimbursing costs at fixed rates to the private hospitals. Ambulance services must be rapidly expanded and properly coordinated so that such transport to both private and public hospitals is promptly available at free / affordable cost to all needy patients. Severely symptomatic patients or those showing suggestive chest X-ray / CT scan, indicating COVID illness, must be admitted and treated as COVID-19 patients, without demanding RT-PCR test reports.
Obligation to urgently expand and make available beds for critical COVID care, with oxygen and other facilities:
Governments must augment the existing capacity for critical COVID care at public hospitals by urgently setting up additional oxygen beds accompanied with human resources and requisite equipment, medicines, etc.
Also, as an emergency measure, a larger number of beds in bigger, especially corporate private hospitals should be taken over by the State government using powers vested in the Disaster management act, thus ensuring the availability of many more oxygen beds and ICU beds. Information regarding the availability of various types of beds needs to be made publicly available on well-maintained dashboards on a real-time basis, primarily to help providers to coordinate for admissions, and also for the information of people.
Obligation to universally ensure increased, required level of continuous medical oxygen supply:
Governments must coordinate and streamline the continuous and uninterrupted supply and distribution of medical oxygen to hospitals and nursing homes, in both government and private hospitals, also ensuring the outlets for non-institutional purchase and refilling of oxygen cylinders, there is an urgent need to regulate price list of oxygen cylinders and their refilling. Information needs to be publicly available on a real-time basis regarding oxygen supply.
Obligation to provide ready access to quality testing:
Governments must ensure that all symptomatic patients must be able to get tested, at home or as near home as possible, and receive their reports within 24 hours. Testing capacity and organization of testing services require to be expanded and improved, and existing testing strategies need to be reviewed based on a comprehensive public health approach.
Obligation to ensure effective contact tracing, quarantine, and isolation facilities:
Governments must ensure that to limit the further spread, proper contact tracing and quarantine of all close contacts, always follow testing. This will need good quality community engagement and involvement of community volunteers who take this on to prevent the local spread and protect their families and communities, enabling education and support for those needing a home or institutional quarantine. Governments must also make good quality institutional isolation facilities available, offering these wherever necessary for those who test positive and have mild or no symptoms. Where home isolation is preferred and possible, it must be well supported by good information and home visits of trained health workers. All such patients need to be regularly monitored through a protocol for timely detection if any, of deterioration so that timely hospitalization occurs.
Obligation to actively promote COVID-19 appropriate behaviours:
(masking, physical distancing, and sanitation): Governments must recognize that different sections of the population have different barriers to the adoption of Covid-19 appropriate behaviors, they should admit that an authoritarian approach with improper messaging which creates high levels of stigma and denial, has failed. Governments must re-vamp and upscale public communication and education strategies and desist from any messages of shaming, victim-blaming, and coercion. Covid-19 appropriate behavior must also be demonstrated first and foremost by the government and people’s representatives themselves.
Obligation to ensure universal vaccination with priority to those more vulnerable:
The Central Government must immediately adopt a policy of nationally uniform pricing of COVID vaccines for purposes of government procurement, and take urgent steps to rapidly increase the supply of vaccines through investing in expanded procurement. They must accept the primary responsibility of purchasing and making available adequate vaccine supplies to all states, enabling universal free vaccination. State governments should multiply the number of vaccination centers, and roll out a public health outreach program to reach the most vulnerable while promoting public education to overcome vaccine hesitancy. There is also a need to put in place a comprehensive adverse effect monitoring system following vaccination.
Obligation to provide all necessary non- COVID-19 health services:
Governments must provide routine primarily to tertiary care for all Non-COVID patients such as tuberculosis, HIV/AIDS, mental health disorders and other NCDs, chronic ailments have been affected, along with reproductive and child health services to all those who require these and ensure arrangements are made for the continuation of these services.
Obligation to protect from exploitation and irrational charges by the private sector:
Governments must cap fees for those seeking testing or treatment in private hospitals, and regularly ensure both medical and financial audits to ensure compliance with Standard Treatment Guidelines prepared by appropriate bodies. Governments must also ensure that hospitals impaneled under publicly funded health insurance schemes provide free healthcare to all those eligible under these schemes. Government must urgently regulate the irrational prescriptions by both private and public hospitals for various medicines such as Favipiravir, Convalescent Plasma which have no role, or Remdesivir, Tocilizumab, etc. which have limited role (that too only in treating certain COVID patients). This ‘Inflated demand’ along with scare among ordinary people is fuelling black marketing, inflated prices, etc, hence the governments must conduct effective public education campaigns to minimize unnecessary demand, towards reducing misuse of these medicines.
Obligation to prevent violation of civil rights and liberties:
Keeping in view that curbs are being placed on expression, Governments must ensure that human rights violations are prevented and loss of rights to dissent and free speech are not compromised in the name of Covid-19 control. In the name of Covid-19 control, weak and vulnerable sections have had to suffer the loss of livelihoods, in addition to violence from authorities and the more powerful.
Need for Governments to coordinate efforts with civil society organisations and community groups
by expanding existing participatory committees or newly forming these when required, at block, district, and city levels. In addition, rapidly form State level public and community health task forces involving Health officials, public health experts, health sector networks to ensure rapid response to developments on the ground, while facilitating social action for health across the state.
Obligations to ensuring rights of health workers:
Governments must ensure the safety of health workers and provide fair terms and conditions of employment for the entire health workforce. While greater public expenditures required for this, the employment, health and social capital generated would be well worth it.
Obligation to ensure dignity in death and ensure the health of crematorium workers:
Governments must ensure adequate cremation spaces so that the families of the deceased do not have to go through the additional trauma of waiting for their turn. Also ensure that the workers at the crematorium spaces, mainly from Dalit / lower caste communities, and who come into close contact with many people daily, are provided with N95 masks and sanitizers and an extra honorarium.
Obligation to provide reliable data on mortality, morbidity, and testing data:
This is required for public information, more effective pandemic management, and better research and understanding of the problem. Currently, there is a serious and dangerous level of under-reporting of deaths, and dedicated administrative and health systems efforts would be required to address this.