Two WHO tales on Indian health systems

India’s ministry of health and family welfare (MoHFW) as well as the Indian media appear to be pleased that the nation’s Accredited Social Health Activists, or ASHAs as they are popularly called, have been chosen for the World Health Organisation (WHO) Director General’s Global Health Leaders Award, as announced in Geneva on May 22.  WHO recognised the ASHAs “outstanding contribution towards protecting and promoting health”, which in other countries would be the job of a public health workforce.

WHO’s website added: “ASHAs support maternal care and immunisation for children against vaccine-preventable diseases, tuberculosis, neglected tropical diseases, communicable disease prevention and control, and core areas for nutrition, sanitation and healthy living.”  The Prime Minister stated on Twitter: “They are at the forefront of ensuring a healthy India.”

There is something very celebratory about the work that ASHAs do in the Indian system. Yet, we must also recognise that ASHAs are technically “volunteers” from and for the community. The Union minister of State, MoHFW, Dr. Bharati Pawar told Parliament last year that ASHAs receive an honorarium of Rs. 2,000 per month effective 2018-19, with an additional Rs.1,000 as maximum incentive (based on visit/services rendered, like preventive antenatal care, immunisations etc.) and Rs. 1,000 further added for Covid-related work. States add top-up payments that vary. Billings and payments are often not transparent, verifiable or audited easily.

In essence, ASHAs are minimally trained community volunteers that are now being seen as the backbone of India’s health delivery.  Are we happy that a large part of the onerous burden of health promotion and disease prevention among low-income families, especially in rural areas, rests on these ASHAs?

It is not that Covid numbers were underreported. We do this with all diseases because the system is geared to undercount

If ASHAs have come in for laudatory mentions from the WHO, then India’s response to the Covid-19 pandemic has received a very different mention from the WHO.

It was only last month that WHO said five million Indians died as result of the pandemic, nearly ten times the official count of 520,000 deaths admitted by India. India stood out as the worst performer of all nations by this count. India was also the only nation to oppose the WHO findings, which were based on independent and robust models that have been upheld by a range of global experts.

That huge disparity became an unseemly dispute limited to numbers, diverting the discussion from core issues of how numbers are counted or not counted as a reflection of the quality of the government’s health management.   

Almost 75 years after India got independence, we do not yet have a system to count deaths as “health events” with a reliable or reasoned out cause of death. We rely on a civil registration system that counts deaths as “demographic events” for estimating, for example, the number of deaths during the pandemic.  This reduces death to a deadpan number rather than the insight it can offer to prevent more deaths, if cause of death is understood and spread of disease is deduced. It is not that Covid numbers were underreported. We do this with all diseases because the system is geared to undercount.

We underreport mortality from all important diseases like pulmonary tuberculosis, extra-pulmonary tuberculosis, malaria, cholera, typhoid fever, leptospirosis, brucellosis, scrub typhus, haemolytic uremic syndrome, viral encephalitis, influenza, acute respiratory distress syndrome, bacillary and amoebic dysenteries, red-tide algal toxicity, and so on. Even death by snake bite is not well reported or appropriately counted.

The lack of a watchful eye on diseases renders all response un-objective and less scientific, less timely or less useful than it ought to be

This is because we just do not have a public health infrastructure to collect reliable numbers of health events and place facts in the public domain every week, like a “marked to market” value that offers the current and live view of a portfolio.

While ASHAs make us proud, the state of the health management system makes us hang our heads in shame.  Is this where India should be in the twenty-first century?  Where are we on a trajectory of improving health management, with a heavy dependence on the contribution of ASHAs to the local communities? 

Globally, health management comprises two parts – a) health care, which is the response to disease and b) public health, the eyes and ears watching health events, studying microbial spread and building the dashboard that managers must use to mount a meaningful response to diseases. Without the public health dashboard, the health care car will not know where to drive, what speed to go and where it has to reach. In other words, the lack of a watchful eye on diseases renders all response un-objective and less scientific, less timely or less useful than it ought to be. It is only the public health system that demands case-based, real-time, comprehensive disease surveillance under which every registered medical practitioner has a legally binding duty to report to the local public health officer any of the many notified communicable diseases. Once clinically suspected, that fact has to be reported without any delay. India has none of this in place.  

Without this understanding, it appears not to matter why the patient died. The number may be reported but the underlying cause is not. This is where the Indian system is going wrong. When the cause is not well reported and understood, it will lead to more deaths, more pressure to underreport these deaths and a reinforcing loop is created that confounds, confuses and leaves us vulnerable. Either by default or by design, we do not have a “public health” wing while we have a whole ministry to supervise the widespread health care hardware, software and personnel under the governments, Union and State, and we have a flourishing set of private sector health care establishments that the MoHFW qualifies as the “health care industry”. 

The term “public health” originated in a Parliamentary Act in England in 1848, which came about as a result of the advocacy of a lawyer-cum-social reformer, Edwin Chadwick.  He had understood that epidemics of communicable diseases had environmental determinants; only the government had the jurisdiction over environment.  The Public Health Act mandated the government to bring about comprehensive sanitation and that resulted in a drastic reduction in disease burdens.

Awards and recognition should spur us to act and not sit self-contented with a pandemic death toll that is the worst anywhere in the world

Diagnosing and treating individuals with disease, be it communicable or non-communicable, remained in the realm of the duties of physicians and the medical establishment.  Thus, a clear distinction was obvious – health care was for individual needs whereas public health was for the benefit of the community as a whole.  Over time, all European nations adopted the twin systems – public health and health care, for health management.  All governments accepted the new political health philosophy or ideology that disease prevention and health promotion were the duty of the government, so much so public health was described as what the government does to prevent diseases and promote health.

We have made huge strides in fighting disease. India has had its contribution too. India created two excellent vaccines – the adjuvanted, inactivated SARS-CoV-2 vaccine (Covaxin) and a live attenuated Rotavirus vaccine (Rotovac) developed from an indigenous virus isolate (by Late Dr Maharaj K Bhan) and extensively researched by US investigators who found it to be suitable for a vaccine.  Thereafter Indian scientists developed and evaluated it until approved as a vaccine that is in current use in our national immunisation programme.

Yet, in terms of the simple cause of death, we appear not to understand that numbers are more than mere numbers, because they tell us exactly how we are performing. Awards and recognition should spur us to act and not sit self-contented with a pandemic death toll that is the worst anywhere in the world.

(Dr T Jacob John is retired Professor of Clinical Virology, Christian Medical College, Vellore, and Past President of the Indian Academy of Pediatrics. Jagdish Rattanani is a journalist and a faculty member at Bhavan’s SPJIMR.)