While much of India was reeling under intense and prolonged heat, the tiny northeastern state of Sikkim recently faced flash floods that left nine people dead and stranded 1,200 tourists. As India awaits the onset of the annual monsoon, past experience suggests the accompanying heavy rain not only causes the kind of flooding experienced in Sikkim but also throws up public health challenges.

Unplanned development, massive destruction of forest, construction of roads, dams and infrastructure and unchecked urbanisation have compounded the challenges manyfold. Even normal rainfall poses challenges. Stagnant rainwater becomes a fertile breeding ground for mosquitoes. Consequently, vector-borne diseases such as dengue and malaria affect entire neighbourhoods, leaving municipal health services in severe stress.

Over the last few years, there has been a surge in dengue cases in smaller towns and peri-urban areas, in states where dengue was unknown a decade ago. One study found that between January and October 2022, 110,473 dengue cases were reported in India. When a landmass is faced with an extreme weather event routinely, its people adapt to the ensuing challenges over time.

The poor most vulnerable

People living in the Brahmaputra flood plains have learned to cope with floods over generations. But their coping mechanisms and strategies remain inadequate when faced with rain fury. A responsive state and its health system need to prepare so the human costs can be minimised. The Indian experience shows that untimely and inadequate response from health systems has disproportionately impacted the poor and marginalised, who lack resources to cope with health catastrophes and challenges.

This is compounded by poor living conditions, inadequate social and family support systems, lack of information, lack of political and social capital, inadequate financial resources and adverse work conditions. All these separately or in combination can shape health seeking behaviour and access to health care for vulnerable households in times of crisis.

While dealing with unprecedented or extreme weather events, India needs a multi-pronged approach which can go beyond the reach and scope of the existing health system. A resilient health system is one which can respond to emergency situations, prepare to deal with impending crises and adapt to changing public health needs.

Much of the action in preparing a robust health system can happen at the local level around primary, preventive and public health initiatives. Greater attention can also be paid to disaster and emergency response programmes. While rural and urban local bodies have a critical role, smaller towns and peri-urban areas are at greater risk as public amenities are stretched at best and rickety at worse.

More investment

A crucial prerequisite for this is greater public investment with immediate focus on urban and peri-urban areas. While the National Urban Health Mission has made modest beginnings in improving primary care systems in urban areas, the limited and varied ability of urban local bodies in generating revenues constrain progress.

In India, public spending on health remains in per capita terms. A National Health Accounts India report says that the per capita current public spending on health was around Rs1,555 ($18.6) in 2019-20.

Bhutan’s spending on health was two-and-a-half times more than India’s, while Sri Lanka’s was three times more. Many BRICS nations spent 14-15 times more than India.

A paltry sum—2.69 percent—of the total government budget is spent through local bodies. This translates to Rs42 per capita—or just 50 US cents—a measly amount given the magnitude of the challenges. Much of the spending happens in larger municipal corporations and metropolitan cities, while preventive health action remains largely absent in smaller towns and rural bodies.

A special fund from statutory institutions such as the Finance Commission, to be targeted towards building a resilient system for vulnerable areas, is urgently needed. Such attention needs to go beyond big cities to smaller towns.

Lack of public spending leads to systemic bottlenecks, which range from high number of vacancies in medical and programme staff, weak systems for reporting and information management, inefficiencies in procurement and distribution of essential medicines and consumables, underdeveloped referral systems and lack of funds for implementing proper planning and management strategies.

Urban health governance is complex, with multiple agencies and fragmented care provision, alongside an increasing presence and dominance of the private sector. The Covid experience showed that public health emergencies need greater coordination and cooperation in knowledge and data sharing. A robust health system cannot be built without robust and actionable data.

Weak health data

India’s health system data architecture remains weak and incomplete. Institutions with access to data do not often collaborate or share data in public. Under-reporting remains rampant. For example, while there were numerous reports in the media of increasing dengue fever in 2023, national and state reports showed a decline.

Government data reported only seven deaths due to dengue in Bihar in 2023. In Patna, the Bihar capital, anecdotal reports indicated more deaths. Protocols clearly spell out that multiple verifications are needed to ascertain dengue or malaria cases and deaths attributable to these diseases.

A moribund health system dealing with epidemic-like conditions often does not have the capacity for due diligence and therefore cases and deaths go unreported. Besides, there is limited compliance from the private sector and lack of appreciation within policy institutions for building an eco-system for robust data which can feed into local planning and implementation.

Systems such as the Integrated Disease Surveillance Programme (IDSP), established to monitor and strengthen disease outbreaks by putting together a decentralised surveillance system for epidemic prone diseases, needs to be universal and comprehensive.

Very little is spent on epidemiological surveillance, risk, and disease control programmes (2.77 percent)—only Rs 43 (US $0.50) per capita. Only Rs 1,944 crore ($238,698.35) was spent on preparation on disaster and emergency response programmes, which constitutes only 0.33 percent of total public spending.

With the complex nature of the health and climate crisis, the current system of vertical disease control programmes, which create parallel systems for different diseases (such as tuberculosis) or set of diseases (vector-borne diseases such as malaria, dengue etc), need to give way to a comprehensive health system approach in management of public health programmes.

An immediate step towards this could be integration of frontline workers across various disease management programmes to create a cadre of multipurpose frontline public health professionals in urban areas, who would be accountable to communities as well as to the health system.

Such integration will also likely address one of the key challenges in India’s public health sphere—shortage of adequately trained workforce in health and allied areas.

-360info