Lack of coordinated interventions are leading to diseases becoming outbreaks.
It is still mid-summer and the vector borne diseases—dengue and chikungunya—are already making headlines. Almost unheard a decade ago, these diseases have become household names, pan-India in presence. Major cities, such as Delhi, Mumbai, Trivandrum and Bengaluru, are commonly affected than smaller towns. The cases, patient attendance at health facilities and deaths reaches a peak—soon after arrival of monsoon. The actual numbers of cases and deaths are always higher than reported officially. Health facilities and authorities invariably get overwhelmed to the extent of public outcry and panic.
Getting rid of vector borne diseases, especially those spread by mosquitoes, is a difficult proposition. Even at the global level, early effort to eradicate the other vector borne disease, malaria met partial success and had to be changed to control measures. However, countries have succeeded in reducing the extent of these diseases and minimise impact on population through a combination of public health measures, ie, strengthened diseases surveillance systems, vector control measures, health promotion interventions (adoption of appropriate behaviour by the communities to reduce mosquito bites), early case detection and management, and a close engagement of government agencies and communities.
As per constitution of India, health is a state subject with department of health in a state, while union government provides policy guidance and a few services as well. Seventy fourth amendment in Constitution of India in 1992, made urban local bodies (ULBs) responsible for delivering public health and primary care services. Since then, state health departments have slowly withdrawn from public health services in urban areas, while ULBs are still attempting to scale up these services. Nonetheless, all three agencies (health departments of Union & state governments and the ULBs) continue to set up facilities for curative services, mostly through dispensaries and other types of clinics (to the extent of duplication); however, a few major corporations such as in Delhi and Mumbai have set up big hospitals and medical colleges as well.
These three agencies are known for limited financial capacity and many competing priorities. However, because of political visibility, curative services and setting up new clinics get priority by all three and funds for public health (mainly preventive and promotive) interventions get a beating. All these services (both curative and public health) are organised with limited coordination and clarity on roles and responsibilities, amongst these three agencies, not to count other stakeholders.
The consensus that tackling public health problems require inter-sectoral and inter-agency coordination as well multi-stakeholder engagement, needs to be translated into an agreed joint action plan, atleast at the state level. Though, an agency, ie, state health department and/or ULBs can lead, there has to be defined roles for different stakeholders. The detailed costing of these activities should be part of the plan to facilitate the allocation of financial resources by each agency. Placing the joint action plan in public domain, with measurable & monitorable indicators would bring accountability. Such plan should be agreed at highest level including chief minister and/or health minister, Chief Secretary, the mayors of ULBs, and heads of other agencies, as deemed appropriate.
Government efforts are unlikely to succeed without sufficient and active participation of communities through influential residents as well as through Resident Welfare Association (RWAs) and market associations.
Setting up of fever clinics, dedicated hospital beds are the popular and the first official initiatives when vector borne diseases peak. Though important component of strategy, these are probably the easiest steps in entire process and less useful in reducing the extent of problem than the preventive and promotive ones. A fast and effective approach to this could be designating the existing peripheral health facilities (dispensaries and other types of clinics), making these functional with assured availability of a qualified doctor. The role of such facilities is that people in need of therapeutic care (those with fever or other symptoms) are attended by a qualified doctor in timely manner. Then, those in need are referred to a linked laboratory for testing or to a large facility for hospitalisation. An effective referral linkage system would allay the fear and panic amongst the general public and de-congest large facilities.
Alongside, the optimal use of information & communication technology (ICT) and mobile applications such as WhatsApp group could be effectively used for real time data collection, reporting, monitoring and actions. These tools could prove extremely useful in making citizen and official inter-face, as well.
While state health departments could take increased responsibility for curative primary healthcare in urban areas; the ULBs, in 3-5 years period, should consider phased approach to reduce their engagement in curative services. The financial resources freed thereafter could be used for delivery of public health services. Irrespective, the funding for public health services by state health departments need a major enhancement, across the country.
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It is not the technical knowledge, rather lack of coordinated and timely interventions by the concerned agencies that preventable vector borne diseases affect people and becomes outbreaks. A coordinated multi-agency response with attention on preventive and promotive health services and actions initiated a few months prior to mosquito breeding season is a way to go for responsible agencies.