Among other things, This will need greater transparency, coordination between the Centre & the states, and standardisation, on multiple fronts
By Deepak Gupta
The second wave of Covid-19 in India, in its extent, intensity and virulence, has overwhelmed society, governments and local administrations. We need to be fully prepared for the third wave. What has happened shows what needs to be done. The following suggestions are being made by a group of retired IAS officers of the 1974 batch.
First, the capacity for vaccine production must be ramped up at the earliest. More compliant units should manufacture at least Covaxin. Here, patent is not a constraint. We should seek agreements for others rather than going the CL route. J & J should be possible. In an article in this paper in September 2020, I had urged that the government invest in vaccine production. Subject to safety and efficacy requirements, neither funds nor regulatory procedures should become a constraint. We must get 200 million doses monthly by August, rising to 300 million thereafter.
Second, the vaccination policy must change. All vaccines must be procured by the Centre at a reasonable price, recommended by an Expert Committee like it is done for essential drugs. Under the current policy, against the backdrop of vaccine-shortage, states and private hospitals have to engage in unhealthy competition, leading to inequity. Manufacturers will have perverse incentives to sell to highest bidder. Moreover, distribution will become ad hoc, as is already happening. By end-May, an expert group of epidemiologists and virologists should provide a vaccination plan, based on expected availability over the next six months. This would identify targets, including how best to prevent spread to children. Private companies and hospitals could import Pfizer and Moderna. We must target 5 million vaccinations per day, increasing to 10, as availability improves. The number of vaccination sites must be increased, while the sites themselves are decentralised, since overcrowding at the sites could lead to spread. The vaccine registration system needs a rethink for the populations in slums and rural areas. States will have to mobilise the required number of vaccinators on a contract basis, more so since routine immunisation must also continue.
Third, a massive communication campaign is required for inspiring Covid-appropriate behaviour. Private advertising concerns can be roped in for this, for sustained messaging across various media. Messages must be in all local languages. Social media outreach is needed too. This could be a huge private sector contribution.
Fourth, a special group must examine how testing capacity can be expanded, and quickly. This may require additional manufacturing and availability of consumables and other ancillary requirements. We may also have to augment staff in the testing laboratory infrastructure in district hospitals. We can create mobile units for testing in rural and densely-populated areas where infection clusters could be developing. The Pulse Polio programme has lessons for community outreach which can be effectively used with WHO/UNICEF help.
Fifth, disease surveillance is fundamental. At the national level this must be monitored by the NCDC, modeled on the US CDC. Reportedly, an expert committee exists that gave a report to the NCDC in early March 2021. It is imperative that this Committee makes its assessment public on a weekly basis, so that it lets the wider public know of likely developments, and for governments to take necessary action on a scientific basis.
Sixth, a national lockdown perhaps is not desirable, but local lockdowns, depending upon evolving situations, will continue. Robust surveillance may identify local hotspots for not partial but complete lock down for two weeks at a stretch—it may be a cluster of houses, a colony or a ward.
Essential supplies have to be externally ensured
Seventh, sufficient beds have to be kept ready at all hospitals. But for each city, town or PHC area, we should have temporary oxygenated hospitals planned which can be made quickly operational. The BMC operational model should be replicated by end of May for all cities, where through control rooms, people are brought from home by ambulances to predetermined beds.
Eighth, we must plan to augment healthcare manpower—doctors, nurses, other para medical staff. Attractive honoraria and other incentives can be a way to rope in professionals who haven’t been hitherto engaged.
Ninth, oxygen supplies have to be increased and rationalised. All district hospitals must get oxygen plants, with piped supply in next three months, funded by PM Cares. The private sector should be encouraged to set up plants wherever they can. Simultaneously, based on a national demand analysis, a transportation and linkage plan must be made to supply from large producers to large consumers. Decentralised centers should be opened where people can refill/exchange empty oxygen cylinders, with supply from the concerned local administration. The demand for cylinders needs to be assessed in all districts and arrangement for supply made as per requirement. It should be specified as to what kind or size of oxygen concentrators are needed for which places, for what purpose, and how they should be used. NGOs can be encouraged to provide oxygen concentrators on rent to avoid a mad rush for purchase.
Tenth, medical care and treatment protocols must be standardised quickly by an expert group and be well publicised, one that is updated on fortnightly basis. This will tackle the problem of often contradictory and confusing recommendations. There is a rush to get certain drugs, which may lead to their injudicious over use. Many instances of black marketing and overcharging are being reported in the media. This is also applicable to CT scan, blood tests, plasma etc. Clarity is also needed over consumption of steroids etc. There are reports of fabiflu being indiscriminately used. Goa is reported likely to use ivermectin as a prophylaxis, while WHO has advised against it. Doctors, especially in small towns and rural areas, must be sensitised on these issues by the IMA/ICMR. It is imperative that a national tele-consultation center be opened with sufficient capacity to cater to large number of requests and these be gradually reduced to FAQs so that state, and even district, tele-centers can handle the load. The IMA could contribute to this effort significantly at all levels. A rapid assessment should be made of the requirements of all necessary drugs; what is being done to produce them and ensuring their easy availability in the market. The Centre should fix prices for all these drugs and treatment protocols. Each state could then procure and supply these to the government facilities and ensure availability at village/panchayat levels.
Eleventh, all these actions are complex and have to be taken simultaneously. Therefore, for each component a small group with relevant experts should be formed, at both central and state levels, to plan, help implement and monitor. These will also serve as feeders to a larger monitoring group under the cabinet secretary at the Centre and under the chief secretary in states, as also an inter-state group. This should meet weekly to monitor the progress, identify gaps and suggest actions to be taken. At the apex level, periodic consultations between the central and state government leadership to get feedback, fine tune the strategy, and take decisions will provide a push to all the efforts. The PM may consider holding all-party meetings to take everyone along. It is a joint fight. There must be trust between the Centre and states, in the real spirit of co-operative federalism.
Finally, on many of the items raised above, there has been a dearth of information and data. Transparency inspires trust, even if the news is bad. Therefore, it is imperative that all data be shared on real-time basis by the Centre, states and districts. We cannot fight the virus without the trust of the people.
The author is Former additional secretary (health), and former chairperson, UPSC