SKOCH Group has been studying the State of Public Health for the past few decades. Our study which is an annual exercise captures micro-level project initiatives at the last mile which have made a major difference in the lives of citizens. These initiatives are benchmarked as best practices and ranked nationally. This year the focus of the State of Public Health study is COVID-19 and the response of government institutions at the centre, state and district to the pandemic.
Corona Pandemic is globally testing the public health systems and how well the governments are able to respond. Linked with this quite tightly are socio-economic issues caused by the pandemic.
Health, being a federal subject, there are vast variations in Public Health Delivery Systems across states. While ICMR and the center prescribe treatment protocols and usage of various drugs, the procurement and adoption are left to the states.
Given Corona, wherein there are hardly any scientifically validated studies on the best course of action even countries are adopting widely differing approaches. The broad contours of consensus areas are:
- Prevention is the Best Course: This encompasses measures like use of masks, social distancing and frequent hand washing. It goes on to imposition of measures like containment zones and lock downs. With each state taking its own course on imposing lockdowns and economic closures, center has been constrained to advise them against it.
- Vaccine Availability is Anyone’s Guess: Several initiatives are on. Experts feel that there is a 70% chance of a vaccine being available by the end of the year and a 30% chance of it never being available like in the case of HIV. If and when the vaccine is indeed available, the production and distribution to a global population is a very formidable challenge and expected to take years to cover everyone.
- Management Protocols Have a Lot of Issues: Starting with state by state or even country by country differing protocols, even institutions like WHO have not been able to evoke a high degree of confidence. Repurposed drugs end up sounding like ‘fad of the fortnight’. Whether it is Hydroxychloroquine, anti-parasitical drugs, Tami-flu, Zinc, Vitamin D or anti-virals, all are undergoing testing and research for efficacy against Corona as we go. This creates imbalance between under-prescription, over-prescription and effective prescription. Learning from each other is the key.
- Health Governance Will be the Biggest Challenge: Given the above, we believe that moving forward health governance would be the biggest challenge and economic growth as well as social equity in various countries and state would be directly linked to the state of health governance. Use of digital technologies as well as incorporation of best practices would be the key to success. Related issue is the procurement, distribution, funding and timely payments for the drugs and treatments. Efficiencies and learning from ‘what worked’ are called for at every stage.
What do experts say?
A recent study by the Centre for Development Policy and Practice which aims to analyse the response of individual states to the Covid-19 outbreak has found that some States are better positioned than others to deliver a public health response to COVID-19. This study prepares indices for the following
- Health expenditure by State as % of GSDP
- Per capita expenditure on health
- Number of beds in hospital/per capita
- Testing per million
It seeks to use health resource allocation and expenditure, testing capacity and health infrastructure provisioning as a proxy for COVID-19 response. According to this study, along the metrics studied within it, the most prepared and least prepared States are as follows:
| Most prepared States | Most Prepared UTs | Least prepared States |
| Arunachal Pradesh | Andaman and Nicobar | Madhya Pradesh |
| Goa | Puducherry | Uttar Pradesh |
| Mizoram | Delhi | Bihar |
| Sikkim | Maharashtra | |
| Assam | Chhattisgarh | |
| Jammu and Kashmir | Jharkhand | |
| Tripura | Rajasthan |
Its key findings are as follows:
- Per Capita Expenditure: Arunachal Pradesh, Mizoram and Sikkim and the UTs of Andaman and Nicobar and Puducherry perform well whereas Bihar, Madhya Pradesh and Uttar Pradesh fare the worst in this regard
- Percentage of GSDP spent on health: North-eastern states of Arunachal Pradesh, Nagaland, Meghalaya and Mizoram perform well. Maharashtra and Haryana fare the lowest on this indicator.
- Availability of beds in government hospitals/population: Bihar and Jharkhand fare lowest in this aspect. Sikkim and Puducherry fare well on this index.
- Tests per million: Goa, Arunachal Pradesh and Delhi on the top. Madhya Pradesh and West Bengal fare the lowest on this index.
However, on the other hand, another recent study by Mudit Kapoor and Shamika Ravi finds that there are some States within which the Case Fatality Ratio is decreasing, whereas it is increasing in others. These States have been divided on the basis of population (<10 million and >10 million)
Some prominent States in which the Case Fatality Ratio is decreasing are
| Case Fatality Ratio Decreasing | Case Fatality Ratio Increasing |
| Maharashtra | Punjab |
| Gujarat | Assam |
| West Bengal | Sikkim |
| Delhi | Ladakh |
| Madhya Pradesh | Manipur |
| Haryana | Tripura |
| Rajasthan | Goa |
| Andhra Pradesh | Andaman and Nicobar Islands |
| Telangana | Himachal Pradesh |
| Bihar | |
| Uttar Pradesh |
As can be seen above, that even within States which have lower comparative availability of health infrastructure and resources as per the CDPP study, the Case Fatality Ratio has been steadily declining. Several States which are ‘least prepared’ in terms of COVID-19 response as per the CDPP study are witnessing a decreasing a Case Fatality Ratio.
Therefore, the following questions remain unanswered,
- How are States with low preparedness being able to reduce their Case Fatality Ratio?
- Is there more going on beneath the surface?
- Are States undertaking micro-level interventions, which are making all the difference on the ground?
- What is changing at the last mile?
The frontline response to COVID has been driven at the third tier, be it at the Centre, State or District levels. These could be specific interventions at the hospital or local municipal level. The innovation and dynamism required to address local challenges is what SKOCH seeks to study. We seek to identify and promote best practices. There may be several variations therein on the basis of felt-needs within specific areas. For instance, the felt-needs of West Godavari district may be very different from those within Tawang. We seek to study well performing project-level interventions and strive to look for beacons of hope, within specific problem statements. These will be benchmarked nationally to serve as inspiration for replicability. Excellence should be applauded wherever it is found.
The battle though is far from being over. SKOCH Group is in the process of documenting such successes and lessons that may be useful for each of us to take note of and learn from. Our annual ‘State of Health’ review is underway and this year the documentation and lessons may just be crucial for the entire humanity.
Our Approach is as Follows:
- Primary Research: SKOCH is known for its independent, primary research that includes field visits and interactions with stakeholders including citizens. Focus Group discussions are conducted to collect the citizen feedback, viewpoint and assessment of outcomes.
- Call for Nominations: Various institutions, central and state governments are being requested to document and nominate what they feel are best practices being implemented by them.
- Secondary Research: It is carried out by SKOCH editors to validate the information submitted by the implementing departments / agencies. It is contrasted with Primary Research for validation. At times, SKOCH editors also feedback the departments / agencies on documentation.
- Participatory Discussion and Evaluation: These are then being discussed between peer groups and expert groups to be evaluated. An integral part of this would be to get states of different capacities, economies and challenges together to be able to exchange notes.
- Knowledge Sharing: The best evaluated interventions would be available as an online exhibition and case studies. There would be a series of Round table discussions and conferences around this.
- Collaborations: We are collaborating with think tanks and experts in health sector in India and abroad to help bring in a plurality of view as well for leveraging their experiences in public health.
- Promoting Best Practices: The best practices would be showcased in social as well as mainline media. These could include features in mainline newspapers.
Expertise is being drawn from health economists, medical professionals, public health professionals, public policy experts and social scientists to bring a multi-disciplinary approach to this review.
A series of Roundtables and Discussions is planned to find answers to specific issues that are being posed under the study.