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At the end of a year that shook the world, India cautiously views what appears to be a slowly receding epidemic, even as Europe and America are caught in a returning tide of covid-19, and countries like South Korea that were exemplars of tight and timely control are again feeling the sting of a virus that just won’t give up. It is no time for India to be complacent, as we now need to focus on building strong and resilient systems that can prevent or quickly curtail health shocks that can result in severe economic and social disruption.

The lessons of the pandemic for India are loud and clear. We must build an efficient and equitable health system that is robust enough to speedily and effectively deploy sufficient surge capacity to deal with a public health emergency, and without neglecting other health needs that are the duty of the health system to address. We also need to expand the capacity and quality of our health workforce, while acquiring self-sufficiency in the production of medical equipment, active pharmaceutical ingredients and research that extends from epidemiology to vaccine design.

Public health begins with health promotion and prevention. We need to create social and environmental conditions that enable people to build high levels of innate immunity with nutritious food and reduced pollution, while promoting health literacy to guide people’s behaviour. Whether it is adherence to advice on masks or acceptance of vaccines, the engagement of communities in a conversation on health is essential.

Epidemics can either erupt from within or invade the country from another. In both cases, a strong surveillance system is necessary. This has to track the potential of microbial spillover from wildlife to veterinary populations and human communities, while predicting and pre-empting patterns of transmission between people who may be stable residents or intermittent travellers. Surveillance systems need to cover many diseases, their causal factors and determinants. Technology will make the task easier and more efficient, but human expertise is the most essential need. This, we must urgently address at both the central and state levels. Epidemiology needs both shoe leather and smart phones. We need public health expertise at all levels, from policy to design, for the delivery, monitoring and evaluation of programmes. Where is the investment in scaling up this expertise and creating multi-disciplinary public health cadres for our state and central health systems?

Public sector investment is needed at all levels of healthcare, but especially so at the primary level. Early detection of outbreaks, contact tracing and containment measures are functions best performed at that level. Even the prevention and control of non-communicable diseases—which are now clearly recognized as the most important risk-enhancing contributors to severe disease and mortality in cases of covid and similar respiratory infections—are best prevented, detected early and treated effectively through continuous care at the primary level. District and medical college hospitals too need to be strengthened, along with emergency transport services. A multi-layered, multi-skilled health force must be steadily developed to meet the many needs of the health system, since neither public health emergencies nor regular needs can be met by hurriedly assembling a dubious mix of skills. India’s private and voluntary healthcare sectors need to be connected to the evolving framework of universal health coverage in a predictable and accountable arrangement that is not driven by expediency. Horizontal and vertical networks of healthcare providers must be developed at and between the different levels of care in every district of the country.

We need to ensure that health shocks do not translate into financial shocks for people. Nationwide architecture for universal health coverage can do this. Whether it is primary care or intensive care, a vaccine or a life-saving drug, access should not depend on the paying capacity of the individual in need. Both the country and its citizens need protection from health shocks.

All of this requires paying sustained attention to building a robust health system and a commitment to provide the financial and planning resources needed. It must happen at both the central and state levels, as the system can give way at its weakest spot. Electric shocks arise from leaky wires. So can health shocks.

These are the author’s personal views.

K. Srinath Reddy is president of the Public Health Foundation of India and author of ‘Make Health in India: Reaching a Billion Plus’.

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