Structural changes needed for health security

Dinesh C Sharma

Journalist and author

The epidemic caused due to the spread of novel coronavirus has been declared a global pandemic. The number of infections and mortality has come down in its epicentre, China, but has shot up in Italy and Iran. More than the medical fallout of the epidemic, the virus is causing social, economic and political repercussions across the globe. It has crippled travel, tourism, hotel, aviation, hospitality and other sectors and its further spread could lead to devastating economic effects. In conjunction with the falling oil prices, the virus is causing mayhem in global stock markets including Indian stock exchanges.

The health sector is facing a double whammy — one, of course, is the direct pressure of handling the rising number of cases, the need for greater surveillance, screening and diagnosis; the second blow comes in the form of potential shortage of medical supplies — essential medicines and equipment — due to disruption in supply chains as China is a major supplier of these essentials globally. Both these factors are important from the health security point of view for India and should serve as a wake-up call.

In response to the outbreak of the novel coronavirus, the Ministry of Health responded with measures like airport screening and visa restrictions, activation of isolation wards in government hospitals, guidelines for self-quarantine, promotion of hand hygiene and social distancing. All these emergency steps are aimed at limiting the spread of the virus. This preparedness is a result of changes in the health system implemented in the aftermath of outbreaks of SARS, avian influenza and swine flu etc since 2000. In 2004, a major structured response was unveiled in the form of the Integrated Disease Surveillance Programme (IDSP) with help from the World Bank. This was to develop the capability to detect and respond to disease outbreaks anywhere in the country rapidly, using a network of trained personnel like epidemiologists, microbiologists and entomologists. This system should serve as the backbone if a Wuhan-like outbreak occurs anywhere in India.

The first lesson that India can draw from the current epidemic is to take steps to strengthen this response system. The government must ensure that IDSP remains fully functional, well funded and staffed. Every state and district should have disease surveillance units linked with the central surveillance unit. These surveillance committees headed by senior officials are supposed to meet at least once in a month and as often as needed during epidemics and outbreaks. Over the years, several of these committees have become defunct and district surveillance units face a lack of staff like trained epidemiologists. The way Kerala has handled outbreaks of Nipah in recent past shows that public investment in health is critical for the health system as well as for health security. The recent move of the government to hand over district hospitals to private sector could weaken the surveillance system. Hopefully, the present crisis will lead to a rethink on this proposal.

The second lesson for India is to review the structure and working of the pharmaceutical sector, in wake of the disruption of supply of bulk drugs or active pharmaceutical ingredients (APIs) from China. It is not just India but all major markets have become dependent on China for supply of bulk drugs. It is ironic that India, which is a major supplier of finished drugs to dozens of countries, is itself dependent on China for its bulk drug requirements. This dependence extends to even commonly prescribed essential medicines and antibiotics such as paracetamol, metformin, amoxicillin, ampicillin, ibuprofen and ciprofloxacin. Experts have been warning that such dependence is not healthy for the health sector, though it may make good sense for the industry.

The development of Indian pharmaceutical industry in the 1970s and 1980s was spurred by the patent law of 1971 that made ‘reverse engineering’ of patented drugs possible and the research backup provided by national laboratories under the Council of Scientific and Industrial Research (CSIR). Large public sector companies like the Indian Drugs and Pharmaceuticals Limited and Hindustan Antibiotics Limited provided bulk drugs and intermediaries. In the post-liberalisation era, the public sector units were neglected and allowed to decay. On the other hand, as the new patent regime came into effect after 2000, the private sector opted for the easy option of low-cost manufacturing of off-patent drugs for export markets. The combined result of these two trends is ‘hollowing out’ of the Indian pharma industry, as pointed out in a 2019 study led by Dinesh Abrol of the Institute for Studies in Industrial Development. ‘Hollowing out’ means deterioration of a manufacturing sector when companies move important activities of manufacturing to low-cost destinations abroad.

The response of the government and the industry so far has been knee-jerk. The industry is seeking subsidies and other concessions to boost local production of bulk drugs and intermediaries, while the government has slapped an export ban on certain APIs. If the objective is to ensure health security of the country — and not just saving export markets — then we need bold structural changes. India needs a clear roadmap to achieve self-sufficiency in all steps of pharmaceutical manufacturing based on global quality standards. This will call for investments in drug R&D in CSIR labs and a revival of public sector units for bulk drug manufacturing, along with giving incentives for developing private industrial clusters. The objective should be to manufacture all essential drugs domestically and their domestic marketing at affordable prices, and not exports alone.

In order to align pharma industry with the health needs of the country, it is necessary to bring the Department of Pharmaceuticals under the control of the Ministry of Health (right now it is under the Ministry of Chemicals and Fertilisers). This makes a logical sense because the Health Ministry, together with Department of Health Research, Indian Council of Medical Research and the Drug Controller-General of India, looks after all scientific and technical aspects of the drug industry. The coronavirus is a reminder for India to invest in health security of the people by strengthening the primary care system and by realigning the pharma industry to meet the domestic health challenges.

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