India's resurgence of COVID-19: urgent actions needed
Authors: Yamini Aiyar, Vijay Chandru, Mirai Chatterjee, Sapna Desai, Armida Fernandez, Atul Gupta, Gagandeep Kang, Tarun Khanna, Kiran Mazumdar-Shaw, Nachiket Mor, Arnab Mukherji, Poonam Muttreja, Thelma Narayan, Bhushan Patwardhan, K Sujatha Rao, Sharad Sharma, Devi Shetty, S V Subramanian, Leila E Caleb Varkey, Sandhya Venkateswaran, Vikram Patel
Journal: The Lancet (2021)

As of May, 2021, the resurgent wave of COVID-19 in India has been spreading to rural populations and other countries in the region. The pandemic has foregrounded the long-standing need for universal health coverage (UHC) in India. The Lancet Citizens' Commission on Reimagining India's Health System was launched in December, 2020, to map the pathway to achieving UHC in the coming decade through a participatory, solutions-driven approach.1Patel V Mazumdar-Shaw K Kang G Das P Khanna T Reimagining India's health system: a Lancet Citizens' Commission.Lancet. 2021; 397: 1427-1430Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar Yet in the present moment, India confronts an immediate emergency to save lives and reduce suffering. On behalf of the Lancet Citizens' Commission, we propose eight recommendations for the central and state governments that share responsibility for the health of the India's people. Our recommendations complement those of Kuppalli and colleagues' call for actions from the international community.2Kuppalli K Gala P Cherabuddi K et al.India's COVID-19 crisis: a call for international action.Lancet. 2021; (published online May 14.)https://doi.org/10.1016/S0140-6736(21)01121-1Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar Our intention in making these recommendations, some of which have been recently voiced by authoritative voices in the country,3Priyamvatha P How India's second Covid wave started, what went wrong, and what can be done: top virologist answers.India Today. April 28, 2021; https://www.indiatoday.in/coronavirus-outbreak/story/india-second-covid-wave-start-went-wrong-top-virologist-answers-details-1795743-2021-04-28Date accessed: May 20, 2021Google Scholar is to amplify and synthesise what must be done urgently. First, the organisation of essential health services must be decentralised. A one-size-fits-all approach is untenable since the numbers of COVID-19 cases and health services differ substantially from district to district.4COVID19 IndiaCoronavirus in India: latest map and case count.https://www.covid19india.orgDate: 2021Date accessed: May 19, 2021Google Scholar District-level working groups that have the autonomy to respond to rapidly changing local situations must be empowered to receive funds and resources to coordinate efforts across all sectors of the health system, from front-line workers to tertiary care. Appropriate technologies could have a role in streamlining the management of resources and supplies, such as hospital beds, oxygen, ambulances, and funeral resources. Several states and districts have successfully used such decentralised systems for quarantine, triage through front-line workers, and community-based primary service delivery.5Express News ServiceTriage centres in districts to fight Covid 2nd wave.The New Indian Express. May 17, 2021; https://www.newindianexpress.com/states/karnataka/2021/may/17/triage-centres-in-districts-to-fight-covid-2nd-wave-2303472.htmlDate accessed: May 19, 2021Google Scholar, 6WHOFrom governance to community resilience: Odisha's response to COVID-19.https://www.who.int/india/news/feature-stories/detail/from-governance-to-community-resilience-odisha-s-response-to-covid-19Date: Sept 17, 2020Date accessed: May 19, 2021Google Scholar Second, there must be a transparent national pricing policy and caps on the prices of all essential health services—eg, ambulances, oxygen, essential medicines, and hospital care. Hospital care should not require any out-of-pocket expenditure and costs should be covered by existing health insurance schemes for all people, as has been done in some states.7FE BureauTamil Nadu govt to bear Covid treatment expenses of public in private hospitals.The Financial Express. May 8, 2021; https://www.financialexpress.com/lifestyle/health/tn-govt-to-bear-covid-treatment-expenses-of-public-in-private-hospitals/2247980/Date accessed: May 19, 2021Google Scholar All local governments must be allocated their grants as recommended by the Fifteenth Finance Commission8Finance Commission, Indiahttps://fincomindia.nic.in/Date accessed: May 19, 2021Google Scholar to ensure they have the resources to augment COVID-19-related health services in their jurisdictions. Third, clear, evidence-based information on the management of COVID-19 must be more widely disseminated and implemented. This information should include suitably adapted international guidelines9WHOCOVID-19 clinical management: living guidance.https://www.who.int/publications-detail-redirect/WHO-2019-nCoV-clinical-2021-1Date: 2021Date accessed: May 19, 2021Google Scholar for home care and treatment, primary care, and district hospital care in local languages that incorporate local circumstances and clinical practice. The guidance must also emphasise what not to do,10Pulla P Covid-19: India's slow moving treatment guidelines are misleading and harming patients.BMJ. 2021; 372: n278Crossref PubMed Scopus (6) Google Scholar and ensure that only evidence-based therapeutics are used. It should also provide information to help prevent increasingly concerning reports of other impacts of COVID-19, including secondary infections such as mucormycosis.11Wadhawan DA Jain P Shrivastava S Kunal K Rajasthan declares black fungus mucormycosis an epidemic cases rising in other states.India Today. May 19, 2021; https://www.indiatoday.in/coronavirus-outbreak/story/rajasthan-declares-black-fungus-an-epidemic-cases-pile-up-in-several-states-10-points-1804470-2021-05-19Date accessed: May 19, 2021Google Scholar, 12Directorate General of Health ServicesGovernment of IndiaGuideline for management of mucormycosis in COVID-19 patients.https://dghs.gov.in/WriteReadData/News/202105171119301555988MucormycosismanagementinCovid-19.pdfDate: 2021Date accessed: May 20, 2021Google Scholar The information should also underline the essential non-COVID-19 health services that must remain fully accessible in specific facilities—eg, for tuberculosis, maternal and child health, and emergency medicine. Specific guidance should be offered by the central government on the appropriate use of Indian systems of medicine, especially for prevention and health promotion interventions, such as yoga.13Ministry of AYUSHGovernment of IndiaAYUSH guidelines.https://www.ayush.gov.in/ayush-guidelines.htmlDate: 2021Date accessed: May 20, 2021Google Scholar Additionally, widespread access to teleconsultation and care delivered by front-line workers needs to be expanded to reduce the burden on hospitals. Fourth, all available human resources across all sectors of the health system, including the private sector, must be marshalled for the COVID-19 response and adequately resourced, particularly with sufficient personal protective equipment, guidance on the use of clinical interventions, insurance, and mental health support. We support the implementation of the decision to deploy final-year medical students and AYUSH (ayurveda, yoga, naturopathy, unani, siddha, and homoeopathy) students in the COVID-19 response;14ET BureauMedical students Covid duty: on duty: final-year medical students and pre-PG doctors.The Economic Times. May 4, 2021; https://economictimes.indiatimes.com/news/india/on-duty-final-yr-medical-students-pre-pg-doctors/articleshow/82378742.cmsDate accessed: May 19, 2021Google Scholar this policy should be extended to nursing and paramedical students. Fifth, central systems to procure and distribute COVID-19 vaccines free of cost should be established in a departure from the current policy of decentralised procurement through state governments.15Lahariya C India's vaccine policy needs an urgent reset.Hindustan Times. May 17, 2021; https://www.hindustantimes.com/opinion/indias-vaccine-policy-needs-an-urgent-reset-101621261092043.htmlDate accessed: May 19, 2021Google Scholar Such an approach would optimise prices and minimise cross-state inequities that may result from differential fiscal and capacity contexts. By May 19, 2021, only 3% of India's population was fully vaccinated;16Ritchie H Ortiz-Ospina E Beltekian D et al.Coronavirus (COVID-19) vaccinations—statistics and research. Our World in Data.https://ourworldindata.org/covid-vaccinationsDate: 2021Date accessed: May 20, 2021Google Scholar up to 250 million COVID-19 vaccine doses are estimated to be needed each month to equip vaccination drives to full capacity and the country only has around 70–80 million doses per month.17Ellyatt H India is the home of the world's biggest producer of Covid vaccines. But it's facing a major internal shortage. CNBC, May 5, 2021https://www.cnbc.com/2021/05/05/why-covid-vaccine-producer-india-faces-major-shortage-of-doses.htmlDate accessed: May 20, 2021Google Scholar State governments must decide on the priority groups for vaccination on the basis of evidence to optimise the use of available vaccine doses, which can be incrementally expanded as supplies improve. Vaccination is a public good and should not be left to market mechanisms. Sixth, community engagement and public participation must lie at the heart of India's COVID-19 response. Grassroots civil society has historically had a crucial role in people's participation in health care and other development activities, such as in strengthening the COVID-19 response in Mumbai.18Golechha M COVID-19 containment in Asia's largest urban slum Dharavi-Mumbai, India: lessons for policymakers globally.J Urban Health. 2020; 97: 796-801Crossref PubMed Scopus (36) Google Scholar We recommend active collaboration between government and civil society organisations to create and disseminate accurate information, enabling home-based care, emphasising prevention, helping navigate access to live-saving treatment, and promoting vaccination. Restrictions on the capacity of non-governmental organisations to access foreign or domestic corporate social responsibility financial resources and human resource support19Sharma A Crippled by restraints, NGOs struggle to help with Covid.Mint. May 12, 2021; https://www.livemint.com/news/india/why-ngos-fight-covid-with-their-hands-tied-11620834069096.htmlDate accessed: May 19, 2021Google Scholar must be immediately withdrawn. Seventh, there must be transparency in government data collection and modelling to enable districts to proactively prepare for the likely caseloads in the coming weeks. Health system personnel require data on age and sex disaggregated COVID-19 cases, hospitalisations, and mortality rates; community-level coverage of vaccination; and community-based tracking of the effectiveness of COVID-19 treatment protocols and long-term outcomes. Additionally, surveillance needs to include urgent investment in genomic sequencing, adequate institutional capacity, and trained personnel20Morgan OW Aguilera X Ammon A et al.Disease surveillance for the COVID-19 era: time for bold changes.Lancet. 2021; (published online May 14.)https://doi.org/10.1016/S0140-6736(21)01096-5Summary Full Text Full Text PDF Scopus (36) Google Scholar to provide real-time alerts of SARS-CoV-2 variants, hot spots, and breakthrough infections. Finally, the profound suffering and risk to health caused by loss of livelihoods should be minimised by making provisions for cash transfers by the state to workers in India's vast informal economy who have lost their jobs, as is being done by some state governments.21Press Trust of IndiaTamil Nadu CM Stalin extends Rs 4,000 Covid-19 assistance scheme.Business Standard India. May 18, 2021; https://www.business-standard.com/article/current-affairs/tamil-nadu-cm-stalin-extends-rs-4-000-covid-19-assistance-scheme-121051800804_1.htmlDate accessed: May 19, 2021Google Scholar Formal sector employers must be required to retain all workers, irrespective of the status of contracts, through a government commitment to offer compensation to these companies when the economy revives. If lockdowns are deemed necessary, on the basis of local epidemiological data, they must be announced well in advance and entail planning for all essential services. There is still time to stem the haemorrhage of life and the suffering caused by COVID-19 in India. We call on the central and state governments to act with urgency and in solidarity with each other and across sectors to address one of the greatest humanitarian crises facing the country since its independence. AF is the Founder Trustee of SNEHA. BP is the Chair, Interdisciplinary AYUSH Research and Development Task Force of Ministry of AYUSH. DS is the Chair of Narayana Hrudayalaya Limited. GK serves on the boards of the Coalition for Epidemic Preparedness Innovations and MSD Wellcome Trust of Hilleman Laboratories Pvt Ltd, and on the data safety monitoring board for the WHO Solidarity Study. KSR is the Former Secretary of Health and Family Welfare, Government of India. KM-S is the Chairperson and Managing Director of Biocon Ltd. LECV is the Senior Adviser, Reproductive Health at the Centre for Catalyzing Change. MC is the Director of Social Security Team of the Self-Employed Women's Association. PM is the Executive Director of the Population Foundation of India. SD is an Associate at the Population Council. SS is a co-founder of the iSPIRT Foundation. TK is a co-founder of Jana Care, a chronic disease diagnostics company but does not have any operating role or board stewardship role in the company. TN is the Director, Academics & Policy Action of SOCHARA. VP is a founder of Librum, a mental health consulting firm, and a co-founder of Sangath, India. YA is the President and the Chief Executive of the Centre for Policy Research. The other authors declare no other competing interests. We thank Shubhangi Bhadada and Shyamli Badgaiyan for their assistance in the preparation of this Comment.