After the Covid-19 crisis, how has Uttar Pradesh’s health strategy changed?

Uttar Pradesh, India’s most populous state, has had over 17 lakh Covid-19 cases so far and the disease has killed 1.34% or, 22,891 people, since the start of the pandemic – a slightly higher rate than India’s 1.3%. At the peak of the second wave, the state reported more than 300 deaths a day. Ground reporting also showed that cases and deaths had been underreported in the state and the mismanagement of the pandemic during its panchayat elections endangered the lives of teachers on election duty.

As the wave began abating across most states, Uttar Pradesh too started reporting fewer cases – on September 28, the state had only 14 new and 177 active cases of Covid-19. However, this monsoon, the state has also been reporting dengue, leptospirosis and scrub typhus.

What lessons did the state draw from its Covid-19 crisis on how to deal with disease outbreaks? In this interview, Jai Pratap Singh, the minister for Medical and Health, Family Welfare, Maternal and Child Welfare in the Uttar Pradesh government, offers some insights.

Excerpts from the interview:

At the peak of the second wave, Uttar Pradesh was reporting almost 350 deaths a day. What are the lessons that the state has drawn from its Covid-19 experience? How would you describe UP’s health system now and its preparedness for disease outbreaks?
We had a very tough time when we first faced Covid-19. That was, if I remember correctly, March 8, 2020, when we got our first cases – people who had returned to Agra from Italy. We did not have any specialised place to look after them so we referred them to Safdarjung Hospital.

We had only one testing machine at the King George Medical University, which could test about 70 cases a day. From that day onwards, our chief minister insisted that we put all our money into increasing our infrastructure, our testing facilities, our bed occupancy, increasing the [number of] beds and [their] availability at the [level of] Community Health Centres, and to make sure that every medicine is available there.

[This campaign] included checking the borders with Nepal, checking trains, whatever possible, on a war footing and in 2020 we did pretty well. Our infrastructure went up – beds of all categories and along with that, medicines, and doctors and paramedics, everything came together in a very short, quick time. And testing, of course, went up quite a bit.

Thereafter, as you know, in 2021, when the virus reemerged as a different, mutant variety, it was a total setback to all our preparedness… whether in UP or all over the world. And we suddenly found ourselves facing an oxygen shortage because [the virus] was affecting the lungs immediately. And, people were running short of oxygen, oxygen cylinders.

Normal oxygen plants, which were running at a very slow pace and were just being used for [surgeries]… were suddenly converted to [deal with] a high intake of oxygen, and [there was] a shortage of oxygen all over the country. And as you know, at that time the Prime Minister and his cabinet stepped in. All the oxygen [distribution] was taken over by the government of India. The allotment was made for each state. Ours came from Bokaro, from Jamnagar and on a war footing we ensured that the tankers reached hospitals – government hospitals in all 75 districts and private hospitals connected to the system.

What has changed for the state’s health system post-Covid? You had a dengue outbreak more recently and that can be debilitating and leads to casualties.
Between the Covid-19 [waves] from 2020 to 2021, we were continuously ensuring that all the gram panchayats, nagar nigams, nagar palikas – cities and villages – were fogging and spraying drains and houses. This is a regular thing which we do each year to [deal with] the larvae. Apart from dengue, we were also dealing with Japanese encephalitis in three or four stages where we were doing 100% vaccination for children above a certain age.

Dengue has a cycle of roughly about once in three years. We had a problem in 2019. And this time, we saw that it suddenly came up again because we had very heavy rains. There was a lot of waterlogging, and we had a lot of problems cleaning up the garbage. We found an outbreak of dengue recently in Firozabad and Mathura. And by the time our people got into action… you see, initially, people who had dengue did not come to government hospitals but went straight to nearby private hospitals where there were a lot of deaths and some children died at home also. By the time we got into action, the damage had been done.

We got our teams together, we started doing house-to-house surveys, ensuring that whatever water was being held up in containers [was emptied], issuing warnings, making people aware of what has to be done.

Mathura was a little different because suddenly you had diseases like leptospirosis and scrub typhus. These were new to us. But again, as they were being tested by the Indian Council of Medical Research, and [depending on] the report we got, we changed the medication and did whatever we could do. So it was contained. But it did us a bit of damage and despite our preparedness, there was a lack of systems there.

So if I were to ask you to define a health strategy going forward, what would it be? How much prevention, how much cure, how much communication? For instance, you spoke about the rains but should that not be a trigger for the administration to start moving?
Before the rains, generally, a directive is given every year to all the departments concerned that every drain should be cleaned just before the monsoon, there should be fogging. Now, when you have more than the required amount of rain – which happened this year – your drains can only take that much water no matter how much you clean.

And so it gets logged in places where there is less construction or maybe construction places where there are gaddhas (potholes). But in the health department, we already have a system – every three months we have a sort of a programme for, not only dengue but also chikungunya, H1N1 flu, kala azar, Japanese encephalitis and diarrhoea.

Now [sometimes] everything happens together – you are just getting out of Covid-19 and suddenly you come across an outbreak of dengue, then the next thing you know is there are a lot of cases of diarrhoea in Lucknow. Then all of a sudden in a different area in the state you suddenly find a few cases of kala azar and then you are rushing around there. So despite the preparedness, I can admit that we were caught on the wrong foot because we had just gone through rigorous Covid-19 management. But we have got that under control now, there is no problem and all the government hospitals are totally prepared.

Almost 80% of India’s healthcare system is private and 20% public. As you said in the case of dengue, maybe more people preferred to go to private facilities first and then when they did not get the right treatment, landed up in public facilities, maybe too late. How do you plan to deal with this in a state that is India’s largest?
Just after April-May, we initiated training of ASHA workers, Anganwadi workers to go to each and every household. They were doing it in 2020 for Covid-19 and also in 2021. And just after Covid-19 started tapering down, we started using the fieldworkers to survey each and every household to see what sort of fever comes up next.

And the idea was to tell them that if you have any sort of fever, which has not been controlled over a period of two-three days, then you must come to the government hospital where you will be tested for dengue and for different types of diseases for which we have the facility now in almost every district.

And we used the force [of fieldworkers] in a big way for an awareness programme – telling them that the government is fully prepared, you must come to the government hospital for any of your ailments. We also used [fieldworkers] for TB fact-finding. We used it to make Ayushman Bharat cards for those who did not have one.

The second way is to get all our hospitals well-staffed with doctors and paramedical staff, [ensure] that Primary Health Centres and Community Health Centres have proper medicines and labs. There is a lot of dependence on the government and when people come to us, they should know that they will be able to get [health services].

The state’s population is huge and our [public] infrastructure covers about 30%-35% of whatever [facilities] we have. You say 65%-70% of facilities are private, yet there is a lot of dependence on our government primary and community health centres. I can tell you that we have an average outpatient department [footfall] of roughly about 10 crores in a year – right from our Primary Health Centres to our community health centres to district health centres.

And today we are evolving [a network] of health and wellness centres and sub-centres where we are going to improve our techniques, especially for [child] delivery. Because the basic primary motive of the health sector is also to reduce our infant mortality and maternal mortality and when this happens you get a better health quality life also.

About 10.3 crore doses of Covid-19 vaccines have been administered in Uttar Pradesh. Seroprevalence studies seem to suggest that almost 80% of your state’s population above 18 years of age is already carrying antibodies. So, is that giving you comfort and if not, what are your plans to deal with the pandemic?
As you said, almost 80% of the population is showing antibodies and about 57.3% of the targeted population has been given the first vaccination and about 14%-15% the second. The ICMR’s finding is that even if you get one dose, your immunity goes up to 96.6%. People now know that they are quite immune because the antibodies are well-developed but even then we are insisting that everybody has to have the second dose.

We are calling them up from our call centre – we have a special day fixed for this, Saturday – and asking them to come in for their second shot because that will give them better immunity from Covid-19 for a longer time. Just yesterday we did about, I think, 36 lakh 88 thousand doses. And we have done almost 3 crore 25 lakhs in one month. So our target is to try and get this entire population vaccinated by December 2021 if we get enough vaccines. And as you know, ICMR is also now finalising Zydus Cadila vaccine for 12-18 year-olds.

So, as you look ahead with Covid-19 in the rearview mirror, what are your key concerns about public health?
Basically, we have to try and improve our health infrastructure, whatever shortcomings Covid-19 showed up. Now as you know that suddenly we were told that the third phase of the pandemic might be coming and it might affect those under 18.

But now, with the sero-survey and the population that has been vaccinated at a fast pace all over India and in UP too, we don’t see any possibility of a third wave. But because of that [fear] we improved the health sector. We initiated all the safety [protocols] regarding paediatric ICUs and trained our doctors and ensured that every type of basic infrastructure – digital X-ray, ultrasound, small ICU, oxygen concentrators, oxygen generating plants – are being put up.

We have already put in a word for specialist cadres through the UP recruitment board. We have already been given 1,000 people who are interested. This will make sure that there are specialists at health centres.

We now have medical colleges being established in every district. Between 1947 and 2017, we had only about 12 medical colleges. Our chief minister has been pushing for each district to have a medical college and nine are already going to be inaugurated by the Prime Minister.

Another 12 or 13 are being constructed and 16 districts are going under the public private partnership model, a tender for which is going to start any day. So overall we are going to have almost 45 medical colleges each with 100 seats. We are hopeful that once this system starts, we will get doctors through an agreement system to work for at least five years at Primary Health Centres. So there will be no shortage of doctors.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.