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JRD Tata Memorial Oratioin Fifteenth_by Dr. Soumya Swaminathan 2020 |
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15th
JRD TATA
MEMORIAL
ORATION
Reimagining Health:
Lessons from the Pandemic
by
Dr. Soumya Swaminathan
Chief Scientist, World Health Organization
21st October, 2020
Celebrating 50 Years
The 6th JRD Tata Memorial Awards & O ration I 1
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e JRD Tata Memorial Oration over the years
1. Democratic Decentralisation and Population Stabilisation Strategies
by Mr. Ramakrishna Hegde (19th September, 1995)
2. Population and Development Crisis in India
by Mr. Chandra Shekhar (26th October, 1996)
3. Role of Empowerment of Women in Population Stabilisation
by Dr. Najma Heptulla (29th November, 1997)
4. Thrust Areas for Population Stabilisation
by Mr. I.K. Gujral (15th January, 1999)
5. A ‘New Woman’ for India - A New India for Women
by Dr. Na s Sadik (13th December, 1999)
6. National Population Policy 2000 - Role of the National Commission on Population
by Mr. K.C. Pant (3rd November, 2000)
7. Role and Responsibilities of Panchayats in Population Health and Development
by Mr. Digvijay Singh (4th December, 2001)
8. Population, Poverty and Sustainable Development
by Dr. Manmohan Singh (3rd February, 2003)
9. Towards Population Stabilization: Role of Good Governance
by Mr. Somnath Chatterjee (30th March, 2005)
10. Corporate Social Responsibility and Issues of Population Stabilisation in India
by Dr. Jamshed J. Irani (22nd July, 2008)
11. Demographic Dividend or Debt?
by Dr. Nitin Desai (26th March, 2010)
12. Women and Other People
by Prof. Amartya Sen (31st July, 2012)
13. Dignity and Choice for Girls and Women in the Post-2015 Framework
by Dr. Babatunde Osotimehin (24th April, 2015)
14. Women Empowerment: The Key to India’s Demographic Dividend
by Dr. Rajiv Kumar (12th October, 2018)
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Contents
About Population Foundation of India
1
Address by Executive Director, Population Foundation of India
2
Dr. Soumya Swaminathan - A Profile
4
The Oration
5
Celebrating 50 Years
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About Population Foundation of India
Population Foundation of India is a national civil society organisation, that promotes and
advocates for effective formulation and implementation of gender sensitive population,
public health and development strategies and policies. The organisation was founded in 1970
by a group of socially committed industrialists under the leadership of the late JRD Tata and
the late Dr. Bharat Ram.
Population Foundation of India addresses population issues within the larger discourse of
empowering women and men, so that they are able to take informed decisions related to
their fertility, health and well-being. We work with the government, both at the national and
state levels, and with other civil society organisations. Our areas of work include family
planning and reproductive health, adolescent development and wellbeing, community
monitoring of public health services and women’s rights, and especially ending violence
against women.
Population Foundation of India is guided by an eminent governing board and advisory
council comprising distinguished persons from civil society, the government and the private
sector.
Our Mission
Advance gender-sensitive, rights-based population and family planning policies and actions
for a just, equitable and prosperous society.
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Executive Director’s Address
Poonam Muttreja
Population Foundation of India
The 15th JRD Tata Memorial Oration I 2
The year 2020 will be remembered in history for the
unprecedented challenges it has posed for humanity.
However, for us, it is also special as it marks 50 years from
the birth of the Population Foundation of India.
In 1970, Mr. JRD Tata laid the foundation for an
independent body to work with government, galvanise
civil society action and respond to the challenges of
population and development. We continue to draw
inspiration from JRD’s vision, words and wisdom. We
strongly believe that if our founding fathers were here
today, they would greatly appreciate the difference the
organisation has made to the lives of millions of people,
particularly girls and women.
Over the years, Population Foundation of India has
adapted to the changing needs of the times and found
lasting solutions to the challenges society is facing.
Today the world grapples with probably the greatest
humanitarian and public health crisis in recent history –
the COVID-19 pandemic.
As a public health organisation working on empowering
women, men and young people, we have been
supporting the government in its emergency response
to COVID-19. Our efforts have included ensuring that
women and young people continue to have access to
safe family planning and reproductive health services
during the pandemic. We also supported smaller
organisations at the grassroots to meet critical needs of
marginalised communities. In addition, targeted social
and behaviour change communication campaigns have
Celebrating 50 Years
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promoted adoption of COVID-19 appropriate behaviours, addressed stigma, and prevented
the spread of misinformation on COVID-19. Population Foundation of India has also
generated and disseminated evidence on the differential impact of COVID-19 on vulnerable
populations such as women and young people. With our renewed focus on young people
and digital technologies, Population Foundation is uniquely poised to meet the challenges
of a future, dented by the impact of COVID-19.
The Oration series was instituted in 1990 and invited eminent national and international
leaders to speak on critical issues related to population, development and national
progress. In 1995, the series was re-named the "JRD Tata Memorial Oration," in memory of
our founder Chairman.
We are privileged to have Dr. Soumya Swaminathan, Chief Scientist at the World Health
Organization deliver the 15th JRD Tata Memorial Oration on, “Reimagining Health: Lessons
from the Pandemic”. In these difficult times, we take strength from Dr. Swaminathan’s words
and inspiration from our fifty years journey, from hardships and challenges faced as well as
overcome.
We will continue to play a catalytic role in this challenging environment to strengthen those
who are most in need. We remain committed to ensuring that policies and programs
empower women and young people, inspire leadership and drive social transformation. As
we look ahead, we are confident of the significance of what we have managed to achieve so
far, and equally excited about the new goals we have set for ourselves.
21st October, 2020
New Delhi
Poonam Muttreja
Executive Director
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Dr. Soumya Swaminathan
A Pro le
Dr. Soumya Swaminathan is Chief Scientist at the World Health Organization (WHO). She
heads the WHO division created to strengthen the organisation’s core scientific work and
ensure the quality and consistency of its norms and standards. From October 2017 to March
2019, she was WHO Deputy Director-General for Programmmes.
Before joining the WHO, Dr. Swaminathan was Secretary, Department of Health Research -
Ministry of Health and Family Welfare, Government of India, and Director General of Indian
Council of Medical Research the apex body in India for the formulation, coordination and
promotion of Biomedical research from 2015-2017. From 2009 to 2011, she served as a
Coordinator of the UNICEF/UNDP/World Bank/WHO Special Programme for Research and
Training in Tropical Diseases in Geneva.
She served on several WHO and global advisory bodies and committees, including the WHO
Expert Panel to Review Global Strategy and Plan of Action on Public Health, Innovation and
Intellectual Property, the Strategic and Technical Advisory Group of the Global TB
Department at WHO, and as Co-Chair of the Lancet Commission on TB.
A paediatrician from India and a globally recognised researcher on tuberculosis and HIV, she
brings with her 30 years of experience in clinical care and research and has worked
throughout her career to translate research into impactful programmes.
Dr. Swaminathan received her academic training in India, the United Kingdom of Great
Britain and Northern Ireland, and the United States of America, and has published more
than 250 peer-reviewed publications and book chapters.
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The 15th JRD Tata Memorial Oration
Reimagining Health: Lessons from the Pandemic
Dr. Soumya Swaminathan
Chief Scientist, World Health Organization
President and Board of Trustees of Population
Foundation of India, Poonam Muttreja, and all sta and
colleagues:
First of all, I would like to say how honoured and
privileged I am to be invited to deliver this oration in the
name of one of the great Indians, JRD Tata, and
especially on the occasion of the 50th year of the
Population Foundation of India.
We know the principles by which Mr. Tata lived his life
and his dedication to serving society through being a
businessman. Investing in women and children,
investing in education and other social services and the
fact that he was way ahead of his time—all these were
recognised by the UN Population Fund, of which he was
a founding member, with a population award. The Tatas
have continued the tradition of social responsibility
while keeping an eye on the cutting edge of science and
technology and trying to link the two.
Of course, this is an unusual time and we're all
connected remotely, but I will try to do justice to the
vision of Mr. JRD Tata by addressing the issues that we
are faced with today with the COVID-19 pandemic. In
particular, as it relates to health systems to women and
children's health. And to see what are the lessons we've
learned and how can we take that forward, especially as
we look at improving our health.
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Let us look at how we will achieve Sustainable Development Goal three, which is
health for all, the same principle on which WHO was founded 70 years ago.
With respect to the global pandemic situation, this of course changes on a
weekly basis, but we can see some trends. Then I’d like to go over what's
happening in terms of women and children's health, speci cally in India. And
how COVID is perhaps a ecting that, and then come to what we can do looking
ahead.
So you can see on this slide (Fig 1, below) the global pandemic is marching on. You
can see the total number of cases really increasing week by week. Today (as on
5th October 2020) I think we have almost 300,000 new cases a day, with an
average of 5000 to 6000 deaths.
Figure 1
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The split you see in the di erent colours is the WHO regions. You can see the
region of the Americas in yellow, which has really had the predominant share of
infections. But the purple, which is the South-East Asia region, is not far behind.
The black line is the number of deaths, which has more or less stabilized at about
5000 a day. But again, that's far too many. We're losing 5000 people every day.
Three countries actually account for 70 percent of the cases. These are India, the
USA, and Brazil, with a number of other Latin American countries also in the top
10.
We are beginning to see worrying increases in some of the European countries
that actually had the infection controlled--the UK, France, Spain, Russia,
Netherlands, Belgium, and so on. The bright side is that there are a few countries
around the world that acted early and were able to contain it to a level at which
it is practically negligible, with occasional clusters. These are countries in
South-East Asia and the Western Paci c regions. If you look at the graph, (Fig 1,
above) the Western Paci c region is shown in pink. Of course it all started in China,
but subsequently, most of the countries there have been able to keep it at fairly
low levels, with clusters occurring that then need to be attended to.
Now this is a world map, (Fig 2, below) showing the cases reported in the last one
week per million population. The darker the colour, the more a ected the
country. You can see that most of Africa is relatively light in colour except for a
couple of countries. That is an enigma that people have been discussing—why
Africa, despite all the dire predictions, has been relatively less a ected. There are
a number of social and environmental reasons, including the demographics and
the relatively young population. We must also remember the very early and
strict action that many countries took. Also their experience with public health
and especially dealing with infectious disease outbreaks. Both the health
workforce, as well as the communities, are very familiar with restrictions and
actions that need to be taken to contain outbreaks.
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Figure 2
This graph (Fig 3,below) shows again the deaths reported in the last seven days per
million population. The darker the colour, the higher the impact. Again we can
see that South Asia and Africa have been relatively better o in terms of deaths
per million.
Figure 3
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Of the lessons that I have learned over the last nine or 10 months, the most
important one is the importance of investing in public health and primary
healthcare. We see examples of countries where investments in primary
healthcare over the past decade or two have paid o now; and on the contrary,
you have high-income countries where they’ve been overwhelmed and haven’t
been able to put in place some of the mechanisms that have been needed.
Especially things like contact tracing, quarantining and data systems for follow
up. The other major lesson for me and a very positive one is the role of science
and scientists. The global collaboration that we’ve had among scientists to take
forward advances in knowledge in an accelerated way so that science is
continuously informing our response to the pandemic is heartening. Also, that
even product research and development have progressed at unprecedented
rates. As you know, we now have a number of new diagnostics, including the
rapid antigen tests. A number of these have been developed in India, including
the ones that have been developed by the Tata Trust. We are of course working
on vaccines. We hope that by the early part of 2021 we will have at least a couple
of vaccines that have been proven to be safe and e ective and that we can then
start using in the most vulnerable and high-risk populations.
On Political will and leadership: I’ll mention later why they are so important, as
well as trust, community engagement, and empowerment.
“ ...this pandemic has exposed societal inequalities
and inequities,...
Whether it’s the Black Lives Matter movement in the United States or the
disproportionate toll on ethnic minorities in the UK. Many countries have seen
these inequities exposed. Finally, I want to talk about managing what we now
call the Infodemic.
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But rst let’s talk a little bit about maternal and child health, which is
Population Foundation of India’s core mandate. Maternal mortality, as we know
has declined, so we had a lot of gains and progress, especially during the MDG
era. We reduced infant mortality. More than 80 percent of births are attended to
by skilled health personnel. This varies a little bit between states and big
initiatives in the National Health Mission, like the Janani Suraksha Yojana and the
Janani Shishu Suraksha Karyakram, which have encouraged women to give birth
in health facilities. On the other hand, only a fth of women receive all the
ante-natal check-ups that they are supposed to have. 62 percent of mothers
receive postpartum care two days after delivery. And if you look at social groups,
especially SC/ST and OBC communities, then it is less than 50% of women who
seek antenatal care.
We have made a lot of progress in achieving replacement fertility levels. Several
states in India have now achieved the replacement levels of 2.1 but there are still
ongoing challenges. There is a high unmet need for family planning. It is
estimated that about 30 million married women who wish to delay or avoid
pregnancy do not have access to contraceptives. Less than half of Indian women
in the reproductive age-group actually use modern contraceptives – particularly
youth and adolescents. 31 percent of India’s population is aged 15-24 years.
They need access to spacing methods of family planning, adequate counselling,
and good quality of care. Child marriage and teenage pregnancies remain an
issue, according to the NFHS-4.
Nine million girls in the age group of 15-19 years are married. These early
marriages are characterised by immediate child bearing. Teenage
pregnancies have a lasting impact on intergenerational vulnerability as well as
malnutrition. One of the reasons for having such a high rate of low birth weight
in India is because of mothers being too young and malnourished
themselves.We still have a lot of unintended pregnancies that end in abortion.
Studies by the Guttmacher Institute showed that of the 15 million abortions that
occurred in India in 2015, 73 percent were through medical abortion, 16 percent
in private facilities, and only 6 percent in public health facilities and ve percent
through traditional unsafe methods.i
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Unsafe abortions also contribute to maternal mortality. There is an unmet need
for improved access to and availability of contraceptive services as well as safe
abortions. COVID-19 is having an impact on maternal and child mortality. A
recent modelling study showed that because of the reduction in coverage of
essential services the prevalence of wasting in children could be increased by 10
to 50 percent—and that there could also be 60 percent additional maternal
deaths because interventions like the administration of utero tonics, antibiotics,
anti-convulsants and clean birth environments are no longer available.ii
This is very worrying; so of course is the impact on education. The pandemic has
created the largest disruption of the education system in history, a ecting 1.6
billion children across more than 190 countries and all continents. 94 percent of
the world’s student population have been a ected and this number is in fact
almost 100 percent in low and low-middle income countries. This year the
school year and college year has been a complete washout for many young
people. This is a terrible situation for them, particularly those from the lower
income groups within countries as well as those living in low- and middle-in-
come countries, because in the higher income groups there has been some
access at least to online education, whereas this has not been available for a
large majority of the world’s children.
The COVID 19 pandemic has also a ected access to nutritious food. We know a
huge number of children depend on school meals, and during the school
closures for the past six months they have been deprived. 368 million children
are missing out on school meals globally.
We have talked about abortion and the impact that COVID-19 is having, partly
because of some of the pharmaceutical product supply chains having been
a ected, especially from China in the early days of the pandemic. In countries
that have laws restricting abortion, women would travel to neighbouring
states or cities or even other countries to have an abortion. However, this is not
happening now. The impact is that there is a ten-fold
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decline in contraceptive use,with many unwanted pregnancies that could occur
as a result.
Another very worrying observation is the global surge in domestic violence,
leading the UN Secretary-General, Antonio Guterres, to appeal to govern-
ments to prevent a horrifying global surge in domestic violence.
“ ...In India a third of women said that they experienced
domestic violence and very few – less than one
percent – actually sought help from police.
Unfortunately, the fact is that many women believe that a husband is justi ed in
beating his wife. We’ve seen that the National Commission for Women has regis-
tered several cases after the lockdown began, but it’s quite possible that the
hidden cases are far higher because women would not have had access to come
forward to report these cases.
What can we do about the gendered impacts of COVID-19? One of the things
we’re saying is that before governments can include violence against women in
the package of essential services.
So that these services are always running even when there is an emergency and
having these hotlines and shelters or other specialised services support women
who may need them. We need to identify and share information on support
services, including opening hours and contact details, establish referral linkages,
nd out what survivors of violence need and how best to reach
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them safely. It is these women who can actually tell us what kind of services they
need.
Health workers of course play an important role of o ering rst-line support,
providing medical treatment and connecting survivors to support systems.
We’ve also seen the gender impact in terms of women who have lost their work
and their livelihoods. More women than men work in the informal economy and
therefore their incomes fell by more than 60 percent during the rst month of
the pandemic. The projections are that about 100 million people are going to be
pushed into extreme poverty and of these, more women are going to be pushed
into extreme poverty than men because of the impact on the informal sector.
“ ...In India 87 million women and girls were already
living in extreme poverty and this is expected to
increase to about 100 million by 2021.
WHO published an advocacy brief a few months ago that really emphasizes the
importance of gender analysis and gender-responsive public health policies.
One of the major issues is the lack of availability of sex- and age-disaggregated
data, which doesn’t allow us to look at things from a gender-disaggregated
point of view. We also don’t have data on violence against women and children
from many countries. Access to sexual and reproductive health services has
gone down and there was increased stigma and discrimination that could a ect
responses. Therefore, we put out this brief basically asking our Member States to
do all of the below following:
Collect data
Report and analyse it disaggregated by sex and age
Include responses to violence against women as an essential service
Maintain access to sexual reproductive health services
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Make sure that frontline workers and social workers, most of whom
are women, have access to training but also access to protective
equipment and psychosocial support
Remove all nancial barriers to make COVID diagnosis, and testing
and treatment free at the point of care
Ensure that services are non-discriminatory.
“ We must make sure that whatever is being put in
place in terms of emergency responses does not
further promote discriminatory practices.
How can we maintain essential health services? We carried out a pulse survey on
the continuity of health services during the pandemic and found that 80 percent
of countries had de ned an essential health service package and a core set of
services. We found that a large majority of countries, even though they had
these packages de ned and had committed to maintain some of these services,
when you looked at the additional funding that was needed to protect those
essential services in low-income countries in particular, these were very badly
a ected compared to the high income countries. But all countries across the
board have disruptions and the reasons were both on the demand and supply
side.
On the demand side, patients could not go for outpatient care or for inpatient
care because of transport disruption, but also because they were afraid of going
to health centres and picking up infections. On the supply side, health service
sta were redeployed to COVID, a lot of the workforce got sick or did not report
to duty and therefore there was a closure of many programmes. If one looks at
what services were disrupted either partially or completely across 25 di erent
essential health services, one can see that right on top is routine immunisation.
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Over 70 percent of countries reported some partial or complete disruption of
immunisation services, as well as a number of others, including
non-communicable disease diagnosis and treatment, cancer diagnosis and
treatment, family planning, contraception, antenatal care, malaria and TB case
detection, treatment facility-based births, and urgent blood transfusions, as well
as emergency surgery. This has had a huge impact, especially in lower-income
countries.
Some of the approaches that can be used are triaging to identify the priorities
we want to have for people coming into the clinic. Some countries have done
this with telemedicine, replacing in-person consultations, task shifting, novel
supply chains and dispensing so that drugs are supplied at home, community
outreach to redirect patients to alternative health facilities and so on. Then we
have a document that basically gives some guidance on how to maintain
essential health services.
Financial protection of course is the other side of universal health coverage. On
the one hand, you have your essential services that need to be provided and on
the other side, there is nancial protection. This can be guaranteed only if there
is some kind of health coverage scheme, either like Ayushman Bharat, which
covers a large proportion of India’s population—about half the poorer segments
of society. Or you have private health insurance, which very few people in India
actually have access to.
I’d like to now mention out-of-pocket payments, which cause a large number of
people – 100 million or so – to fall into extreme poverty every year and 800
million people globally spend more than 10 percent of their household budget
on health care. This is one of the goals and one of the things that WHO has been
promoting to ensure nancial protection as well as e ective coverage of health
services. These two elements will produce a healthier population. There was a
recent paper published in the Economic & Political Weekly by Muralidharan and
colleagues from IIT, Chennai, looking at what has happened to
out-of-pocket-expenditure in India between 2014-18. If government health
expenditure increases then what happens?
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What they found is that between 2014 and 2018 the cost of care, particularly
in-patient care and private facilities, has risen signi cantly by more than Rs.
4000, which has been driving patients even from the higher income groups to
seek expenditure from public institutions. In the case of out-of-pocket
expenditure in public facilities, that has actually fallen. This graph (Fig 4, below)
shows data for all of India; the bar in black is for Tamil Nadu. We see the share of
public facilities people were accessing in 2014 and again in 2018. There is a
dramatic increase, particularly in Tamil Nadu compared with the all-India
average. Perhaps because of the quality of services that are now being delivered
through public outpatient facilities and also because inpatient care actually
became more expensive in private facilities. Whereas in the public health care
facilities that you see on this graph, the out-of-pocket expenditure for inpatient
care has come down all over India, both in the Empowered Action Group (EAG)
and non-EAG states. Whereas when you contrast it with private health care
facilities you see the out-of-pocket expenditure has increased during the same
time period.
Figure 4
An important point is how we measure universal coverage by these services,
how do we know that it’s of good quality?
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A recent paper in The Lancet from the Institute for Health Metrics and
Evaluation group in Seattle looked at the trajectories and what will happen
between 2018 and 2023 in terms of increasing Universal Health coverage and
comparing it to what the WHO had projected as our goal. That goal was one
billion more people accessing universal health coverage in this ve-year period.
Now we de ne service coverage as a spectrum of services ranging from health
promotion and prevention all the way through treatment, rehabilitation and
palliation. This model actually showed that there would be an additional three
to four hundred million people who have accessed e ective coverage, well
short of the one billion.iv
You can see di erent regions of the world and now how things are changing (Fig
5, below) . The e ective coverage index looks at the provision of these services and
how e ective they are in terms of health outcomes. We see that between 2018
and 2023, in South Asia, for example, the index goes from 46 to 48 and
Sub-Saharan Africa from 44 to 46. You can see on the right most corner that still
3.1 billion people worldwide would not be covered if we continue to do what
we’re doing.
Figure 5
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What we can do better?
We rst need to measure e ective coverage. E ective coverage is not just
process indicators; one has to measure the need to use and quality and combine
that into a single metric, because it actually measures the health gains that
you’re supposed to get from providing a certain coverage. For example, take
oral rehydration salts (ORS) for childhood diarrhoea. You may have ORS available
in health facilities so if you measured that you might think that you’re doing
relatively well. But is it being correctly deployed and given to the children who
need it and does that translate into reducing deaths due to diarrhoea? If you
measure the mortality incidence ratio of a particular disease you know whether
the interventions are actually having the desired impact.
“ Moving away from just measuring process or inputs
and actually measuring outcomes is
where we need to get to.
The issue of course is that many countries do not have the data systems to be
able to accurately measure both mortality and the incidence of certain diseases.
This is something that India needs to invest in—our vital registration system.
While birth registration is very good, registration of deaths and particularly the
medical cause of death falls far short, at somewhere around 20 percent, so there
is a long way to go. 80 percent of deaths in India do not have a proper docu-
mented cause of death and so it becomes very di cult to analyse both the
burden of disease, the changes over time and where policies need to focus and
resources need to be placed. So this is an area that we need to invest in. We need
to train people, including doctors, to use technology to make this happen.
Talking of digital technologies, this is a time when many countries have actually
moved into using platforms to provide telemedicine, for example, to get over
the problem that people could not meet physically and platforms like the echo
platforms, which have been used in many states
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in India, to train healthcare workers. Also, the e-sanjeevini platform that’s been
set up by the Government of India, which is enabling telemedicine
appointments to happen.
It’s been done in many places around the world. We know that we now have a
national digital health blueprint and a roadmap. We want to move towards
electronic and portable health records. It is also very important to think about
not only data governance principles, which are important, but also new ways of
collecting, using, and sharing data. It is about using data to make local,
contextualised decisions. Presently the system is set up in a way that all the data
feeds up and then goes into a black box; or policy makers are using it at the
highest levels but the people who are delivering services are not really getting
any feedback on their performance, things that they can do better and things
that are actually going well.
We also need to think about working with the private sector. It plays a very big
role in technology. But what are those technologies that are considered public
health goods? At the Arvind Eye Hospital in Puducherry, for example, they did
an experiment with shared medical appointments. We know that specialists in
India are scarce. Any specialisation you look at, the moment you go into rural
areas, there is a scarcity of specialists. What they did was instead of a one-on-one
appointment, they actually brought together 10 or 15 patient with the same
disease. In this case it was glaucoma, which is a disease where the pressure in
the eye builds up. The doctor then does an examination of these patients and a
discussion of their problem with those 10-15 people sitting in the same room
ensues. This results in bene ts for both patients as well as providers and seemed
to result in better health outcomes as well as higher productivity and reduced
costs, saving a lot of time for doctors. So if we could combine virtual – that’s
telemedicine – with shared medical appointments we could try a completely
new paradigm, particularly for managing people who have chronic diseases
who otherwise may have to come to the doctor every 1-3 months. This way they
can communicate with the doctor, who can ask questions, and there are 10
other people listening. At a diabetes clinic, for example, each one is learning
from the interaction.
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There is also a lot of peer learning that goes on, so we need to think about
leapfrogging and advancing some of these things and accelerating them.
We talk about health system resilience a lot and its ability to prepare, manage,
and learn from shocks like the one we’ve all just experienced. We look at shock
in four stages. There is, of course, the initial preparedness, which is what helps
you to withstand it. There’s a shock onset and alert. There’s the impact and
management and then there’s the recovery and learning. There are many
strategies for enhancing resilience, which relate to better governance to
nancing making sure that you can suddenly upsurge in nancing, having
proper information systems and ows, resources and service delivery. One
needs to prepare in advance for a resilient health system. But leadership and
political will have played an important role in this pandemic. We’ve been looking
at case studies. We communicate with our Member States on a weekly basis,
where they share their experiences. As a result, we have 194 Ministries of
Health. Often it is the ministers themselves who participate and everyone has
learned from each other. Some of the lower middle-income countries have had
lessons that could have been learnt by countries that may be more well-o . If
you look at Vietnam, for example, what they did was to lead a very early and
strong response. They activated a response system. There was government
leadership, mobilisation of resources and a whole-of-society approach. They
managed to use their primary health care system and community health
workers to go after clusters of cases so the rst few cases were identi ed, their
contacts were traced and they were isolated and quarantined. In the rst six
months they had no fatalities due to COVID and so it was an incredible response.
Even today they have a few cases but it’s under control. Similarly, Thailand was
one of the rst countries to react because they get a lot of travel from China.
Three days after China reported the gene sequence of the novel coronavirus,
Thailand did the same. They did a risk assessment and they did triage, they told
people who do not need to come to the health centre to stay away and those
who needed to come for emergency services. They were able to provide extra
surge capacity so they thought through what needed to be done and they were
able to implement it.
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A few words now about COVID and nutrition. We know that diverse food supply
is an essential part of the health and nutrition response. They are very closely
linked and disruptions in trade a ect food systems. We know that there are
traditionally food insecure hotspots. As you can see most of them are in Sub-Sa-
haran Africa, others in the eastern Mediterranean region, and particularly those
countries that have been having con ict and war. And then some countries in
Latin America. We need to start taking a systems approach to nutrition and
integrating it into the socio-economic response. There is a portion of India that
is trying to do exactly this, but we need to further integrate social protection
systems, food systems and health systems inorder to really have an impact on
the nutrition of individuals and families. Without really looking at the three as
whole, we are not going to be able to solve the basic structural issues as to why
certain families, certain children, or certain villages remain chronically under-
nourished. Now there could be a global food emergency as well because of the
disruptions that we’ve had in trade and so on.
There are things that we can do to ensure these services:
Designating services, such as food production, marketing and
distribution, as essential services
Ensuring that we protect those workers
Keeping trade corridors open
Ensuring that they are part of our social protection programmes.
In India this has been done but needs to be extended and expanded to protect
the most vulnerable population groups. Tailor nutrition-sensitive social protec-
tion programs, either in kind or cash or vouchers or through the PDS and
integrate data platforms. The data on nutrition is fragmented. Some of it goes
through the Anganwadi centres and sits in the Ministry of Women and Child
Development and the other part of it comes into the Health Department.
This now needs to change and there needs to be one integrated data system.
This is a report that just came out a few months ago, again with dire warnings of
worsening food security and the increase in the number of people who might
actually be hungry.v
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What are some of the unique challenges that we have faced? We’ve come up
with this term called “infodemic”. It’s about having too much information, which
includes false or misleading information, mostly in the digital sphere,
particularly on social media platforms. What does it do? It leads to confusion,
risk taking, harmful behaviours, and ultimately mistrust in governments and
public health response. Our Director-General very early on said “fake news”
spreads faster and more easily than this virus and is just as dangerous.
“ ...We are ghting not just an epidemic but also an
infodemic.
What we did do? Of course, we tried to reach out through webinars through all
the expert groups we have, our networks of collaborating institutions where we
were able to amplify some of the clear and credible messages we developed.
Hundreds of risk communication materials, including things like myth-busters
and video, animation, infographics. We have developed training courses. We’ve
had more than four million people actually take those training courses in
di erent languages. We worked with social media companies, including
Facebook, Twitter, and WhatsApp to do a couple of things. First to make sure
that they directed users to credible information. So, if somebody types in
something in the search, they should be directed to their government sources in
their own country or to WHO or to the CDC and so on. Where you know you can
get credible information. The second is that we started pointing out to them if
we saw certain worrying or false or dangerous messages and they would
immediately take it down or post an alert on that. And third, we started doing
innovations like having these chatbots and things in di erent languages again
where people could actually chat and ask their questions and get credible
answers, based on WHO guidance.
In the last eight months we have done an incredible amount of work with many
tech companies, many of them actually doing pro bono work as well as putting
out advertisements on behalf of WHO.
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But infodemic management is not straightforward; it is really linked to people’s
beliefs and behaviours. It is the way they act and what actually changes. What
lever do you actually pull in order to change people’s behaviour? It’s not just a
question of providing information. Therefore we’ve set up this behavioural
insights group to give us insights into how to bring about behaviour change. I
know that the Population Foundation of India has also done a lot of work on this.
They have excellent outreach and communication programmes. I’ve watched a
number of their lms, which are basically advocacy lms with strong messages.
But when you watch them, you wouldn’t think so. They are well done. I think
that’s the way that we need to communicate with people. Not by just giving
more facts, but by subconsciously reaching them. This is something that my
good friend Dr. Mohan Agashe, well-known psychiatrist, actor and lm director
always talks about. He says you have to be a smuggler of ideas, because when it
comes through a story or lm that a ects you emotionally, then the messages
are heard and retained much better, than if I were to read ve facts or if someone
were to instruct me to do this or do that.
This is very true for mental illness and mental health. But it’s also true for a
number of other things that actually a ect personal behaviour. We are seeing
polarised debates today on whether to wear masks or not. Something that is just
a question of pure common sense and science is getting politicised and polar-
ised. Every issue is being debated in these non-constructive ways. We need to
turn to messaging that will help us communicate the right messages to people.
I think I would like to end with the fact that COVID-19 has underscored for us the
importance of investing in preventive healthcare and primary healthcare.
Countries that invested in primary healthcare in the past found themselves in a
much better position to deal with the pandemic.
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“ ...Within India again, states that have invested in
primary health care, and have a public health cadre
and public health department have been able to
respond better.
The other important point I’d like to make is that we often think about health as
health service delivery. We need to start thinking a little upstream. The risk
factors and the social and environmental determinants of health, things like the
quality of water, availability of sanitation, quality of air, indoor and outdoor air
pollution, road safety, mental health, housing and shelter that is available. All of
these have big impacts on our health; in fact, they a ect our lifespan much more
than having access to a health facility. So, it is important to invest in these. It is
much more di cult as they lie outside the health sector. So, it is a question of all
governments really looking at the impact of their policies on health.
Using telemedicine, digital health to provide health care and to improve the
access to health is, I think, a no-brainer. We need to make sure we’re using
technology in the right way; technology cannot solve all our problems, but it can
help. It can certainly assist our frontline health workers who are our main
strength. We have more than one million ASHAs, 1.4 million Anganwadi Workers
and a similar number of ANMs. These are the people who do the bulk of the work
and we depend on them a lot. We need to invest in them. We need to make sure
that they have the tools they need. That they have regular training and mentor-
ing, that they are protected and of course well paid and looked after so that they
can in turn do their work properly. We need to invest in institutional mecha-
nisms and capacities. I can’t underscore this enough.
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“ ...Strong institutions, whether there are regulatory
bodies, whether they are research institutions or
whether they are the public health institutions.
By strong institutions, I’m talking about the people in those institutions. So, it is
critical to invest in human resource capacity building. Particularly we can see
areas where there are gaps, and we need to invest in for the long term. Countries
that have done that have reaped the bene ts.
Health literacy is very important. We’ve seen so much of fear, psychosis, stigma,
discrimination, and belief in these false rumours that go around on social media.
“ ...Health literacy has to be built up over a period of
time, and this is where listening to scientists and
public health experts becomes very important.
I’ve talked about Universal Health Coverage. India is on the path to investing a
lot in that. We need to speed it up, but it’s not just a question of nancial
resources, though very important, but also human resources and in engaging
and empowering communities. A health system cannot be only on the supply
side. It has to keep in mind how to involve the citizens, the people that it is trying
to serve and have them involved in developing the services that we are bringing
them.
And nally of course this is Population Foundation of India, and with Poonam
being such a champion we have to keep equity, human rights, gender issues,
and social justice in mind. These need to underpin everything that we do. For a
lot of the indicators we look at, there are di erentials when you look
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between the socio-economic groups and therefore we need to design the
programmes that will lift and a ect those who are currently at the bottom of the
pyramid.
With that, I would like to again thank you for having invited me and given me
this wonderful opportunity to honour the memory of Mr. JRD Tata by delivering
this oration, particularly at such a momentous time as the 50th anniversary of
Population Foundation of India. I wish Population Foundation of India another
50 glorious years. We have a lot of work to do in many of the areas that you work
in. I consider myself lucky to be associated with you all. Thank you very much.
Namaste.
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References
i. Singh S, Shekhar C, Acharya R, Moore AM, Stillman M, Pradhan MR, et al. The incidence of
abortion and unintended pregnancy in India, 2015. Lancet Global Health. 2018; 6:e111–20
ii. Roberton T, Carter ED, Chou VB, Stegmuller AR, Jackson BD, Tam Y, et al. Early estimates of
the indirect e ects of the COVID-19 pandemic on maternal and child mortality in low-income
and middle-income countries: a modelling study. Lancet Global Health [Internet].
2020;8(7):e901–8
iii. V R Muraleedharan, Girija Vaidyanathan, Sundararaman T, Umakant Dash, Alok Ranjan,
Rajesh M, “What Do NSSO 71st and 75th Rounds Say? Invest More in Public Healthcare
Facilities”, Vol. 55, Issue No. 37, 12 Sep, 2020
iv. “Measuring universal health coverage based on an index of e ective coverage of health
services in 204 countries and territories, 1990–2019: a systematic analysis for the Global
Burden of Disease Study 2019”, Lancet 2020; 396: 1250–84.
v. 2020 Global Hunger Index: One decade to zero hunger linking health and sustainable food
systems
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Population Foundation of India
Head Office: B-28, Qutab Institutional Area, New Delhi - 110016
T: +91-11- 4389 4100, F: +91-11-4389 4199
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T: +91-522-400 5091
Website: www.populationfoundation.in
Facebook: @PopFoundIndia
Twitter: @PopFoundIndia
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34 I The 6th JRD Tata Memorial Awards & Oration
Celebrating 50 Years