Christopher Elias on Ayushman Bharat, universal health coverage and more

India’s frontline health workers and surveillance infrastructure that helped eradicate polio will strengthen primary health and scale up Ayushman Bharat, but the world needs far more preparedness against a fast-moving airborne pandemic, said Christopher Elias, president of the Global Development Division, Bill and Melinda Gates Foundation.

Do you think Ayushman Bharat will work?

I’m excited about Ayushman Bharat, which addresses both financial protection as well as strengthening the primary healthcare system by building on the largest per capita of number of frontline health workers with the ashas (accredited social health activists), anganwadi workers and ANMs (auxiliary nurse midwives). It is early days and it has had a rapid expansion in the first 100 days to reach quite a few people but it has an ambition to reach a lot more. And as with most things, as it proceeds, it will learn where it needs to adapt and strengthen.

How can India keep up its universal immunisation (intensified Indradhanush) momentum, given that there is no endgame, like for polio?

There is no endgame but there is a clear goal, which is 90% plus universal immunisation coverage for basic childhood vaccines. The number of new vaccines that India has introduced in the last few years is unprecedented – the MR vaccine, pneumococcal vaccine, rotavirus vaccine, injectible polio vaccine, the switch from bivalent to trivalent polio vaccine… What mission Indradhanush has done is build a strong momentum in the immunisation field so it can both increase coverage and introduce new vaccines.

To keep up that momentum, you need strengthening the logistics and to support that cold chain reaching everywhere. The other is good vaccine-preventable disease surveillance. India has probably the largest and most effective polio surveillance programme in the world. Since polio is gone, there has been a repurposing and broadening of focus of the National Polio Surveillance Programme to look at broader vaccine-preventable disease surveillance.

Does India need to add more vaccines to its routine immunisation programme?

The biggest impact will come by expanding the recently introduced rotavirus and pneumococcal conjugate vaccine at the national level against the most common causes of childhood mortality, diarrhoeal disease and pneumonia.

Is India on course to achieve universal health coverage?

Yes, you are headed in the right direction. You are not there yet, very few countries are. But you are addressing the key factors — protection against financial ruin and strengthening primary healthcare. It’s a long road, it’s sometimes a bumpy road, but are you headed in the right direction? Yes.

What will be the next big public health challenge for the world?

Can I give you two? One is the certain and slow challenge, which is the rising incidence of NCDs (non-communicable diseases). The best way to deal with NCDs is primary healthcare (PHC). It’s not an easy one-time fix. You need preventive and promotive treatment, which is best provided through the frontline workers through the PHC system.

The second is a less certain and more acute risk of a significant airborne pandemic. Every since the Ebola outbreak five years ago, we have been focused on the preparedness for haemorrhagic fevers like Ebola or other viral diseases like MERS (Middle East respiratory syndrome), Nipah or Lassa fever. Those are challenging, but they are not airborne.

If we were to see today an outbreak like the world saw a hundred years ago with the Spanish flu, we are not prepared. Not just India, United States, nobody is prepared for a fast-moving airborne high fatality epidemic. A hundred years ago, in 1918, the Spanish flu spread quickly around the world. That was before we had planes. Imagine how quickly it would spread today. The closest thing we saw was the H1N1 outbreak (popularly referred to as swine flu) in 2010 and that was in eight countries before we knew we had a pandemic.

In the 20th century, we had three pandemics of influenza; so far in the 21st century, we’ve had one. We know based on the history of the 20th century that we are likely to see a big influenza pandemic in this century. The world is not prepared in terms of medical infrastructure or policy infrastructure, vis-a-vis transportation and trade. We must get the right medical counter-measures developed (and global partnerships) like the Coalition for Epidemic Preparedness Innovations (CEPI), which is investing specifically in Nipah, MERS and Lassa fever.

There are all kinds of things we didn’t know about. We didn’t know about HIV till it emerged, we didn’t know about Ebola too, we didn’t know about Nipah 20 years ago. We knew about Zika but we didn’t know it had potential for serious outbreaks till a couple of years ago. So we have to be ready for the completely unknown, something called pathogen X.

First Published: Jan 13, 2019 12:16 IST

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