Need for a Robust Public Health System
By Dr R Neerunjun Gopee
Even before the Covid-19 saga is over, there is a fear that another pandemic is probably in the making.
Jeffrey Sachs, Professor and director of the Center for Sustainable Development at Columbia University, lamenting the failure of his country (USA) to mount a coherent response to the epidemic, had this to say: ‘Why did the Asian countries succeed while the US and many in Europe failed so badly? The answer is national leadership and public health readiness.’
It may be noted that Prof Sachs chaired the WHO Commission on Macroeconomics and Health, and the Report was submitted to the Director General, Dr Gro Harlem Bruntland, in 2003. It showed that ‘investments in health can be a concrete input to economic development’, effected through ‘well-tried interventions that are known to work’.
Does Mauritius have the requisite Public Health Readiness to face a future pandemic?
The answer is yes and no.
Yes, because our Public Health System (PHS) has a solid track record in the control of infectious diseases, in particular malaria, which WHO certified as far back as 1972 that we had eliminated. Since then, in all missions to promote the country as a healthy and safe destination, besides other advantages flagged, the fact that we were malaria-free has always been a very strong point.
No, because its PHS has not modernized and its staff have not been accorded the status nor given the incentives they deserve as specialists in their own right, effectively discouraging more doctors from choosing the specialty.
Both the bureaucracy and the medical profession must share the blame for relegating them to a secondary role, by not according them specialist status and authority, when in fact they have a primary, fundamental role as frontliners of the country’s health system. For, in fact, it is the discipline of Public Health which ensures the enabling environment (salubriousness, quality of water and air, freedom from infectious diseases, food safety, health and safety of occupations) for human existence and a country’s development.
The starting point for a robust PHS are bold and forward looking policy decisions that are urgently needed to drive the structural reforms that will ensure our Public Health Readiness. Amongst others, public health infrastructure needs to be strengthened. The key elements that ought to be looked into are:
- a capable and well-qualified, well- motivated workforce, with staff trained in public health research methodology;
- a strong data and information system;
- a strong public health laboratory for disease surveillance.
The critical issues to be addressed are:
- Grant specialist status to doctors with Public Health qualifications and create a career pathway that is on a par with clinical specialties.
- a) This starts with amending the Medical Council Act’s criteria for registration as specialist. Currently it is a one-size fits all biased towards clinical specialties, with a minimum duration of training of three years. Public Health must be registered as a non-clinical specialty. The standard duration of training post the basic degree (MBBS or MD) is one year leading to a Diploma or a Master’s in Public Health.
- b) The current career pathway should likewise move through to Senior Specialist and Consultant levels, and from the latter grade the Regional Public Health Superintendents (RPHS) can be selected.
Once appointed as specialist, scholarships must be granted for further training of interested candidates in infectious disease epidemiology, NCD epidemiology (offers for the latter were made by Prof Paul Zimmet of Melbourne, but stifled by bureaucratic red tape), biostatistics. A must is regular updating and upgrading by attendance at appropriate international forums – there is no dearth of offers (WHO and other organizations).
The Mauritius Institute of Health and the University of Mauritius are resources that are underutilized for overseeing such training, that can include fieldwork locally; they are networked and have experience of international collaboration, organisation and certification.
The same remarks about specialist recognition pertain to Occupational Health, the difference being the fields of further training/upgrading.
- Strengthening of laboratory services – the project of setting up a National Health System Laboratory has been in the pipeline for over a decade. A site was already identified. This project needs to be reactivated and completed at the earliest. The Virology division must be upgraded in terms of equipment and staff, with enough technicians to carry out the hundreds of tests that will be inevitably required, and at least two full time virologists.
The project includes a dedicated public health laboratory, as mentioned above.
- Setting up of a Health Intelligence Platform, headed by an infectious disease epidemiologist and comprising virologist, health statistician, health economist, demographer and information system specialist. This unit can meet quarterly at a conducive venue (e.g. MIH as secretariat, away from the crisis-driven MOH environment) and its task will be to track local, regional and global disease surveillance & population data and trends in infectious diseases, decide on the appropriate tests, and advise MOH accordingly. At the slightest indication of an impending epi- or pandemic, this platform will morph into an Epidemic/Pandemic Management Cell and meet as often as the situation demands.
- Mandatory accreditation of all laboratories, public and private, by MAURITAS which, by virtue of its affiliation to ILAC, guarantees the quality of testing and reliability of results, for Covid-19 – as the pandemic is likely to be protracted – and new viruses that may surface in future.
It is then up to the authorities to put in place the framework to instrumentalise this assurance about tests, as was done in the case of malaria, to again market the country as a safe and healthy destination for international visitors and tourists. A necessary condition will of course be the rigorous implementation of legally enforceable norms for epidemiological surveillance (screening, contact tracing, etc) of the latter, and working out the arrangements that must be planned for isolation, quarantine and treatment if indicated. Similarly for the workforce, upon whose sound health depends the opening up of economic activity – as Covid-19 has forced us to realise.
Former Director General Health Services
* Published in print edition on 17 April 2020
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