Kerala Health in These Themes Were Shared with the Wider Audience and Now Available Online on the Web Portal As Well As on You Tube

Govt. of Kerala Department of Health & Family Welfare

Contents

Message 5 Foreword 6 Introduction 8

Opening Ceremony 10 COVID-19 pandemic: Health System Response –Resilience–Preparedness 28 COVID-19: Health System Global Response 31 India’s Fight against COVID–Role of ICMR 39 Crisis leadership & Workforce resilience 47 Pandemic & Preparedness 48 Fighting Pandemic: Experiences by Districts Administrators, Kerala 56 Achieving SDGs related to MMR & IMR–Dream or Reality? 64 MMR Reduction-Kerala Experience 66 Experiences on MMR reduction with regard to Kerala. 67 IMR Reduction–Experiences from Kerala 68 IMR reduction: Field success story to bring in connect of policy with the interventions 69 Panel Discussion: ‘Accelerating the reduction of Maternal & Infant Mortality in developing countries’ 70 Meet the SDGs–Beat the NCDs 72 Achieving the SDGs related to NCD 76 Experience Sharing Session: Other NCDs 79 Prevention of Cancer through Primary Health Care 84 Moving towards TB Elimination–A call for Action 87 TB Free Islands 101 Closing Ceremony 105 Acknowledgement 106 Support for Documentation 107 Annexure: Program Schedules 109

WEBINAR PROCEEDINGS 3

Message

he department of Health and Family Welfare has conducted a webinar series from 17th February to 4th March 2021 on various Tthemes such as Universal Health Care, Maternal and Child Health Care, Non-Communicable diseases, COVID pandemic and elimination of Tuberculosis. I appreciate the efforts taken by the department to conduct webinar series on such important themes to bring focus on Sustainable Development Goals. The webinar series succeeded in bringing the health experts from across the countries, researchers together to discuss these themes. The efforts of the Kerala Health in these themes were shared with the wider audience and now available online on the web portal as well as on you tube. I am happy to note that the book on Webinar is published by the department. I would urge the department to institutionalize this initiative and make it a regular feature. I thank the Guest speakers participated in the Webinar series Kerala Health- Making the SDG a reality and guided us. I congratulate the Kerala Health team and wish all the success in the future endeavours.

K K Shailaja Teacher Minister for Health & Family Welfare, Social Justice Woman and Child Development Foreword

ny department in the Government does planning for the year to conduct various development projects and introduces new Aprograms. However, in 2020, all these plans got disturbed with the spread of COVID throughout the world. The Department of Health and Family Welfare got completely immersed in containing the pandemic and mitigation activities. Initially the world was expecting to contain the pandemic within six to nine months. But world over, month-after-month, the circulation of virus continued and different pandemic cycles were experienced. This had put enormous pressure on all and more so on the Health care workers. This situation demanded continuous efforts by everyone in the health sector to work throughout. The department was facing issues such as health care workers experiencing fatigue and burn out in high stress situations. From the management perspective, it was very challenging to ensure motivation level was high and to ensure continuity of interventions in the field activities as well as in the institutions with the same vigour all the time. Therefore, in order to reinvigorate the teams, a series of webinars were conducted to showcase the works done by the Health Department not only in area of COVID pandemic control and mitigation but also in other key areas such as Maternal and Child Health, elimination of disease by taking a case study of Tuberculosis, tackling Non-Communicable diseases with a focus on Cancer Care and universal health care. Such a forum would give an opportunity to all to inform regarding the works done as well as to learn from the world’s best practices in these areas. The proposal was supported and approved by the Hon Health Minister and Hon Chief Minister. Later, the concept was discussed with all the Heads of the Departments, Heads of the Organizations and the partners from the private sector working in Health sector. The thematic committees were constituted,

8 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 nodal officers were designated to coordinate with the Guest speakers, the subject specific committees coordinated the various organizational aspects. All the major works related to webinar were handled through a 3 member management unit attached to the Principal Secretary and the Information and Technology committee. A total of 74 eminent speakers from various organizations and institutions from around the world and from the state participated in the Webinar. We have put up the recording of the sessions available to all in the web portal keralahealthconference.in The webinar series was organized successfully with wholehearted cooperation from all the field functionaries and state level officers. It was our effort to make it content rich and informative. We are earnestly grateful to all the eminent speakers who graciously accepted our invitation and participated in the webinar, Kerala Health – Making the SGD a reality.

WEBINAR PROCEEDINGS 9 Introduction

he world enters its sixth year of the unfinished 2030 Agenda, and the second year of its fight against the COVID-19 pandemic. As we Tstand at a crossroads, our plan of action for the people and the planet faces unprecedented challenges and scrutiny. Health is a central theme of the Sustainable Development Goals, with 13 targets in SDG 3 to ensure healthy lives and promote well-being for all at all ages. Health is also related to the other 16 SDGs, or is indirectly linked to gains in them. As the ongoing pandemic continues to test the resilience of health systems all around the globe, the actions of people have given hope to understand the interconnected issues and collective fight. Kerala has put up her fight on the scientific rationale and knowledge in managing the pandemic by involving all the stakeholders, institutions and governance structures to make it a public action. Kerala’s health system ensures equitable access to quality healthcare through its multi-pronged approach that balances conventional priorities such as maternal and child health with upcoming challenges focusing on non-communicable diseases. It grows towards the idea of a resilient and responsive system that ensures quality universal healthcare, and catalyses the quest towards the SDG. It is at this juncture that Department of Health & Family Welfare, Kerala planned to bring experts all together, and become the crucible for a renewed discussion on the achievement of the SDG. This conference offered a platform to discuss broad themes that are the central pillars of the Kerala experience. The conference brought in policy makers, program managers, health experts, public health intervention specialists, academicians, front line fighters and civil society across the globe to share the experiences, facilitate cross learnings and plan for future to achieve the SDGs.

10 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 February 17.00 -20.00 Universal Health Coverage: Moving 17, 2021 Hrs towards better health

February 17.00 -20.00 COVID-19 pandemic: Health System 18, 2021 Hrs Response – Resilience - Preparedness

February 17.00 -20.00 Achieving SDGs related to MMR & IMR – 24, 2021 Hrs Dream or Reality?

February 17.00 -20.00 Meet the SDGs - Beat the NCDs 25, 2021 Hrs

March 4, 17.00 -19.30 Moving towards TB Elimination – a call 2021 Hrs for action

Conference Features • Total 32 varied sessions with 74 subject experts over 5 days • Deliberations by 26 International, 20 National & 28 Within state experts • Policy Makers from Developing Countries, Academicians from Premier institutes, Technical leads and representatives of World Health Organisations, UNICEF, World Bank and other developmental partners, subject experts in particular fields and public health program managers • 8 plenary session • 6 Panel Discussions • 5811 conference registrations

WEBINAR PROCEEDINGS 11 Opening Ceremony

Kerala Health: Making the SDG a reality, a five-day international webinar hosted by the Department of Health and Family Welfare, Government of Kerala, was inaugurated by Sri. Pinarayi Vijayan, Hon. Chief Minister of Kerala, on 17.02.2021.

Dr. Rajan Khobragade IAS, Principal Secretary, Health and Family Welfare, Govt. of Kerala, welcomed the distinguished guests. While setting the tone for the webinar, Dr. Khobragade elucidated how the state intended to translate its health vision to get it institutionalized and become a knowledge management hub through the webinar series.

The webinar was declared open by Shri. Pinarayi Vijayan, Hon. Chief Minister of Kerala. In his inaugural address, the Hon. Chief Minister highlighted the prompt action and COVID-appropriate behavior adopted by people of Kerala, and how its health system responded proactively. Shri. Vijayan highlighted the state health system’s productive measures in flattening the curve and minimizing the mortality during pandemic. He called upon all stakeholders to learn and redesign from shared experiences to ensure healthy lives through a bottom-up approach.

In her presidential address, Smt. K.K. Shailaja, Hon. Health Minister, Govt. of Kerala, enumerated the novel projects instituted by the state for prevention and early detection of diseases. Smt. Shailaja spoke of how the state made commendable in-roads in managing the COVID-19

12 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 pandemic while spelling out the substantial tasks at hand. The Minister ensured larger investment in health facilities, quality treatment and better accessibility for the poor. She said the state would adopt all practical aspects discussed during the forthcoming sessions and design a model for the way forward as she believed the webinar would be a torchlight for Kerala health.

Keynote address was delivered by Sri. Rajesh Bhushan IAS Secretary, Ministry of Health and Family Welfare, Govt. of India. Shri Bhushan congratulated the department for organizing the first international webinar on health and well-being, and appreciated the state for its robust response to achieve SDG Goal 3. He spoke on the greater need to contain Kerala’s lifestyle diseases and highlighted the epidemiologic transition witnessed in the state.

Dr Vishwas Mehta IAS, Chief Secretary, Govt. of Kerala, in his special address, drew attention to the SDG targets achieved and the pressing need to work towards its finality. He highlighted the need for standardizing the comprehensive health system to ensure accessibility to the last mile.

While proposing the vote of thanks, Dr. Rathan Kelkar IAS, Mission Director, National Health Mission, Govt. of Kerala, invoked Mahatma Gandhi on the substantial significance of health over any other human facet.

WEBINAR PROCEEDINGS 13 Plenary Session: Challenges in Health - 2020-2030

Dr Peter A Singer, Special Advisor to the Director General, World Health Organization, Geneva, delved into the ‘Challenges in health sector & preparedness’. He set the scene for universal health coverage (UHC), multisectoral determinants on health, the response to COVID-19 and health emergencies, and the way forward. Dr Singer elucidated how Kerala would accelerate back post-COVID, considering 2020 was difficult for all but marked the test of global solidarity with due importance to community-based health measures. He shed light on Kerala’s Primary Health Care led equitable recovery from COVID.

Smt. Sujatha Rao IAS (Rtd), Former Secretary, Ministry of Health & Family Welfare, Govt of India, spoke on the need to strategize in the new normal owing to the pandemic. Smt. Rao emphasized the urgency to rebuild the system to ensure all citizens had access to essential health services. Engaging local communities, promoting a culture of wellness and good healthy behavior that implied effective demand for social determinants, she said, were key to achieving SDGs. While appreciating Kerala for its excellent start in trying to reform the system, she also drew attention to the big long road ahead to ensure out- of-pocket expenditure was brought down by 20%.

Sri. Rajeev Sadanandan IAS (Rtd), Former Additional Chief Secretary H&FW, Govt of Kerala presented the targets for Kerala 2020 under SDG-3, and spoke of how Kerala was well on track and ahead of the curve. The reorganization of the health system with a focus on primary care and referral pathways, changes in financing systems through tax funding, creating a mechanism for offering right incentives to providers and developing governance mechanism that facilitated its regulation with the private sector, were some of the key

14 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 pointers discussed by Mr. Sadanandan.

Summary of Orations – Challenges in Health 2020-2030 • The COVID pandemic has set the world off course in the achievement of SDG targets and Triple billion target. • Equitable vaccine distribution is the most important challenge of 2021. • The large out of pocket expenditure can be reduced only by achieving Universal health coverage through primary health care. • To accelerate back to SDG, we need to innovate, use data and target interventions at the lagging areas. • The focus in the coming years must be on Primary Health care and the system must be redesigned to meet the emerging challenges. The Primary Health care system must be valued and strengthened. • Using technology for better efficiency and appropriate data collection are essential for better productivity and monitoring. • India’s Public health spending remains one of the lowest in the world, while the Out-of-Pocket expenditure continues to be among the highest, especially in the State of Kerala. • Kerala had set its own targets to be achieved by 2030, based on the SDG and present achievements. The state is on track to achieve most of the targets, but the high rate of Non communicable disease continues to be a challenge which must be proactively tackled. Policy Implications for Kerala – From the Orations – Challenges in Health 2020-2030

1. Strengthening of public health care system with special focus on primary care • Promoting a culture for wellness and good behaviour to reduce consumption of alcohol, tobacco, drugs and to promote healthy lifestyle. • Further shifting the role of a PHC where the institutions is responsible for health and wellbeing of specific number of families under its care with priority for vulnerable families • Strengthening of emergency centres in Taluk and District hospitals. 2. NCD care through primary health care services

WEBINAR PROCEEDINGS 15 • Through decentralization, NCD care has to me made available at primary level and thereby it has moved away from specialist care alone. Community ownership to be strengthened for prevention and control of NCDs. 3. Realtime data management and use of digital technology • Demographic and vulnerability to develop diseases need to be captured family wise with the help of e-health technologies. 4. Strengthen Public private partnership for the people • The Government need to work with the private system to improve efficiency and cost effectiveness. People should be at the centre of such public private partnership models. Kerala’s progress towards Universal Health Coverage Dr. Rajan Khobragade IAS, Principal Secretary (H&FW), Govt. of Kerala, spoke on the policy interventions related to Aardram Mission and Dr Dahar Muhammed, Medical Officer, Family Health Centre Noolpuzha, Wayanad, Kerala, elaborated the implementation strategy The Government of Kerala has launched the AARDRAM Mission in the backdrop of SDG to provide comprehensive health care including Preventive, Promotive, Curative, Rehabilitative, and Palliative services. Aardram Mission was launched by Government with the objective of making it Peoples campaign in betterment of health and improving all government health facilities – from primary health centres to medical college hospitals. The conversion of Primary Health Centers (PHC) to Family Health Centres (FHC) is one of the major components of this program.

Conceptual framework for FHC model is as follows:

PRINCIPLES

Universal, family-basis, equity and non-discrimination, comprehensiveness, financial risk protectin, quality, rationality, portability and continuity of care, protection of patient rights, community participation, accountability and responsiveness.

16 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 INPUTS OUTPUTS OUTCOMES

• Stewardship, • Field based service • Health Outcomes Organization & delivery (Mortality, Quality Improvement • Facility based service Morbidity, Risk • Health information delivery Factors) systems • Target linked • Financial risk • Human resources coverage (may be protection • Financing embedded above) • Responsiveness • Essential medicines, • Efficiency diagnostics and devices

INTERSECTORAL LINKAGES COMMUNITY PARTICIPATION

Linkages to various departments Arogyasenas (police, social security mission, Social audits social justice, priority schemes)

To improve access to health care services by improving services at primary, secondary and tertiary care levels • At primary level: Transformation of Primary Health Centres (PHCs) into Family health Centres (FHCs) and a comprehensive primary clinical care guideline (treatment protocol) was developed and treatment were given based on that. • At secondary level: Standardization of district Hospitals and taluk hospitals with a treatment protocol • At tertiary level: Up gradation of Medical Colleges to Centres of excellence and treatments made available based on the treatment protocol.

Table 1: Interventions adopted by the state

At primary care At secondary level At tertiary care

People friendly All district hospitals Medical colleges outpatient services were equipped with were upgraded Cath lab, cardiology, (n=8) nephrology and neurology depts.

WEBINAR PROCEEDINGS 17 Extended the OP District hospitals Started new service to afternoon (n=14), general and medical (functioned till the Taluk hospitals (n=25) Colleges(n=4) forenoon earlier) were equipped with COPD management clinics

PHCs were Established stroke Started online reengineered clinics (n=8) at district registration into FHCs - in hospitals system to reduce terms of physical waiting time infrastructure, service provision and monitoring (n=765)

Comprehensive Installed Mydriatic Established OP primary health cameras at all district consultation care services made hospitals and started room for all available for the diabetic retinopathy departments to marginalised and screening ensure privacy vulnerable population

Chronic obstructive Established dialysis Established pulmonary disease units (n=44) at taluk patient friendly is addressed at Hospitals waiting areas specialised clinics at with amenable FHCS – ‘SWAAS clinics’ infrastructure and super speciality facilities

Mental health Established Digital technology programme helps chemotherapy units has applied in the in identification at (n=24) form of e- health in field level – ‘ASWAAS’ (N=210 hospitals) clinics

18 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Started New born care corner (NBCC), New born Stabilization Units (NBSU) and Special New born Care Unit (SNCU) and Child audit services

New born screening programme at District hospital and taluk headquarters hospitals to identify metabolic diseases

The state also designed a monitoring framework to see how the interventions are moving forward. • The state introduced Universal health insurance coverage scheme known as “Karunya Arogya Suraksha Paddhathi” which works in synergy with central government’s Ayushman Bharath. It integrates all existing health schemes to bring in standardization in operations and better management by convergence. The integrated scheme covers Rs 5 Lakh per family per year for both secondary and tertiary care treatments which consisted of 1667 procedures covering all the costs related to treatment, including drugs, supplies, diagnostic services, physicians’ fees, room charges, surgeon charges, OT, ICU charges etc.

Focusing on efficiency, cost containment and equity • The mission tried to improve the acceesibility of services to tribal Eg: Gothrasparsam - Free antenatal care is given to tribal population.Those from deep forest whose accessibility to health care is difficulty, are taken care in an antenatal space where they are taken care of and are shifted once they reach their EDC. • For detecting TB cases,a health worker residing in the tribal area was trained and she collected sputum in the early morning from the houses of suspects. • The mission considered elderly population also. Eg: E auto served as the mode of free transport to patients especially the elderly ones who attended the Non communicable disease OP.

WEBINAR PROCEEDINGS 19 It helped to aviod drop outs and to follow up on a regular basis

Enabling factors • Huge political commitment • Role played by decentralized governance • Convergence with other departments in addressing social determinants of health • Community participation through ‘Arogyasena’ volunteers • Special focus on NCD care especially cancer care and renal care

Conclusion Through ‘Aardram mission’ the state health system is trying to mitigate the newer epidemiological and demographic challenges. The mission focuses not only on curative part, but also focuses on preventive and promotive aspects of care. The most important approaches adopted by the state included operative governance structures at grass root level, effective stakeholder’s participation, community mobilization and intersectoral coordination can be replicated by other countries and states. “The secret of success dwells in cultivating the feeling that the hospital is owned by each one of the staff from the part time sweeper to the treating doctor” Progress in UHC at Thailand ‘Progress in UHC at Thailand’ which was presented by Dr Viroj Tangcharoensathien, Senior Advisor, Ministry of Health, Thailand. He outlined the evolution of Health Systems Development with respect to the full geographical coverage of district health systems and extension of population coverage, and the developments after achieving Universal Health Coverage (UHC) in Thailand, in 2002. While listing down the success factors of UHC, Dr Tangcharoensathien said solid platform and continuous development of health services system, including primary health care strengthening, sustained political commitment, the institutionalization of strategic purchasing capacity, participatory and responsive governance and consistent improvement were key. He detailed the ways adopted by Thailand on managing non- communicable diseases. Thailand is internationally known for its Universal Health Coverage

20 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 (UHC) policy and health development success. This session throws light on the historical evolution of Thailand’s health development culminating in Universal Health Coverage (UHC) in 2002. Thailand’s health development since the 1970s has been focused on investment in the primary care. Empirical evidence shows substantial reduction in levels of out-of-pocket payments, the incidence of catastrophic health spending, and in medical impoverishment. The scheme has also greatly reduced provincial gaps in child mortality. Certain interventions such as antiretroviral therapy and renal replacement therapy have saved the lives of adults. Well-designed strategic purchasing contributed to efficiency, cost containment, and equity. Remaining challenges include preparing for an ageing society, primary prevention of non-communicable diseases, and effective coverage of diabetes and tuberculosis control. In 2001, prior to the achievement of universal coverage of health care, approximately 30% of the Thai population were uninsured despite the gradual extension of coverage to various population groups. Universal Health Coverage was introduced in Thailand for achieving financial protection while accessing health care

Infrastructural development to improve coverage Improving the coverage by improving the health delivery infrastructure at the district level and below with a focus on improvement of Primary Health Centres (PHCs). As a result of these earnest efforts, by 2000- full coverage was achieved. This enabled in forming a solid network of district health system. Increasing the coverage by infrastructure development in rural areas in a phased manner for catering to a target population in a geographical area. Building a Health Centre in every sub district- with a catchment population of -5000. A District Hospital in each (800) district- catering to a catchment population of 50000

Improving the quality and quantity of Health workforce Improving the quality of services by capacity building of the health workforce and retention of the trained staff is a major problem faced by all developing countries. • This included increased training, • Redeployment of Doctors, Nurses, and Pharmacists to rural areas • Retention through three-year period of mandatory services in rural

WEBINAR PROCEEDINGS 21 areas (rural postings) were introduced for doctors, nurses, dentists, pharmacists soon after graduation.

Improving access through health insurance Improving access to health care by provision of financial protection through health insurance schemes is one of the strategies that have become successful in different developing countries including Thailand. Universal Coverage Scheme (UCS) was introduced, providing health coverage to those insured by the previous Medical Welfare Scheme for low-income households and socially disadvantaged groups, and the publicly subsidised Voluntary Health Insurance for the informal sector, and additionally extended coverage to 30% of the population not previously insured. The UCS and CSMBS are solely financed by general tax revenues while SHI is tripartite contributory program, paid equally by the government, employer, and employee. Together with the Civil Servant Medical Benefit Scheme (CSMBS) and Social Health Insurance (SHI), UCS resulted in the full health coverage of the Thai population. Three public health insurance schemes that were present & constituting UHC in Thailand: 1. CSMBS- Civil Servant Medical Benefit Scheme 2. SHI- Social Health Insurance 3. UCS- Universal Coverage Scheme- • Targeted insurance schemes for different population groups have improved financial access • General taxation to finance the Universal Health Coverage Scheme without relying on contribution from members • Making health service financially accessible by focusing and targeting on specific population groups until UHC was attained on a phased manner

Focusing on efficiency, cost containment and equity Introducing benefit packages for reducing mortality due to specific illness • 1975-Low-income scheme- social welfare- low income, elderly, children & disable • 1983- CBHI-Voluntary based • 1980- CSMBS- civil servant & their dependents • 1990- SHI- Employees in private sector • UCS- Those not covered by CSMBS & SHI

22 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Table 2: UCS benefit package positive list approach-elaborated in the table

Year Benefit Package Extension

2002 Initial package: • comprehensive OP, IP, high cost, A & E, personal prevention & health promotion services, rehabilitation

2006 • Universal ART ARV, VCT, CD4 monitor, viral load test, condoms

2008-2009 • Thai traditional medicines • Renal replacement: PD First policy, haemodialysis, transplant- include of all related medicines • Voluntary methadone replacement • Access to expensive medicines in NLEM • Seasonal Influenza vaccination in at-risk groups

2010 • Cover all orphan medicines & antidotes in NLEM • Psychiatric inpatients treatment with no limits LOS

2011 • 2nd prevention DM & HT • Specific medicines for psychiatric patients— (cost effective methods)

2012 • Liver transplantation, hepatic failure age <18 years • Heart transplantation

2013 • Extension of seasonal flu vaccine to more target groups • Stem cell transplantation in leukemia & lymphoma with specific indications

2015-2016 • ART policy ‘Detect & Treat’ at any CD4 level • Long term home & community care for frail elderly

2017-2018 • HPV Vaccine to preventing cervical cancer for primary school girl students • Screening of colon cancer

WEBINAR PROCEEDINGS 23 2019-2021 • Pre exposure prophylaxis (PrEP) to prevent HIV infection for high-risk groups • HPV DNA test for cervical cancer screening • Automated peritoneal dialysis • -rare disease- inborn error of metabolism • Medical acupuncture for stroke patients (rehabilitation) • Medabon for safe termination of pregnancy • Comprehensive screening for TB • Hematopoietic Stem Transplantation for Thalassemia • Long term home & community care extended for all frail, not only elderly • Liver Transplantation for medium & late stage of cirrhosis • Gene testing (HLA-B*1502 & HLA-b*5801) before getting carbamazepine & allopurinol to prevent severe drug allergy • Newborn hearing screening & cochlear implantation as needed *All these positive lists were found to be cost effective except dialysis

Comprehensive package with • OP, IP, high-cost treatment modalities, A & E inclusive of medicines • Personal preventive, promotive services and rehabilitative services • Medicines referred to National List of Essential Medicines • Nominal copayment 30B for any visit/admission • Public contracting model applied: OP: age adjusted capitation, register with district health systems network IP: Global budget & DRG Others: fee schedule for high-cost intervention • Approval of new interventions into benefit package subject to • Rigorous HTA • Long term budget impact assessment • Ethical/equity considerations • Supply side capacity to deliver • Budget was guaranteed based on prevalence of different condition & cost of treatment

Participatory Governance The UCS is managed by the National Health Security Office (NHSO), an autonomous public agency that was established by the National

24 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Health Security Act of 2002. The UCS is governed by the National Health Security Board chaired by the Minister of Public Health. The board has 30 members, five of whom are from civil society organizations. Co- payments benefit package, standards guidelines, quality standards, contract processes, and payment mechanisms are all decided by the Board, including strategic goal setting. The national Health Security Act 2002.Section 13 ‘National Health Security Board” include 5 representatives of Civil Society Organization, elected among themselves from the nine CSO constituencies: • Children & adolescents • Women • Elderly • Disabled or mental health patients • HIV or other chronic disease patients • Labour • Populous communities • Agriculturists • Minorities • Members of all sub-committee of the Board also include CSO to voice citizen’s concerns & needs Participatory governance is a prerequisite for government responsiveness which aims to increase citizen participation in public policy processes which in turn increases responsive governance which aims to meet the health needs of citizens, and promote and improve access and quality of health services. Participatory and responsive governance in universal health coverage (UHC) systems synergistically ensure the needs of citizens are protected and met.

Enabling factors • Solid platform & continuous development of health services system including primary health care strengthening • Sustained political commitment to UCS despite protracted political conflicts • Institutionalization of strategic purchasing capacity • Participatory & responsive governance • Consistent improvement: ‘leave no one behind’ (e.g. rare diseases)

Barriers • COVID-19: Recession & fiscal space for health in 2021-2023 • Medical disruptive technology & alternative health delivery system

WEBINAR PROCEEDINGS 25 • Access to healthcare by vulnerable groups • Potential losing war against NCD: low effective coverage, health literacy in the context of commercial determinants of ill health • Disparity & slow progress in harmonizing the three public health insurance schemes

Conclusion The strategies used by the Thai public health system in achieving aspects of UHC can be used by neighbouring countries and states too. Key takeaways include the importance of continued political support, evidence informed decisions, and a capable purchaser organization. Kerala should utilise the technology for HTA and make it a tool for building evidence in the coming years.

Panel discussion on ‘Universal Health Coverage- outlook for developing countries The first panelist for the session was Dr Mala Rao, Senior Clinical Fellow, Imperial College London. She outlined the WHO strategic goals for UHC and the lessons from UHC journey so far. For a successful roll-out of UHC, Dr Rao said a comprehensive primary care for UHC was required. She highlighted the pressing need to address the social determinants of health, especially in the COVID era. While applauding Kerala’s efforts, she said the state had the vision to achieve UHC and to show others the way forward. Answering a question on the impact of the pandemic in achieving UHC, Dr Rao said that countries had come together to address the needs of the community in unprecedented ways during unprecedented times in a great show of strength.

The discussion was then taken forward by Dr. Luigi D’Aquino, Chief of Health, UNICEF, India who spoke on ‘Progressing in UHC: the way for sustainable health and achieving SDGs’. Mr. D’Aquino accentuated the need for universal access to quality care without financial hardship, as health was a human right. He highlighted active community participation as being a key in the implementation of the UHC. Mr. D’Aquino spoke of UNICEF’s complex approach to UHC through PHC, and reflected on UHC during COVID-19. With regard to the link between children and UHC, he said children needed to be made active participants in the system and gender gaps in children had to be bridged.

26 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Sharing the experiences with respect to the progress of UHC in Africa, Dr G.N.V Ramana, Ex Lead Health Specialist, World Bank broke down the subject into four buckets – progress of UHC in Africa, UHC evolution in Kenya, accelerating UHC achievement by Africa and key lessons on UHC scale-up in Africa. He elucidated the call to action for developing countries on how they must follow an incremental approach towards UHC but he said it wouldn’t be possible without adequate tax-based funding. He also added that the governance of UHC institutions remained critical as they were not just about delivering clinical services.

Dr. Rathan Kelkar who moderated the panel summed up the session that there was no tailor-made solution as every country had its own set of challenges to overcome. However, he added that UHC was not a distant dream if we had the right policies, the right plan for implementation, adequate financing, good inter-sectoral coordination, people-centric approach towards meeting health-care deliverables, robust public- health infrastructure, adequate investing in work-force and community participation.

Summary of the Panel - Universal Health Coverage- outlook for developing countries At least half the population in the world does not receive the health care they need. Lack of a UHC is pushing millions into hunger and poverty and is causing large number of deaths in children. Comprehensive primary care based UHC can ensure health security stability and sustainability. Enacting multisectoral policies and investment in in primary health will be essential

Problem • Lack of UHC in a major section of population even though Health is a human right • Half of the world do not receive the care they need due to fragmented health care delivery • 100 million falls into extreme poverty due to out-of-pocket expenditure • Lack of adequate health care causes large number of child deaths in LMICs • Visible urban-rural and socio-economic inequities in access to care

WEBINAR PROCEEDINGS 27 • Addressing mental health is inadequate in several regions of the world • Tackling non communicable diseases along with communicable diseases

Policy options with implementation strategies Comprehensive primary care based UHC- Essential for health security, stability and sustainability • Investment in primary health systems › Establish a Competent first point of contact › UHC Should be person focused - ensuring ongoing care › Encompass all components of health system not just curative services › Begin with Minimum Package and progressive expansion › One Health Coordination is essential • Empowering people and communities › Population based services such as public health campaigns › Proactive engagement with all sections of society • Close working between LSG and health institutions › Multi-sectoral policies and action › Addressing social determinants of health • Invest in capacity building › Value staff and their Services › Train multiprofessional teams › Make use of Community health workers to link with services • Make primary health center attractive and provide standardized integrated care › Enhance public confidence in public care - letting staff lead activities will be helpful

Financing • National and sub-national funding (2%of GDP) • Increase allocation for ‘near to community’ services • Involve private sector in UHC reforms • Earmarking of taxes for health financing • Tax based finances • Promote quality and efficiency through PBF

28 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Continuous supply of medicines and equipment • Good quality of medicines at cheaper rate can be ensured using economy of scale • implementing Institutional mechanism for pooling and strategic purchasing • Design new technologies

Research and evaluation as to what works in current programmes and its consequences • identify areas for improvement • Independent evaluation of govt programmes is essential • Shared learning with other states and countries • RMNCH strengthening • Refer only when necessary and back referral should be received • Focus on equity • Target vulnerable • Introduce pro-poor interventions • Mandatory insurance for formal sector

Improve governance • Monitoring and supervision • Disease preparedness - increased surveillance • Ensure transparency - access to data on UHC to citizens • Ensure Citizen participation in policy making

Enablers • Political commitment • Having an established institutional mechanism for pooling and strategic purchasing • Inclusion of Outpatient Care (main contributor for Oops) in the benefit package • Mixed mode of service provision – Public, Private and Faith Based • Strong analytical skills – Actuarial and Health Economics

Barriers • Climate change • Less focus on mental health • Interdepartmental coordination • Population minorities with varied needs • Increasing Public Financing

WEBINAR PROCEEDINGS 29 • Reforming NHIF – Rationalize packages, better pricing based on costing, strengthen internal control & IT systems, enhance efficiency and transparency; Handling false/exaggerated claims • Developing more realistic and pro-poor benefit package including NCD screening and management • Enhancing efficiency of Public facilities – Autonomy and incentives • Strategic purchasing of specialized services from private sector

Conclusion Interventions focusing the Primary Health care by making PHCs attractive with adequate training for the staff, ensuring continuous supply of good quality medicines will all help to achieve UHC. Addressing wider determinants of health and using community health workers to take services to the people will also be essential. Fostering community ownership and private sector participation is the way to go forward.

30 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 WEBINAR PROCEEDINGS 31 DAY 02 COVID-19 pandemic: Health System Response– Resilience–Preparedness

on. Minister of Health Smt. K K Shailaja opened the floor by congratulating the chief guest Dr. Maria Van Kerkhove, COVID-19 HTechnical Lead at the WHO and Prof. Balram Bhargava, Director General at ICMR & DHR Govt. of India for the tremendous work and leadership they have been rendering in this historic fight against the pandemic of the millennium. She talked about the COVID-19 pandemic overwhelming health Smt. K K Shailaja systems, challenging its resilience and overall governance of almost all Hon. Minister for countries across the globe. She touched on the disparity in the response to Health, Social the pandemic among developed and developing nations. This began from Justice, Women and Child Development, identifying, reporting cases and even the definition of the deaths due to Govt. of Kerala COVID-19. Also, in robustness of surveillance systems and effectiveness of medical and social support mechanisms. However, there are few indicators that provide a reasonable evaluation when adequately fed with data, she adds. She recalls “Yesterday I was going through the World Mortality Dataset developed by few eminent universities across the globe which tracked excess deaths across countries during the COVID-19 pandemic. They evaluated the excess deaths during the pandemic period with reference to the same period in the previous years. Of the 77 countries evaluated in the study, 51 of them had significantly high numbers of excess deaths during the pandemic year compared to the previous years. This relative

WEBINAR PROCEEDINGS 33 increase is highest in Peru (77% increase in excess deaths with reference to previous years), 14% in USA and 13% in UK to name a few. What is interesting is that in 6 countries all-cause mortality is decreasing during COVID-19. Obviously in best performing nations like New Zealand the deaths decreased by 6%. It’s in this context that excess death analysis done in Kerala holds strong and really encouraging. Excess deaths analysis done based on the data from Comprehensive and Universal Health Death Registration in the state showed all cost mortality decreased by over 10% during the COVID-19 period when compared with previous years.” This achievement was worth mentioning given the fact that Kerala had many demographic and epidemiological challenges at hand. Among demographic challenges was Kerala being a thickly populated state with its population density being 680 for 1 square kilometre and 430 being the national average. To add to that Kerala has a high number of old age population (almost 15% of the total population). The burden of NCDs or lifestyle diseases is high in Kerala exacerbating the situation. The task at hand was to reduce mortality rate especially for high risk, co/multi- morbid patients. Despite these challenges, Kerala successfully fought the virus and ensured that there were no excess deaths in Kerala. One of the primary factors that led to this significant achievement is the basic and decentralized public health initiatives and interventions that Kerala undertook during the COVID-19 periods especially the Break the Chain Campaign. Kerala was quick to adopt strategies and set some models when the first case came from Wuhan to Kerala. The team campaigned with the people to use masks, soap, sanitizers, wash hands and to keep physical distancing. This campaign reached 80% of the population who obeyed these protocols and hence the campaign succeeded in reducing the spread of the virus and associated mortality rate. Another strategy was adopting a scientific testing method for COVD- 19. The team did not omit any cases who had COVID-19 symptoms. The testing was even happening at the primary health centers. Kerala’s PHC’s were better prepared to manage the pandemic as these centers were being strengthened from the past 5 years under the Aadram Health Mission. At the PHC level, Kerala was trying to trace and test the virus and its symptoms. This way they were tracing, quarantining those with COVID-19 symptoms and also testing for cluster occurrences. Tests per million for Kerala stands at 185000 and more. Kerala’s strategy was to trace, quarantine, test, isolate and treat COVID-19 patients. This strategy is also reflected in ICMR’s sero-study and is clearly evident from the Sero

34 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 survey that even though Kerala was the first state to report COVID-19 case, it is the last state to peak with the latest (Dec 2020) sero prevalence report from ICMR showing it as just 11.6%. There were two ways to delay the peak of the virus. One to use the mitigation method which allowed the virus to enter the whole society and hence have herd immunity. Second was to slow down the peak by protecting people from the virus and wait to give the people artificial immunity through vaccination. Kerala was smart enough to choose the latter to lower the peak of the virus, much credit goes to the Break the Chain Campaign, reverse quarantine, and scientific testing methods. That is precisely that our health systems across the globe need to be resilient to pandemic fatigue and to be better prepared for facing new challenges, pandemics or infections with pandemic potential emerging in various parts of the world again sooner or later. And it is our collective responsibility as humankind to build systems and partnerships to deal with them effectively because just like the Spanish Flu of the last century, history gives us an opportunity for revolutionary reforms and changes, just once in a century. Hon. Minister of Health Smt. K K Shailaja ended the inauguration note by asking everyone to play their role in making more resilient and better prepared health systems and partnerships at all levels.

WEBINAR PROCEEDINGS 35 Chief Guest’s Address

COVID-19: Health System Global Response

Global Epidemiological Trend The global epidemic curve is the overview of the epidemiological trends since the start of the pandemic. Below is the timeline: • 31st December 2019 – WHO alerted of a cluster of pneumonia of unknown etiology • 1st January 2020 – WHO activated the Incident Management Team Dr. Maria which started operating non-stop since Van Kerkhove • 5th January 2020 – WHO issued first alert through EIS and Disease COVID-19 Technical Outbreak News Lead, World Health Organisation • 10th- 11th January 2020 – WHO issued the first package of technical guidance on finding cases, collecting samples, protecting Dr. Maria health workers, caring for patients and a whole overview of what presented on the global overview needs to be done to find where this virus is. of the COVID-19 • 30th January 2020 - WHO Director General Dr. Tedros Adhanom pandemic, current declared a public health emergency of international concern. situation and gave Highest level of alert under the international health regulations. an overview of some of the elements • 4th February 2020 – WHO issued first Strategic Preparedness of the pandemic Response Plan (SPRP) response till date. Every region has a different type of transmission occurrence. In general, there is a reduction in the number of COVID-19 cases and also reduced deaths especially in the last five weeks. Transmission situations in different countries can be divided into 4 broad categories: 1. Countries avoided large outbreaks, not allowing the virus to seed in their country and take off. 2. Major outbreak but brought under control and have seen small outbreaks here and there. 3. Number of countries that have had major outbreaks which they have brought under control but now are seeing resurgence as societies

36 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 have opened. 4. Some countries have really dealt with intense and ongoing transmission WHO’s Global Strategy for COVID-19 WHO issued the first Strategic Preparedness and Response Plan (SPRP) on 4th February 2020 which focused on 3 major elements: 1. Suppress transmission 2. Protect the vulnerable and prevent amplification 3. Save lives These global strategic objectives issued last February 2020 remain the same till date. Actions and objectives important to achieve suppress transmission, save lives and livelihoods includes: 1. Mobilizing all sectors and communities to ensure that every sector of the government and society takes ownership of and participates in the response and in preventing cases through hand hygiene, respiratory etiquette and individual level physical distancing. 2. Control sporadic cases and clusters and prevent community transmission by rapidly finding and isolating all cases, providing them with appropriate care and tracing, quarantining and supporting all contacts. 3. Suppress community transmission through context appropriate infection prevention and control measures, population level physical distancing measures and appropriate and proportionate restrictions of non-essential domestic and international travel. 4. Reduce mortality by providing appropriate clinical care for those affected by COVID-19, ensuring the continuity of essential health and social services protecting frontline health workers and vulnerable populations. 5. Develop safe and effective vaccines and therapeutics that can be delivered at scale and are accessible based on needs. The Strategic Preparedness Response Plan (SPRP) 2021 has some very important integrated pillars. These are: 1. Laboratories and diagnostics 2. Surveillance, contact tracing and isolation 3. Infodemic management and Risk Communication and Community Engagement that empowers communities 4. Clinical management 5. Infection prevention and control

WEBINAR PROCEEDINGS 37 6. Maintaining essential health services 7. Good trade, travel and points of entry guidance 8. Vaccine and vaccination All these integrated pillars are underpinned through: 1. Coordination and planning 2. Operational Support and logistics 3. Accelerated research and innovation Science drives WHO’s understanding of COVID-19 till date. The team is learning about long term effects of COVID-19 to those affected by the virus. Much work is underway to have proper research and rehabilitation for people suffering from long term effects. To make sure that mortality and its drivers due to COVID-19 are well understood, the science behind infection severity and transmission are constantly being researched. WHO is still learning about secondary attack rates in different settings in which transmission can be amplified.

Science driving our understanding

Severity Transmission • Natural history and disease progression • The importance of intensity, duration and • Risk factors for severe disease and death context of exposures • Recovery and long term effects • Relative contributions of the different modes of • Morality (CFR, by population) transmission • Infection fatality ratio (IFR) • Transmission during course of infection • Settings in which transmission can be amplified • Secondary attack rates and cluster investigations • Extent of infection as measured by seroepidemiology (leg, lim, neutralising antibodies, T-cell) • At risk groups and underlying conditions, including health workers Verify R et al. Estimates of the severity of Coronavirus disease 2019: a • Transmission among children by age group model based analysis. Lancet Infect Dis. 2020 Mar_51473309320302437

Turning Know-how to How-to WHO is constantly translating evidence into knowledge and coordinated action so that evidence drives policy. To do this they use a feedback loop that comprises of:

38 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 1. Evidence, science and leveraging the world’s expertise through their networks, collaborating centres, strategic advisory groups, online consultations, multi country studies and trials etc. 2. Authoritative, accessible guidance that is constantly re-evaluated, multidisciplinary, multi- lingual, multi-agency, adapted to different contexts and the content is shared through multiple channels. 3. Monitoring and learning through KPI driven M&E, country case studies and reports, targeted operational research, infodemic monitoring, regional consultations etc. 4. Implementation via digital transformation of knowledge into learning using OpenWHO training platform, 150+ country offices, 6 regional platforms, multi-agency operational platforms.

Key Achievements in WHO’s COVID-19 Response 1. Delivery of materials- almost 300 million items of Personal Protective Equipment (PPE), diagnostic and medical supplies shipped around the world 2. Developed rapidly PCR tests. From the availability of the full genome sequence (on 10th -11th January 2020), WHO and partners were able to develop a PCR – assay. First developed by Charite University, Berlin and published on WHO website on 13th January 2020, less than 2 weeks when WHO first learnt about the cluster of pneumonia in Wuhan, China. a. From then WHO worked with companies to develop PCR kits and they were shipping those around the world by February 2020. b. Since then WHO has been working to improve the global supply chain to ensure that they get PPE to frontline health workers across the world and to those who most need it. 3. The global supply has improved but it is still not fixed. WHO is still lacking the ability to get PPE, gloves, gowns, goggles, masks, respirators to frontline health workers. 4. Continuing to look at innovation in different ways. 5. 14000+ patients enrolled in the Solidarity Trial for COVID-19 treatments, in nearly 500 hospitals in 30+ countries. 6. 190 economies signed up to COVAX to have fair and equitable access to vaccines. 7. 1.3 billion+ people reached with crucial health information through WHO’s website. 8. 500+ COVID-19 documents published, from 125+ guidance documents to 10 research protocols.

WEBINAR PROCEEDINGS 39 Challenges Ahead Despite WHO’s achievements there are uncertainties ahead especially with the SARS CoV 2 Variant. 1. Virus variants that have been recently detected in the UK, South Africa and Brazil show us that this virus is evolving. This is natural, viruses are constantly changing through mutation and SARS CoV 2 is no different. This is expected. Many of these mutations are neutral but some may be detrimental to the virus. A small number may confer an advantage to the virus. 2. Specific mutations and variants of concern identified in different countries highlight the importance of increasing diagnostic and sequencing capacity globally, timely sharing of sequence data internationally and of bioinformatics and close collaboration to study potential impacts. 3. Given that most countries have limited capacity for sequencing, data and epidemiology should drive public health and social measures (PHSM). A tiered approach at the sub-national level is recommended using the PHSM guidance 4. Experiments with live viruses in advanced laboratories are ongoing to determine the impact of specific variants on transmission, disease presentation and severity, impact on diagnostics, vaccines and therapeutics. 5. Coordination of research across partners is critical; these include WHO’s Virus Evolution Working Group, WHO R&D Blueprint for Epidemics, Researchers and Manufacturers. To cater to this major challenge, WHO is working to establish a risk monitoring framework to evaluate SARS CoV 2 variants of concern. This work in progress monitoring framework has many components and principles that are needed for its success.

These components are: 1. Surveillance: Epidemiological; Molecular diagnostic testing; Monitoring virus circulation with genomic sequencing, including virus evolution and phylogenetics. 2. Research studies on potential variants of interest (VOI) and variants of concern (VOCs) a. Protein modelling studies b. Laboratory studies (in vivo and in vitro) 3. Evaluation impact of evolution on available and future diagnostics, therapeutics and vaccines.

40 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 The principle of successes is: 1. Robust framework and assessment; building from/enhancing existing systems 2. Regular communications 3. Strong collaboration 4. Increased capacities for sequencing and bioinformatics 5. Platforms to support sequences and phylogenetics 6. Clear, consistent and evidence-based communications and actions WHO established a virus evolution working group in June 2020 to have a mechanism in place to outline the laboratory studies that are crucial and to coordinate laboratory studies across the world, spread work around to evaluate these overtime, to link R&D colleagues, link research to diagnostics, therapeutics and the vaccines. WHO is playing a key role in coordinating this important work. This will feed into WHO’s Rapid Risk Assessments and any revisions needed for guidance in terms of public health and social measures and any changes that will be required for diagnostics, therapeutics and vaccines.

Looking Ahead – Stay the Course We collectively know much more now than one year ago about COVID-19. We have developed operational and scientific solutions but we have not yet applied that knowledge and those solutions comprehensively or evenly. Hence, we need to stay the course. The epidemiological situation is dynamic and uneven, further complicated by variants of concern, however, many countries continue to suppress transmission. Health care systems and workers have saved countless lives but are under extreme pressure in many countries in terms of capacity, workforce and supplies. Surveillance systems are finding it hard to cope with the high force of infection. Case and cluster investigation contact tracing and supported quarantine of contacts remain underpowered. Communities are suffering and struggling to maintain Public Health and Social Measures as well as suffering loss in social cohesion, education, income and security. There is the issue of infodemic but empowered communities have played a key role in the control of COVID-19, although misinformation and disinformation continue to undermine the application of an evidence- based response and individual behaviour. Science has delivered on solutions and these are being scaled up and

WEBINAR PROCEEDINGS 41 strong mechanisms exist for equitable delivery (eg: COVAX). However, in some cases demand and utilization is suboptimal (eg: RDTs) and equity is under threat.

Looking Ahead - Stay the Course

Epidemiological Situation: Dynamic and uneven, further We collectively know much complicated by variants of concern; however, many countries more now than one year continue to suppress transmission ago. We have developed Health Care Systems and Workers: have saved countless lives but operational and scientific are under extreme pressure in many countries in terms of capacity, workforce and supplies solutions but we have not finding it hard to cope with high force yet applied that knowledge Surveillance Systems: of infection. Case and cluster investigation, contact tracing and and those solutions supported quarantine of contacts remain underpowered comprehensively or evenly Communities: Are suffering and struggling to maintain Public Health and Social Measures as well as suffering loss in social In 2021 we must redouble cohesion, education, income and security our efforts to suppress Infodemic: Empowered communities have played a key role in the control of COVID-19, although misinformation and disinformation transmission, protect continue to undermine the application of an evidence-based the vulnerable and save response and individual behavior lives in a comprehensive Science: Has delivered on solutions and these are being scaled up coordinated and equitable and strong mechanisms exist for equitable delivery (e.g. COVAX). way However in some cases demand and utilization is suboptimal (e.g. RDTs), and equity is under threat.

Critical Focus Areas Going Forward We need global collective action to end this pandemic with strong national leadership, implemented by all of the government and all of society’s plans. This needs to be coordinated not only at the global level but also at the regional level. These tools should be applied evenly and consistently so that we can drive transmission down, save lives and livelihoods. We need to reduce and control transmission, prevent transmission amplification events especially in closed indoor settings where there is poor ventilation. This can be done by empowering, engaging and enabling individuals and communities with knowledge and resources for increasing and sustaining risk reduction measures. It is important to scale public health initiatives to detect, test, care, isolate cases, trace and quarantine contacts, ensure ample trained public health workforce, and testing platforms, data management tools and resources are available to support rapid isolation of cases and support quarantine of contacts.

42 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 We need to save lives and to protect vulnerable groups and communities and ensure rapid and high-quality clinical care. We need to provide clear, consistent and open communications, acknowledging our humility when we don’t know everything and communicating uncertainty in these difficult times. It is crucial to accelerate development and access to COVID-19 diagnostics, therapeutic and vaccines through global collaboration and fair allocation. Additionally, to build vaccine acceptance and prepare for vaccine roll out campaigns.

Critical Areas of Focus Global collective action to end this pandemic is needed • Strong, cohesive national leader sNp and implementation of all ot government, all of society plans • Coordinated regional and global implementation of strategies using available tools to suppress transmission, save lives and save livelihoods Reduce / control transmission and prevent amplification events • Empower, engage and enable individuals and communities with knowledge and resources for increase and sustaining risk reduction measures • Scale up pubic health measures to detect, test. care, isolate cases, trace and quarantine contacts, ensure ample trained public health workforce, and that testing platforms, data management tools and resources are available to support rapid isolator of cases and supported quarantine of contacts • Providing clear, consistent and open communication Save lives • Protect vulnerable groups • Ensuring rapid and high quality clinical care Accelerate development and access to COVID-19 diagnostics, therapeutics and vaccines • Through global collaboration and fair allocation • Build vaccine acceptance and prepare for vaccine campaigns

Make sure that we are reducing exposures, infections, mortality and transmission. We do this by empowering individuals and communities, collectively for actions. We need to constantly engage with communities and have open, honest dialogue about how we work together and how these interventions are implemented at the local level. We know that informed, engaged and enabled communities are what drives action and we should really strive to make sure that in a consistent and continuous way throughout this pandemic.

WEBINAR PROCEEDINGS 43 India’s Fight against COVID- Role of ICMR

ossible reasons that this century had to witness COVID-19 pandemic among several exotic viral infections like SARS, MERS, PEbola, Yellow Fever, Zika, Nipah are change in environment and ecology, rapid urbanization, extreme connectivity with easy travel and movement, neglected public health and inadequate spending. India being the world’s largest democracy, the COVID-19 response here Prof. Balram has been with respect to people’s voices to recalibrate its intervention Bhargava measures which has been a success story because India was serious Director General, from the very beginning and it was a whole of government approach Indian Council of with calibrated, proactive and pre-emptive and graded response. Medical Research & DHR, Govt. of India The response was science driven with best practices and evidence based. India had strong leadership with excellent communications with all the states and stakeholders that helped tremendously to keep the country together and guide it from the central leadership. India adopted the 5T strategy of test, tract, trace, treat and use technology. And most importantly, India restricted the concept of herd immunity. Many countries fell flat on the face when they adopted herd immunity. Some examples are the UK, Sweden, some parts of the USA who embraced herd immunity and had problems. National Testing Network The first case in India was detected on 30th January 2020 by ICMR, Pune. Subsequently, India set up various labs scaling them to 2376 (1217 government labs and 1159 private labs) till date. India took 10 months to do the first 10 crores tests and 3 months to do the second batch of 20 crores tests. By Feb 2021 20.4 crore tests are conducted across India. India had a calibrated expansion for tests ever since the first case was detected in India. In January 2020 we had only one lab testing, the next month

44 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 we tested more travellers. By March 2020 we had more labs for testing, and we had a paucity of kits. Much of the kits were being imported and some were supplied by WHO to India. We also scaled out testing that included SARI patients, health care workers and contacts. By April 2020, India repurposed the molecular tests (TrueNat that had been used for TB effectively and has also received WHO prequalification) In June, India innovated and used the Rapid Antigen Test for the first time in the world. This test got WHO prequalification in September 2020. By September, India had demand testing available with many immunocompromised, pregnant women, high risk population, atypical hospitalized patients, pool testing etc. were all calibrated efforts. Yet all these depended on availability of kits, labs and trained personnel. India scaled up its testing facilities with the vision to have labs in every district. We even had labs in difficult to reach terrains like Andaman and Nicobar Islands, Leh Ladhak, Jammu and Kashmir, Sikkim and Lakshadweep. Currently, there are RT-PCR test labs in 659/741 districts, all districts have Rapid Antigen Testing facilities and 526/536 medical colleges are equipped to deal with COVID-19 cases. Increasing access to diagnosis was done in large cities and urban areas (phase 1) with RT-PCR labs, district level deployed TrueNat, BNAAT and Abbot machines and field level had antigen tests. India has 2530 True Lab (also known as lab in a suitcase) workstations operational in 1008 sites in 530 districts of India. India had used this technology earlier for TB diagnosis, Nipah and Leptospirosis so there was no difficulty in repurposing and using it for COVID-19. Even though the number of tests done on this machine remain low, the plus point is that it weighs on 3 kgs, can be taken to remote areas, has network data transfer and automated reporting and minimum biosafety and biosecurity requirements. To increase diagnosis 14 mentor institutes were established to hand hold new labs, labs were established in remotest of areas and 16 depots were established for efficient distribution of supplies (24X7) with the help of Operation Lifeline Udaan, Indian Air Force, India Post etc. To this the government issued a gazetted notification to equip BSL-2 facility mandatory for MCI registration of medical colleges. High throughtput labs, cobas 6800/8800 have been installed all over India. Combination of RT PCR machines and automated RNA extraction machines are being used. These ensure minimum human intervention and can test more than 1000 samples per day. When COVID-19 reached its third peak in New-Delhi, there was a need to upscale RT-PCR testing to 70000 tests. This was done using mobile

WEBINAR PROCEEDINGS 45 testing labs for COVID-19, these were deployed in different areas of Delhi and these tested 2000 samples per day. Inventory and Data Management For managing inventory there was a demand forecasting platform which enabled information on stock-out status, lab requirements and suggestive quantities. 20 ICMR depots were established for seamless distribution of testing commodities across the country. A single source of truth for all data was used which was ICMR’s data entry portal that monitored disease trends, policy making, resource planning and even clinical decision making. Capacity Assessment and Matching Procurement Capacity assessment was done, and it noted the type of machine: RNA/ PCR/high throughput, type of stock mix, manpower and operating hours. To streamline procurement processes and to upstream the supply chain there were nuanced models for robust projections of testing commodities, the tendering platform of Government of India fast tracked for use and Government of India’s GEM portal was used for procurement and vendor registration. Atmanirbhar Bharat To ensure self-reliance in diagnostics and vaccines, ICMR developed the first indigenous human ELISA COVID-19 testing kit which was used for the first sero-survey for testing. ICMR validated 1184 diagnostic commodities and approved 419 indigenous kits as on 11th February 2021. These include 228 VTM kits (194 approved, 182 indigenous), 260 RNA extraction kits (161 approved, 102 indigenous), 197 rapid antibody kits (26 approved, 19 indigenous), 336 RT-PCR kits (156 approved, 87 indigenous), 94 ELISA kits (25 approved, 17 indigenous) and 65 rapid antigen kits (18 approved, 12 indigenous). Quality control and assurance is met and maintained via 38 labs for RT-PCR and 24 labs for RAT testing. Transparency and fair procurement practices for COVID-19 testing kits, these are made available on the government e-market place (GeM) to ensure decentralization of procurement by augmenting states to procure on their own. Achievements for India Initially the cost of one RT-PCR test was 1727 INR in March 2020 but now it has drastically come down to 135 INR per test. India played a

46 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 crucial role to regulate international markets to reduce the cost of their COVID-19 kits and India went from import dependence to export surplus. India was the 5th country in the world to isolate the SARS-CoV2 virus, aided in developing ELISA, monoclonals, lab assays, antiviral screening and vaccine development. India was the 1st country in the world to isolate and culture the SARS-CoV2 variant. India conducted 3 national community ser-surveys (NCS) across 70 districts, 21 states, 24000 individuals. The 3rd sero-survey included 7000 health care workers. The results also published in the Lancet Global Health were: 1st NCS: 0.7% seroprevalence, 2nd NCS: 7.1 % seroprevalence and 3rd NCS: 21.5% seroprevalence. ICMR also initiated sewage surveillance to detect SAR-CoV2 with a standardized method of sample collection and processing which was implemented in 20 sites of Mumbai and a phased expansion with WHO- India at polio sewage surveillance site is underway. Clinical and Research Studies WHO Solidarity Trial: Remdesivir, Hydroxychloroquine, Lopinavir and interferon – little o no effect on overall mortality, initiation of ventilation and duration of hospital stay. Study on HCQ: useful for prophylaxis in health care workers. PLACID trial (Largest trial in the world): Convalescent plasma did not lead to reduction in progression to sever COVID-19 or all cause mortality. Monoclonal Antibodies: developed for treatment Antiviral screening: Evaluation of more than 100 drug candidates/ repurposed drugs for treatment. India has 3 dedicated volumes of India Journal of Medical research on India an COVID-19. The 4th volume is in compilation COVID-19 Vaccine Development ICMR supported Bharat Biotech (COVAXIN). It was provided with the virus strain, characterised vaccine strain, preclinical studies were conducted in hamsters and monkeys, technical and lab support was provided for phase 1 and 2 of the trials and financial support for phase 3. ICMR provided the Serum Institute of India with technical and lab support for phase 2/3 studies of COVISHIELD (AstraZeneca), phase 2/3 studies for COVOVAX (Novavax). The preclinical studies were done on hamsters and indigenous candidates. ICMR also supported preclinical studies in monkeys for Zydus Cadila Healthcare at ICMR-NIV , Pune.

WEBINAR PROCEEDINGS 47 Other studies in the pipeline include preclinical studies in monkeys of biological Evans vaccine candidates and preclinical studies in rats and hamsters of vaccine candidates of Reliance Industries. There are large volumes of published pre-clinical data for COVAXIN on mouse, rabbits and rats (iScience), monkeys (Nature Communications) and hamsters (iScience). Clinical trials have been published in the Lancet (Infectious Diseases) phase 1 (375 volunteers) and phase 2 (380 volunteers). Phase 3 has completed recruitment of 25800 volunteers. COVAXIN neutralizes the UK variant of SARS CoV2 is accepted for publication in the Journal of Travel and Medicine. The Indian SARS-CoV-2 Genomic Consortia (INSACOG) has been launched. Coordinated by the Department of Biotechnology (DBT) along with MoH&FW, ICMR, and CSIR, the strategy and roadmap of the National SARS CoV2 Genome Sequencing Consortium (INSACOG) has been prepared. The overall aim of the proposed Indian SARS-CoV-2 Genomics Consortium is to monitor the genomic variations in the SARS-CoV-2 on a regular basis through a multi-laboratory network. This vital research consortium will also assist in developing potential vaccines in the future. The consortium will ascertain the status of new variant of SARS- CoV-2 (SARS-CoV-2 VUI 202012/01) in the country, establish a sentinel surveillance for early detection of genomic variants with public health implication, and determine the genomic variants in the unusual events/ trends (super-spreader events, high mortality/morbidity trend areas etc.) SARS CoV2 Variants UK Variant (B.1.1.7) has been isolated and cultured. Research has been published on this in the Journal of Travel Medicine and the team found neutralization potential with the UK variant matches with other heterologous virus strains in India. The ICMR is still attempting to isolate and culture the South Africa Variant (B.1.351) of SARS CoV2. The Brazil variant (P.1 lineage) virus strain has been successfully isolated and cultured at ICMR-NIV, Pune. Experiments to assess vaccine effectiveness are underway. Repositories, Registries and the National Task Force Biorepositories for COVID-19 have the objective to well characterize samples for R&D for developing indigenous diagnostics, therapeutics and vaccines in line with the ‘Make in India’ initiative.

48 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 The clinal repositories for COVID-19 have the objective to develop a digital COVID-19 registry to collect data related to clinical features, lab investigations, treatment and outcomes of patients. In March 2020, the government of India established a National Task Force on COVID-19 having the main responsibility of: 1. Calibrating testing strategy 2. Advising government on lockdown and containment strategies 3. Develop advisories on discharge policy 4. Provide oversight for ongoing research 5. Recommend on required clinical trials (drugs/vaccine) 6. Explore newer, repurposed 7. Treatment options 8. Develop clinical management protocols

Kerala’s Response to COVID Team led by Dr Rajan Khobragade (Principal Secretary, Health & Family Welfare, Govt of Kerala) including Dr Sakeena (District Medical Officer - Malappuram), Dr Sandhya R (District Surveillance Officer-Kollam), Dr Raman V (District Program Manager, NHM, Kasaragod), Dr Dilipkumar, General Manage, KMSCL & Dr Aravind R, Member, State Medical Board. Dr Sakeena (DMO - Malappuram) mentioned that Kerala was the first state affected by COVID-19 pandemic in India and it successfully flattened the curve of the pandemic with - testing, quarantine, isolation and treatment. Even attention to food supply and medicine for migrant laborer was given. When the COVID alert came in January 2020 the State had a unique response of opening COVID control cells. Medical teams were deployed, training and alert to the health team was done, a daily follow up of international travelers and field surveillance was done by rapid response teams with people from the community. Multidisciplinary teams were formed for contact tracing cells. New testing centres were started in strategic locations. The system was ready when the first case got recorded in the State. There was a flight crash and had a possibility of a larger outbreak but they could contain it. Decentralized planning of human resources and infrastructure is mentioned as the key component. Strengthening of public infrastructure offered an opportunity to strengthen public facilities, training and capacity building of critical care management, continuum of care through covid treatment care and covid hospitals, IEC materials on ‘break the chain’ campaign, walk in testing centres, District Project Support Management Units under the DDMA under chairmanship of DC - which did transportation and

WEBINAR PROCEEDINGS 49 referral of serious patients. Dr Sandhya R (DSO - Kollam) stated that they had quarantined all the travelers from Wuhan and the other countries - they did symptom surveillance and picked up the first case on Jan 30th 2020. The sample was sent to NIV Pune, later they started doing it in the state’s NIV. There are 2245 labs all over the State testing. There are walk-in testing in private labs. Routine testing facility is going on in labs - there is the sentinel surveillance facility, the sero surveillance facility, and cluster containment strategy and the ILI surveillance. In Sentinel surveillance category - the most vulnerable ones are tested - the HCWs, police, migrant, unorganised sector workers. She shared a success story around this in Kollam where through sentinel surveillance a HCW was detected positive and a detailed contact tracing done for the past 14 days regarding her travel and traced all her 8 contacts and were contained. The cases were contained at that point. For 15 households there was one government servant who would form a social group and people in quarantine would be kept in that area and their needs be taken care of by them. She emphasized on good surveillance, contract tracing, testing, cluster containment activities, ILI testing - and mentions that Kerala is in the right path of containing the disease. Dr Raman V (District Program Manager, NHM, Kasaragod) mentioned the two major challenges faced by every district in the State - one was on arranging facilities to manage Covid suspects and cases and how to manage human resources. The State had prepared and planned well for the pandemic. He highlighted that Kerala is the only State in the country to have the 5-tier structure of COVID management - COVID care centers, COVID second line treatment centres (managing mild asymptomatic treatment), COVID hospitals, COVID first line treatment centres and COVID domiciliary care treatment centres. He mentioned that the district hospitals have been converted into COVID hospital without disrupting the routine functioning - by decentralizing the internal processes, by PPP and telemedicine and delivering medicine of chronic patients at their houses. For those - such as in tribal areas - there were no facilities for home isolation, they were taken to COVID domiciliary care centers where they were provided free treatment care. He also showed a table that showed the number of beds available over a year which is around 2 lakhs. These beds are in addition to what is available in the regular health systems. This helped manage the case load and prevented the health system from collapsing during the pandemic. He also highlighted four strategies for HR management - HR pooling, rapid recruitment of staff, COVID brigade programme, psychological

50 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 support to frontline workers (tele counselling and celebrity chats). Government created more than 1000 posts and filled existing vacancies. Additionally, the government has posted more than 14000 of COVID brigade of 85 categories. Kerala brought together past experiences, improved healthcare system and decentralized governance to overcome the challenges. Support from the local self-government and the Police was received too. Dr Dilipkumar, General Manage said that KMSCL already had an Emergency Plan of Action because of experience from NIPAH and Kerala flood in 2018. There is institutional buffer stock which was used during the initial surge of cases. He cited a few challenges faced during the pandemic - global supply chain disruption being the first one. Space and HR constraints were there. Supply collaborations, pre- procurement sample evaluation by experts, intelligent work flow, etc. helped in overcoming these challenges. The State has been increasing lab tests, critical care amenities, setting infrastructure, quality staff and good PPE for them. ‘Preparedness and practice are the backbone for everything’, ‘built for today ready for tomorrow’ and ‘acting with speed and confidence however bad the situation is. Dr Aravind mentioned that despite Kerala having demographic vulnerabilities such as high elderly population, and diabetes and hypertension, the case fatality to COVID-19 rate remained pretty low at 0.4%. The sero-prevalence in Kerala in December is 11% i.e., half of India’s average. This was achieved by coordinated action. The State medical Board came out with all the policies - testing, medical management, logistics and resource mapping, adoption of best practices and probability-based modelling, and SWOT analysis. The HCW mortality in Kerala is lowest in the world i.e., 0.06%, cumulative death analysis - and for people above 100 years age the CFR is 6%. Seamless transition from homecare to the ICUs has been made possible by decentralised and centralised nature of response. Psychosocial support was offered to patients - 70 lakhs were calls made to patients in quarantine. Dr Rajan mentioned that a protocol was decided in 2019 for a mock drill to handle epidemic outbreaks - and conduct a mock drill a year. This was planned after going through case studies of mock drills from Israel and Japan. He also mentioned about the Aardram and Jagrata campaigns empowering people in 2019 itself. He emphasized on ‘active’ action and not ‘reactive response. Evidence based dynamic action is taken, and that strategies are changed based on data which are locally specific. He focused on 3 key points as the way forward - surveillance strengthening for variants and immune escape cases, prevention of community spread and vaccination.

WEBINAR PROCEEDINGS 51 Crisis leadership & Workforce resilience

e talked about the center for army leadership model in the context of running of the Staff College for leadership in healthcare - he Hsaid Kerala has set an example of a similar course of action. He set the context with three intersecting principles - definition of purpose - clarity of plan, appropriate decision-making and risk management, and at the level of an individual - looking after ‘your people’ and ‘look after Dr Ajit Abraham yourself’ and ‘be a leader with integrity and humility’. He highlighted acknowledged the importance of creating psychological safety, and importance of the outstanding followership as much as leadership and the need to learn from mistakes. response of Kerala He highlighted a key point in which NHS has responded to the crisis to COVID-19 and said there’s much for is - it is impelled to move away from a top-down approach to a mission the UK to learn from command approach and with far greater reliance on quality of leadership Kerala - this is cited as a welcome change. Decision making has been moved to the frontlines. He also highlighted five paradigm shifts in thinking - recognition of inequality and its impact on health outcome, lasting reform in social care, need to improve collaboration with the community, put the workforce at the centre-stage, accelerating digital change and reshaping relations with communities and public services. He then presented a schematic of a plan of resting and repatriating those redeployed followed by reflection and recovery before restoring services. Integration of quality improvement - to develop staff resilience - from as basic as providing food to providing psychological support to the staff. Mindfulness and yoga sessions are also provided to the staff using the RAIN method. Competency training, supervision, linked health and wellbeing, equitable identification of staff for deployment, communication have been big learnings from Surge 1 of the pandemic.

52 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Panel Discussion Pandemic & Preparedness

• A year ago, we were just beginning to think about vaccines. Currently, we are in a situation where some vaccines have already been rolled out. Such a short turnaround time has never been witnessed before • While promising, the short timeline raises concerns among people, and it becomes important to understand and answer questions pertaining to the safety of vaccines • It is important for the scientific community to communicate what is Dr Gagandeep known and what is not known so that the public understands how Kang decisions pertaining to the vaccination are made The Wellcome Trust Research The landscape Laboratory, Division of Gastrointestinal Sciences Christian Not yet in Safety and Expanded safety/ Approved for Efficacy Medical College, human trials dosage immunogenigenicity use Vellore

Licensed 4 (Pfizer, AZ, Pre-clinical Phase 1 Phase 2 Phase 3 Moderna, 200+ 37 20 6 Gamaleya) +2 (Cansino Bio, Sinopharm)

In May 2020, CEPI estimated a production Four abandoned vaccines (post-phase 1) capacity of 2-4 billion doses in 2021 Limited use EpiVacCorona Estimate now-up to 6-9 billion

• The landscape of vaccines is varied. The safety and dosage of vaccines are tested following which, the immunogenicity and safety is expanded. Lastly, efficacy is tested before they are approved for use. • There are over 200+ vaccine candidates in the pre-clinical phase, 37 in phase 1, 20 in phase 2, 6 in phase 3 and 4 that have been licensed

WEBINAR PROCEEDINGS 53 for use. There were 4 abandoned vaccines (post phase 1) limited use EpiVacCorona • It is important to understand how much vaccine can be made. In May 2020, CEPI estimated a production capacity of 2-4 billion doses in 2021. Current estimates are up to 6-9 billion. Actual production is likely going to be the lower limit of that figure (around 6 billion)

• There are different types of vaccines – Vaccines that are based on virus like particles, recombinant DNA, vectored vaccines, DNA and RNA Vaccines. • In the case of SARS COV-2, the spike protein is what is being focused on. We are focusing on this because the virus has morphonology similar to the previous outbreaks of SARS (2003) and MERS. • RNA vaccines focus just on the ‘message’ and not on the production of the entire virus in the body, they are hence quicker to develop

54 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Vaccines in use

• Currently, as per the vaccine scenario, India ranks 4th, US, China and UK being ahead in terms of absolute numbers of total vaccines administered. The rate of vaccination in India is 0.1 in 100 people

• Maximum vaccines have been administered in UP, North and Central India

WEBINAR PROCEEDINGS 55 • However, when we look at how many vaccines have been given per million people, there is still a way to go. India has currently administered merely 8,522 vaccinations per 1 million people Dr. Kang then proceeded to answer the 10 most common questions pertaining to vaccines:

Q.1 What is the correlation of protection? Given the fact that we are going to be giving many vaccines and we don’t have the capacity of performing phase 3 clinical trials, it is important to answer this question. This is going to become even more important in light of mutant strains.

Q.2 What are the long-term safety considerations for vaccines? Most vaccines are very safe in the long term, but it needs to be documented

Q.3 How long will the protection last? It is currently estimated that protection may be up to 1 – 2 years but until measurements of reinfections and vaccinated populations are done, it cannot be conclusively stated

Q.4 & 5 Do vaccines protect against infection and do they decrease transmission?

56 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 There are indications that for some vaccines, there is a reduction in transmission. In case of the AstraZeneca vaccine, early data indicates that there may be some protection against infections. But for many vaccines currently in use, data from the phase 3 clinical trials is not available and further research is required to understand this

Q.6 Which vaccine is the best? All vaccines are meeting the bar that WHO had set (i.e. >50% efficacy in phase 3 efficacy trails). Vaccines where programs have been abandoned have been done so at earlier stages.

Q.7 Should previously infected people be vaccinated? This could be supported based on our understanding of immune responses but further studies are needed. France, for instance, has decided to give a single dose to people who have a history of infection.

Q.8 Will vaccines work in the elderly? All vaccines work less well in elderly. Germany and some other countries aren’t vaccinating the elderly.

Q.9 Can vaccines be mixed in a multi-dose schedule? The UK is currently conducting studies to answer this question. Similar studies are required in India also

Q.10 Will vaccines work against variant strains and how frequently will we have to change vaccine formulae? • We already know that some variants (UK) vaccines are working. However, in others (South Africa Strain), results are different. Over time we will understand how frequently we need to change. • Moving forward and looking ahead, it is important to understand that a lot has been done; a lot more has to be done in terms of surveillance capacity. Kerala govt. has established an institute for virology in addition to announcing new institutes across the country. This is a welcome step. • We need to think about building resilience and equity in health. By focusing on these tools for the next pandemic, we may even have a vaccine in as less as 6 months.

WEBINAR PROCEEDINGS 57 erala has taught the rest of the Indian states how to be proactive. It was able to anticipate virus inflation, quarantine effectively, Kimplement contact tracing, solicit and encourage people’s participation, ensure that both public and private health companies worked smoothly and eventually, flatten the curve • However, with the currently ongoing second wave, it is important to understand what is needed and what can be done Dr. Jacob John Virologist and • In the absence of public surveillance in India, we are totally in the former professor dark about the real numbers in India, the magnitude of the epidemic at the Christian and the total mortality. Medical College, Vellore • Kerala can continue to play a leadership role by model building and upscaling models. But it is important to answer how we may balance science, logic and evidence within health management? • Healthcare demands evidence-based responses. However, evidence-based responses are re-active, not proactive. However, public health needs to be proactive and anticipatory. Kerala instinctively adopted the later approach. Partly due to its experience with its successful handling of the Nipah Virus outbreak in 2008 • Health management requires 3 elements in modern medicine: 1. Public health 2. Healthcare 3. Research • Kerala can design and demonstrate the profit associated with investing in public health. In 2011, the Kerala govt. allotted 110 million rupees for creating a health protection agency through a proposal that was written by Dr. Jacob and one of his colleagues. However, for a decade, this fund has remained unutilized. • A health protection agency is synonymous with public health. A health protection agency would introduce surveillance which has been missed partly in almost every state (including Kerala). Surveillance is necessary for better preparation for controlling not only pandemics but also endemic diseases such as typhoid, hepatitis, etc. • Once we have created such a platform, we would be able to better prepare for pandemics in the future • Kerala is vulnerable to many zoonotic diseases particularly because of its location in the shadow of the Western Ghats. There is a need to adopt the One Health Approach toward preventing disease outbreaks. There needs to be a lead agency to foster this operation and the aforementioned health protection agency can assume a leadership role in creating such an approach.

58 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 e need to ensure preparedness momentum generated by COVID – 19 is not lost. We need to ensure we don’t not Wperpetuate the cycle of panic (during the time of crisis) and neglect (during times of peace) • This momentum would need to be matched by a deliberative analysis of the lessons of the pandemic. Many of the countries that have invested the most in preparedness have been the hardest hit Dr. David Wilson by COVID in terms of both cases and deaths. Program Director, • Countries with the highest WHO joint external evaluation World Bank preparedness scores: The US, UK, Netherlands, Sweden and France have also been the ones hardest hit by COVID in terms of cases and deaths • In a lot of instances, public health and epidemiological interpretation has been contradicted by unfolding experience. This isn’t surprising because of how rapidly the situation was changing. This is an unprecedented time • Countries that were feared to be experiencing a greater stress with respect to pandemic preparedness (E.g Africa) were less affected during the initial stages of the pandemic than feared. Conversely, the countries judged to be successes have experienced severe waves. • Countries of East Asia which had supervised quarantine since the outset of the pandemic have fared better too

The lesson that we can learn is to act early and act fast. • Science has been the standout star in the pandemic. Investments in science have reaped enormous and fast benefits. For instance, the virus was gene sequenced within weeks of being discovered which led to the rapid vaccine progress that followed • In terms of global responses, manufacturing and supply chains have been relatively less successful. The global supply chains are very concentrated and fragile. This was exemplified during the manufacturing of PPE and now again for vaccines. This may change in the time to come as more countries require vaccines for their own COVID 19 variants and would be reluctant to manufacture thousands of miles away • There is a need for a pandemic surge capacity in core public health functions to track, trace, quarantine, isolate, and treat. There is also a need for better surge capacity in urgent and intensive care. This could be provided by multi-skilling existing health workers ensuring their preparedness skills remain refreshed and current

WEBINAR PROCEEDINGS 59 even during times of peace. This would be an important post-COVID priority for health systems • Health systems that focused successfully on the moral mandate for providing UHC were not necessarily best prepared to return to core public health functions in times of the pandemic • We need a greater global genomic capacity. Currently, the UK does >50% (210,000 genomes) of the world’s genomic surveillance. South Africa does nearly all of Africa’s surveillance. It is then unsurprising, that these countries have found variants of concern that have become associated with them. The UK has identified more people with the variant strain that was identified in Nigeria than Nigeria did itself • There is a greater need for coordinated crisis response in governments for disasters emergencies and pandemics. This needs to be a core government skill and we need crisis response institutions.

60 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Fighting Pandemic: Experiences by Districts Administrators, Kerala

• Guiding principles in Trivandrum’s strategy were Test early, Trace completely and Isolate Effectively • In order to conduct dynamic surveillance, the district studied the geography and demography of the district, where the populations were vulnerable in order to assess epidemic status. The District was divided into containment and micro containment zones • It took 8 months for cases to peak in the district (March – October) Dr Navjot • This gave 8 months of preparation time to the district for preparing Khosa IAS infrastructure and taking stock of preparedness District Collector • The peak was short (<13 days) and has shown a declining and Thiruvananthapuram plateau since then • Reverse quarantine was done because 15% of the population in the district are 60 above and very vulnerable to the virus

Surveillance zones in Trivandrum District

Thiruvananthapuram district was divided into five surveillance zones: 1. Coastal Zone 2. Corporation Zone 3. Rural Zone 4. Zone with interstate border (South Thiruvananthapuram) 5. Tribal Zone

WEBINAR PROCEEDINGS 61 CONTACT TRACING

• Contact tracing at District Level > 25 member team in war room • Tracing done up to Secondary Level • Focus on Route map with time stamp preparation for all unlinked cases. • Extensive capacity building for peripheral health institutions - effective decentralisation • Testing, tracing and isolation of contacts ensured.

• Contact tracing began in March • Route maps were put in public domain; people were encouraged to read and assess if they had been exposed. This helped with community engagement during the early stages of the outbreak • July – August – focus shifted towards Capacity building

CLUSTER MANAGEMENT AND CONTAINMENT

• All possible clusters identified by presence of unlinked cases and potential of spread. • Focus on breaking the chain of transmission. • Containment/micro containment zones were regularly identified and mobility restrictions imposed. • Evaluation of containment zones were carried out twice weekly and decision on extension or withdrawal carried out.

62 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 hese were the different elements of COVID – 19 management in the district. Experience with the handling of Nipah virus outbreak Thelped in assignment with these nodal wings

Training & Call Centre Surveillance HR Management Awareness Management Generation Mr. Suhas S IAS IEC/BCC Private Hospital District Collector Travel Surveillance Sample Tracing Documentation Management surveillance Ernakulam

Transportation & Community level Interdepartmental Psychological Contact Tracing Ambulance volunteer coordination Support Management Coordination

Tracing course of Expert Study Finance Infrastructure Data Compilation Epidemic Coordination Management Management

District COVID-19 War Room

• Interventions were planned and conducted as per daily assessment • Innovations were documented across the verticals of Sample management, patient transport patient management, data management

• The district established Walk in sample collection kiosks (WISK) – for the collection of specimens. This helped Minimize PPE usage, overcoming limited space constraints and in optimizing HR deployment

WEBINAR PROCEEDINGS 63 • A Designated mobile collection Team (DMCT) was deployed to cater to bedridden and elderly populations • District Mobile Medical Units (DMMU) were also deployed for catering to COVID and non COVID health needs of patients – geriatric, palliative care, etc.

• As per state orders, Ernakulam was the first district to set up Domiciliary Care Center for asymptomatic patients across all panchayats in the districts • First Line Treatment Centers (FLTCs) were piloted and were extensively employed for patients with minor symptoms – that did not need to be admitted – This ensured care of patients under the Covid Category A at peripheral level. This reduced the load on Covid centers • Second Line Treatment Centers – COVID patents with secondary symptoms (Category B-A) were also set up. This ensured sufficient beds at peripheral level and reduced loads at main COVID hospitals

64 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 • The KarmiBot initiative companion for COVID – 19 diagnosed patients - Basic delivery of food and amenities were handled by robots – This helped with employment of skilled HR in other places across the hospitals and patient care • The Integrated supply of PPE and medical equipments initiative Ensured COVID – 19 compliance

WEBINAR PROCEEDINGS 65 • For patient care, an erstwhile shutdown hospital was converted into a COVID – 19 apex center and establishment of the CARE Platform – monitored Covid 19 transports • In conjunction these led to a lowered Case fatality Rate (CFR) and the proper management of life saving equipment like ICUs and Ventilators

he emphasized that Wayand has a high tribal population, low health infrastructure and has to deal with Border populations SThe Care and support within the district were divided into: • Health support • Community Support (Community kitchens) • Tribal Support Dr. Adeela • Job Support Abdulla IAS District Collector • Support for persons living with COVID Wayanad Success of the Wayanad district was outlined as follows: • The entire district macheiry worked as a single team • The district was successful in bringing all essential needs to the doorstep of the people • Panchayats were made to take the ownership • Commercial activity and job security were ensured

r. Raman Gangakhedkar presented an epidemiology analysis and next steps for control of the COVID – 19 pandemics. At the Doutset, Dr. Raman emphasized that these are individual views based on evidence and interpretations. • Most countries are showing a decline in the number of COVID – 19 cases and within in a month, perhaps the most precious period to Dr Raman control the pandemic will begin. Gangakhedkar • While most states across India are also showing a decline in the Head of Epidemiology (Rtd), number of cases, the national curve can mask the heterogeneity ICRM Govt of India • Maharashtra and Karnataka appear to be different in their confirmed cases and testing statistics.

66 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 MAHARASHTRA DAILY CASES CURVE & DAILY TESTS DONE - COVID-19 INDIA

Tested Tested 17 February 17 February 3,405 +190 49,517 +1516

KERALA DAILY CASES CURVE & DAILY TESTS DONE - COVID-19 INDIA

• A stronger adherence to lock-down coupled with strong public health measures may have prolonged the first wave in Kerala • But new variants that spread rapidly or escape vaccine induced immune response can pose additional challenges. The SARS COV2 tends to mutate slowly compared to HIV and influenza. Transmission dynamics are complicated • 2 possible reasons why SARS COV2 could be mutating could be: Due to the repeated use of convalescent plasma and infection among immunocompromised hosts • Genomic surveillance was started by ICMR in March 2020. It has since expanded now with DBT and DST labs under NCDC. However,

WEBINAR PROCEEDINGS 67 with a large caseload, there is uncertainty if India has mutant strains • Also, there is early evidence which suggests that escape mutants may evade the immune response from certain vaccines. Whether or not this is going to be a threat, time will tell. It might not be • Nonetheless, International travel guidelines have been made more stringent recently. As long as the numbers are small, their isolation and contact tracing has been done. Whether or not these measures will ensure that variants will not challenge us remains to be seen. The more the number of cases, the more likely the virus is to mutate. We should avoid the use of convalescent plasma(?) • The bigger challenge is sustaining and adhering appropriate COVID behavior. According to data from the IHME, mask use has fallen from 71% from the start of the pandemic to 64% currently and observed reduced mobility has fallen from 42% to 23% only. This would be particularly challenging in light of the lockdown lifting and reopening of schools, colleges, etc. • Strategies for lifting the lockdown would likely differs there are differences in the levels of the outbreak in smaller geographic areas, size of social networks, adherence to COVID appropriate behavior and quality of implementation • A decentralized approach is vital for implementing one or more appropriate strategies, there needs to be monitoring of opening of schools and colleges. Surveillance is vital. Prompt closures of institutions following the identification of positive cases is also vital • It is also important to promote COVID appropriate behaviors among the migrant populations • MOST importantly, we should focus our efforts and base our strategies on the pillars of: Test, Trace, Isolate and Treat • Rapid vaccination and vaccine acceptance is essential • What needs to be strengthened is community mobilization and Group Specific communication as to why COVID appropriate behavior needs to be encouraged. Peer based approaches to information and adherence are vital. The involvement of key opinion leaders across different strata are important. There also needs to be development of an ideal demonstration field site that has complete package of intervention including vaccines • Lastly, there needs to be recognition of the fact that maintaining the health of people is not merely the government’s responsibility. But also, of the individual and broader community.

68 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 DAY 03 Achieving SDGs related to MMR & IMR–Dream or Reality?

mt. K.K. Shailaja in the opening remarks said that Kerala’s IMR was at 12 out of 1000 live births in 2015, but the state had aimed Sto reduce it to a single digit. It was brought down to seven in 2019, and according to the latest NFHS survey, it had gone below five, she added. The state’s concerted efforts were acknowledged by the Centre as it was awarded for reducing MMR below the level declared by the UN and for achieving the lowest MMR in India. Smt. Shailaja said several Smt. K.K. Shailaja path-breaking initiatives were put in place by the state in this respect in Hon. Minister for the last five years, and more would be done based on the discourses that Health, Social ensued at the webinar. The state, she said, aimed to achieve its target of Justice, Women and MMR 20 by 2030 and become a model in this sector as well. Child Development, Govt. of Kerala

e Set the tone for the session on ‘Achieving the SDGs related to maternal and child health’ by drawing parallels between India’s Sposition on under-5 mortality and maternal mortality with South Asia and the Global rate from 1990 to 2005. Dr. Rutter succinctly outlined the five keys to acceleration -- Strong focus on increasing the coverage of key interventions, quality, primary health in all its three components, investment, and learning and sharing. Dr. Paul Rutter Regional Health While enumerating the need for data-driven obsession with improving Adviser for South the coverage of key interventions, he also listed the components of Asia, UNICEF

70 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 delivering quality service through availability of essential medicines, evidence-based clinical interventions, adequate infrastruture, motivated staff and solid documentation. While lauding Kerala for it endeavour in reducing MMR and IMR through community engagement, social accountability and leveraging decentralised governance to improve quality, Dr. Rutter called attention to the pressing learning agendas of increasing private sector role and engagement, and considerable investment in systematic quality improvement.

WEBINAR PROCEEDINGS 71 MMR Reduction- Kerala Experience

MR reduction-Kerala Experience was shared by Dr. V P Paily, State Co-ordinator Confidential Review of Maternal Health M& Senior Consultant Rajagiri Hospital Aluva.. While lauding the state for achieving the MMR of 29 in March 2020, he called on all stakeholders to work towards sustaining it. He added that the prime factors for low MMR in the state were female literacy, institutional delivery, a large number of health centres of various standards, easy Dr. V P Paily State Co-ordinator transport and willingness of people to spend on health and education. Confidential Dr. Paily also shed light on the downside of the system, owing to large Review of Maternal inaccessible areas in the state, tribal population and private hospitals Health & Senior not being under the government’s direct purview. He also enumerated Consultant Rajagiri Hospital Aluva how a partnership was developed between the government, private healthcare providers and the professional organization KFOG (Kerala Federation of Obstetrics and Gynecology), and an order issued by the state to all the hospitals to hand over anonymised copies of case records of all maternal deaths to KFOG for auditing. He added that the principle of MDSR (Maternal Death Surveillance and Response) suggested by WHO was followed by the state to identify the leading causes of maternal deaths. Dr. Paily concluded by sharing that efforts to bring down MMR should be a dynamic ongoing process because though women giving birth change, doctors and nurses change, but the system should prevail.

72 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Experiences on MMR reduction with regard to Kerala.

r Remla Beevi, Director Medical Education, Govt. of Kerala, succinctly spoke on ‘The Medical Education Sector: Its role in the DMMR reduction drive’. She said there had been a collaborative effort between the Directorate of Medical Education, the private sector and Directorate of Health Services. Dr Beevi then charted the journey thus far with special reference to ORRT (Obstetrics Rapid Response Team), training, protocols and auditing, which contributed to achieving the MMR targets set by the state. The role of medical colleges in the implementation of Laqshya project was also highlighted, along with the long-term plans laid out by the state.

r. Krishnaveni, RCH Officer, Kollam Field functionalities began his presentation by detailing how the state was addressing Dadolescent anaemia. She highlighted the robust primary healthcare system that was put in place to strengthen antenatal care and all the 98 delivery points in the government sector in Kerala. Shee spoke about the measures undertaken to improve infrastructure, treatment facilities, equipment, training of service personnel, quality standards and infection control measures.

WEBINAR PROCEEDINGS 73 IMR Reduction–Experiences from Kerala

MR reduction- Experience from Kerala was presented by Dr S S Kamath, Former National President Indian Academy of Pediatrics. IThough IMR in the state had reduced considerably from 58 in 1997 to 12 in 2011, the numbers had been largely stagnant since 1991. Some of the challenges, he said, were conflicting figures from different sources of data, regional variations, deaths occurring in transit or outside the institution in the periphery and problems in ascertaining the cause Dr S S Kamath Former National of death. Dr. Kamath then elaborated on the three main causes for President Indian IMR — prematurity, congenital anomalies and sepsis. He also listed Academy of the path-breaking initiatives of the state to reduce IMR through new- Pediatrics born Metabolic Screening programme, Sepsis Management, training for birth asphyxia prevention, infant death audit, Hridayam project - diagnosis and management of heart diseases, JSSK programme for free treatment, Mathruyanam for free transport management of disability and immunization campaign – ‘Immunise Kochi’. He concluded with the war cry that the state would put in all it could to ensure that ‘Every child in the state is able to celebrate his/her first birthday’.

74 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 IMR reduction: Field success story to bring in connect of policy with the interventions

r Saritha R L, Director Health Services, Govt. of Kerala shed light on the field-level activities undertaken through multi-purpose Dhealth workers and ASHA workers who provided uninterrupted services for IMR reduction. She briefly highlighted the state’s supported- breastfeeding techniques and the state-of-the-art milk bank started in Ernakulam. She added that special medical camps were set-up for guest workers to educate them so that their infants too could enjoy all the health benefits provided to other children in the state.

r Srihari State Nodal Officer Child Health, NHM Kerala, spoke on the institutional-level activities carried out in the state to Dreduce neonatal and IMR. He said the state had strengthened infant death reporting, review and audit, and was addressing the causes of avoidable infant mortality. Dr Srihari then spoke of the patient-care continuum which followed the process of recognition, diagnosis and prioritization, referral, stabilization and transport, treatment and follow-up. He briefly spoke of Shalabham, an initiative focussing on quality survival.

WEBINAR PROCEEDINGS 75 Panel Discussion: ‘Accelerating the reduction of Maternal & Infant Mortality in developing countries’

rof. Richard Cash, Harvard T H Chan School of Public Health, USA provided a global perspective on ‘Accelerating the reduction of PMaternal & Infant Mortality in developing countries. He set the tone for the discourse with the factors that led to the slowing down of MMR and IMR in South Asia. Though not rapid, the slowdown was progressive, he said. Dr. Cash added that apart from a robust healthcare facility, several external determinants too contributed to the steady downward Prof. Richard movement, like education, family planning, increased number of women Cash Harvard T H Chan in the workforce and higher legal age for marriage, to list a few. While School of Public lauding countries faring well on the MMR and IMR indices, Dr. Cash said Health, USA we couldn’t solely depend on the healthcare system to sail us through, but other determinants of health like preventive medicine too had to pitch in because the health system could only take us so far, but much improvement must come from all the other contributing factors.

r. Vivek Virendra Singh, Health Specialist, UNICEF India extolled Kerala’s incredible health machinery, and called on other states Dto take the cue. While stating the factors that led to the decline of IMR, Dr. Singh said the advent of the National Rural Health Mission and fiscal inputs in health were major contributors. He added that ‘taking health to people’ had been an exemplary initiative for the corresponding low IMR in Kerala. Adding to Dr S S Kamath’s war cry, Dr. Singh said since Dr. Vivek Virendra Singh Health Specialist, 76 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 UNICEF IMR had reached 10 and neonatal was at eight, we must pledge that every child is not only able to see his/her first birthday but should do so with the best of developmental milestones. He added that it could be achieved by just the right concoction of social security, community empowerment and local governance. Our next focus should be equity, Dr. Singh said, while adding that with UHC we could help achieve health-related SDGs. He concluded with the Decade of Action 2030 plan to mobilise everyone, demand urgency, and design new innovations and solutions.

r Ahmed Reza Hosseinpur, Health Equity Monitoring Lead, WHO Geneva bifurcated his session into two — Health inequality Dmonitoring and live demonstration of Health Equity Assessment Toolkit (HEAT). Health equity monitor, the largest equity database, he said, was a platform for data disaggregation and health inequality monitoring. Launched in 2013 and updated annually, Dr Hosseinpur added that the database covered 30 health indicators, mainly maternal Dr Ahmed Reza and child health. This was followed by a live demonstration of HEAT Hosseinpur that enables exploration and comparison of within-country health Health Equity inequalities across countries. He added that countries should use the Monitoring Lead, WHO Geneva toolkit optimally to find surveys and indicators, and consequently plan for health points that needed priority and action.

r. Rakhi Dandona, Professor, Public Health Foundation of India spoke on infant mortality and neonatal mortality, and what Dneeded to be done to reduce it further from the single digits that we already had achieved. She delved into the details on Mortality burden, Inequity, Cause of death and Morbidity. She highlighted how community participation, perception and integration, education and welfare service were of paramount importance in bringing down IMR. Dr. Rakhi Dandona Professor, Public Health Foundation of India

WEBINAR PROCEEDINGS 77 DAY 04 DAY 4

Meet the SDGs–Beat the NCDs

This was followed by a brief question and answer session with the panellists led by Dr Santhosh Kumar, Chair, State Medical Board, Kerala

Context The last decade has witnessed rising burden of Noncommunicable Diseases (NCDs) worldwide and it is estimated that in India, NCDs such as diabetes, heart disease, and hypertension account for more than 60 percent of deaths in the country (ICMR, 2017). Further, as per the recent Comprehensive National Nutrition Survey (CNNS) report, one in ten school-age children and adolescents are pre-diabetic and a high percentage of them have deranged lipid profile (34% and 26% of school age and 16% and 28% of adolescents have high serum triglycerides and low HDL levels respectively) – major risk factors for NCDs. Therefore, it is felt that there is an urgency to arrest and reverse this trend among adults, youth and children in the country. Objective The objective of the conference was to bring together the national and international experts, policy makers and practitioners to deliberate, share experiences and facilitate cross learning to fight the rising incidence of non-communicable diseases (NCDs).

WEBINAR PROCEEDINGS 79 Summary/ Key Takeaways On February 25, 2021, Representatives of the Ministry of Health, delegates from various national and international organizations, technical experts from across the globe, researchers, civil society and other stakeholders came together for a dedicated session on NCDs during the 5-day Kerala Health Conference. The session was an attempt to reiterate the urgent need to focus on NCDs, the ongoing efforts in this domain, and the ways to integrate NCDs into health care structures. More specifically, the session deliberated around various approaches in practice and how lessons and information from these can be used to strengthen the national and more specifically Kerala’s response from the health systems. The conference particularly underlined the importance of a multi-sectoral approach to the mobilization and engagement of the stakeholders, the importance of the engagement of civil society, task transfer approaches to strengthen the capacities of the health system and the wider mobilization of resources. Key messages that emerged from the session specific to Kerala are as follows: • Although the state is at the forefront in fight against NCDs, strengthening of Primary Healthcare will be critical to halt/ reverse the trend. • Development of Kerala Cancer Strategy is an important step in improving the cancer care and treatment; the state needs to bolster the efforts in its effective implementation. • The state has numerous ongoing programs that require multisectoral engagement, hence, going forward multiple stakeholder engagement strategies will need to be strengthened. • Developing Human Resources for Health (HRH) especially for cancer specialists is another area that the state would need to focus in its fight against NCDs. • Innovations in leveraging the private sector in healthcare will be critical for expanding the services across the state. This report documents the proceedings of the session and summarizes the key messages conveyed during the sessions.

80 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Keynote address

r. Varghese opened the Conference by congratulating the State of Kerala for receiving the award for its “outstanding contribution” Dtowards the non-communicable diseases-related sustainable development goals recently announced by the World Health Organization (WHO). Reiterating the findings from the recent National Family Health Survey-5 (2019-20), Dr. Varghese expressed his concern and emphasized the need for sustained efforts in this direction. Key messages Dr. Cherian • Make healthier choices as easier choices. Varghese • (i) Strengthened regulations (especially for trans fats, HFSS foods, Coordinator NCD physical space for physical activity, healthier transport, air Management, WHO Geneva pollution); (ii) Bolstered legislation (reduce tobacco and alcohol availability); (iii) Differential taxation (making unhealthy products more expensive); and (iv) Health literacy are four critical actions for reversing the rising trend of NCDs. • Primary Health Care (PHC) management is critical and thus the state may consider placing a Public Health Officer in each PHC in addition to trained clinicians to specifically cater to NCD problems. • For cancer control enhanced focus on: (i) HPV vaccination and targeted screening; (ii) publishing survival rates for cancers; and (iii) Making case reporting mandatory from all facilities. • Attempt to establish Schools of Public Health which can offer Dual Degree programs including targeted focus on digital health education. • Focus on implementation research by creating ‘Learning Labs’ across the state to cater to population of 1 million. • Leverage and repurpose institutional capacity to meet the NCD challenge. • To address the challenge of availability of timely, reliable, validated and comparable health data, WHO’s SCORE (Survey, Count, Optimize, Review, Enable) Technical package may be leveraged to improve health outcomes in the state.

WEBINAR PROCEEDINGS 81 Achieving the SDGs related to NCD

r. Frieden congratulated the State for being at the forefront of Dr. Thomas R Frieden tackling NCDs in the country. He stated that high morbidity President & CEO, and mortality from NCDs leads to a large social and economic Resolve to Save D burden in low and middle income countries (LMICs). The projected Lives, Former cumulative lost output due to NCDs in LMICs is around 7 trillion USD Director CDC (2011-2025) which outweighs the cost of implementing set of high impact interventions (estimated to be around 11.2 billion USD). Hypertension is the leading risk factor for preventable deaths worldwide (10.7 m) and kills more than any other condition and more than all infectious diseases combined. Further, annually 3m deaths are attributed to excess sodium consumption. WHO’s “mpower” strategy was effective for tobacco control and the world needs similar strategy for reversing the trend of NCDs. [Monitor, Protect, Offer, Warn, Enforce, Raise]. It is the low hanging fruit which must be prioritized in the healthcare programs. Control of Hypertension and reduction in the consumption of Sodium are two effective strategies to bolster the fight against NCDs and which is critical for the State of Kerala as well. Key messages for Kerala State: • Only 1 in 8 hypertensive patients in Kerala have it under control which is similar to the global figure of less than 1 in 7 people with hypertension have controlled condition. • The key challenge for the state is to reduce the gap between those who are treated and those with controlled hypertension. More citizens need to be diagnosed and treated effectively. • “Treatment inertia” is another challenge that Kerala faces and that needs urgent attention by the State Health department. • Strengthening of Primary Healthcare is critical for providing effective hypertension treatment services. • Front of pack warnings, use of low sodium salts in processed foods, setting up food specific targets, Government buying standards and educating the public are few approaches for reducing the consumption of sodium in daily diets.

82 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 • There is also a need for a Public Food Procurement Policy for popularizing healthy nutrition standards for all food and beverages that are purchased, subsidized, served or sold by government agencies.

WEBINAR PROCEEDINGS 83 SPECIAL ADDRESS

he Minister of Health affirmed that health is a priority Kerala and congratulated the Department for having a focused discussion Taround NCDs. She reiterated that NCDs is a leading cause of mortality and morbidity not only globally but also in Kerala. Although the state is at the forefront of various health indicators, it is important to note that it is also the diabetes capital of the nation. Although the state has Smt K Shailaja good Human Development Index but is witnessing reduction in physical Hon. Minister for activity and lifestyle modifications is an important factor for the rise in Health, Social NCD levels. Justice, Women and Child Development, On the lines of global SDGs, the State has devised its own aims and Govt. of Kerala reduction in NCDs including intensifying efforts for cancer care and diabetes are the key. The state has developed cancer control strategy and efforts are on for devising population-based cancer registry, early detection and proper treatment. Further, the state is successfully running the “Amrutha Aarogyam” Scheme in an attempt to control and prevent NCDs especially the control of diabetes and its side effects. For controlling the pulmonary disorders, the PHC’s are upgraded to become Family Health Centers (FHCs) and have dedicated Chronic Obstructive Pulmonary Disease (COPD) clinic at each FHCs. Going forward, the state has planned to have enhanced focus on increasing the physical exercise and promote sports for children and adolescents in partnership with the Sports department. Reiterating the rising numbers of cancer, diabetes, hypertension and CVDs in the State, the Minister emphasized the State’s commitment to intensify efforts in controlling NCDs.

84 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Experience Sharing Session: Other NCDs

Kerala’s story of tackling NCDs r. Bipin Gopal described how Kerala is dealing with a high burden of NCDs. He mentioned that the state is undergoing Depidemiological transition, increasing urbanization and change in lifestyle that is leading to rise in NCD figures. The State has identified nine SDGs linked to NCDs and the efforts to achieve each of them is ongoing. Dr. Bipin Gopal India Hypertension Control Initiative (IHCI) is setup as a multi-partner approach to reduce hypertension and diabetes in the state. So far IHCI has over three lakh registrations. To manage the diabetes complications, Diabetic Retinopathy Clinics have been setup in 14 District hospitals, 168 FHCs and dialysis units and Diabetic Food Clinics have been setup across the State. Stroke units are functional in nine district hospitals and 14 Coronary Care Units (CCUs) are functional at district hospitals with more than 10,000 angioplasties done so far. The State has launched ‘SWAAS’ program to intensify dedicated efforts towards the control of COPD. For the first time such an initiative is launched under Primary Health care program and all the drugs and aerosols are provided free of cost. Further, the program has complementary services like counselling, early detection of tuberculosis and pulmonary rehabilitation. To tackle the challenge of physical inactivity, the State has started the School NCD program wherein BMI checking is done for all students; College Health Program and Workplace interventions are in place to promote physical activity, sports and yoga. Similarly, open gyms have been opened in all districts to promote physical activity.

WEBINAR PROCEEDINGS 85 Mental Health Program of Kerala r. Kiran shared the details of the Kerala’s Mental Health Program which started in the district of Thiruvananthapuram in 1999. DThe program has now expanded in all 14 districts of the state and conducts over 250 monthly clinics catering to over 45,000 patients. The program has five key activities including, (i) Clinical services at Dr. Kiran Community Health Centre (CHC); (ii) Provision of mental health training to primary care doctors, paramedics and health workers including ASHAs; (iii) Targeted intervention programs; (iv) IEC activities; and (v) Rehabilitation activities on community based days. Dr. Kiran shared that the state has dedicated targeted intervention programs for mental health and the details of each are summarized below: • Sampoorna Manasikarogyam: The program aims to find the undetected mental health case burden with the help of ASHA and regular follow ups are provided to reduce the treatment dropouts. The program is running successfully in over 350 FHCs. • Aswasam: It is an exclusive program for managing the depression among citizens. The program is run by the FHC staff and till date over 55,000 patients have been screened of which around 19,000 patients are found to have depression symptoms and currently over 6000 patients are on treatment protocol. • Amma Manass: It focusses on screening of stress, depression, anxiety disorders and other mental health issues especially among pregnant and nursing mothers during and after antenatal checkups. • Jeeva Raksha is the dedicated program for suicide prevention wherein high-risk groups for depressive disorders are screened at sub-center and intervention is given if required. Community gate keepers (elected representatives, doctors, police, teachers, religious leader) are the prime focus and eyes and ears of the program. Voices from the field r. Naveen & Dr Mathews shared experience of implementing NCD related activities at the district level wherein promotion Dof healthy diets and increase in physical activity were the key. He shared that all patients above the age of 18 years are screened for Dr. Naveen blood pressure at the district hospital. The hospitals are fully equipped DPM Kozhikode & Dr Mathews to undertake advanced diagnostics and provide high-quality treatment. Numpelil, District At each level of care, appropriate focus is given on actions that will help Program Manager, to tackle NCDs. Ernakulam

86 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 At FHC level, screening and lab facilities along with counselling and basic medicines are provided. Referral services and follow-up is critical at this level and efforts to strengthen the home care system is also underway. At CHCs, chronic disease management unit is setup with a team of trained doctors and paramedic staff. Monthly specialty clinics are operating to focus on specific NCD problems along with specialist inpatient and outpatient services. At sub-district hospital, along with availability of specialist doctor, imaging services, cancer early detection services, dialysis facility and hub and spoke model lab facilities are in place for the patients. District hospital provides super specialty services and special team of monitoring and coordination keeps an eye on the progress made on various NCD related programs and activities. Cancer Care In Kerala r. Nair presented an overview of the evolution of Cancer Care in Kerala – spanning from setting up of Regional Care Centre D(RCC) TVM in 1981 to development of 10 year action plan for cancer control in 1988 to launch of district cancer control program in 1991, setting up of Kerala Cancer Control Strategy in 2018 to release of standard treatment guidelines in 2019. Dr Rekha A Nair She elaborated on the various achievements that the state has made Director Regional Cancer Centre over five decades in the area of cancer treatment and prevention. The Thiruvananthapuram RCC has played pivotal role in achieving various milestones in this domain including, preparation of “Oral Atlas” for early diagnosis of oral neoplasia; establishment of first community oncology department in the country; low cost screening strategies for common cancers like oral, breast and cervix; establishment of pain and palliative network; setting up of telemedicine platform in 2004 and development of training manuals for early detection of common cancers. Dr. Nair also shared how innovative ways of reaching out to patients were tested during the complete lockdown period due to COVID-19. The Centre focused on running teleconsultations and virtual OPDs for follow up cases. Further, doctors from 21 peripheral centers were brought together as a virtual team and patients on active treatment were connected to the nearest peripheral center for receiving the treatment. RCC also innovated with transfer of data (in the form of case sheets and clinical summary) with the peripheral centers so that doctor could know the case-history and provide appropriate treatment accordingly. For

WEBINAR PROCEEDINGS 87 timely delivery of quality drugs, another innovation was tested during COVID times wherein Kerala fire and rescue servicers were leveraged for delivery of drugs. Patients informed these services about their drug requirement which was communicated to the RCC early in the morning, drug necessity was verified, and drugs were issued by RCC pharmacy to be delivered to the patient. Kerala Cancer Strategy r. Satheesan focused his address on the status of cancer care in the state of Kerala. He stressed on the need to reduce out- Dof-pocket-expenditure due to cancer and on improving the availability of quality care to the cancer patients. Quality of Data was another issue highlighted by Dr. Satheesan in his address and shared Dr. Satheesan B the details of the Kerala Cancer Control Strategy (2018-30) which aims Director Malabar to address the key challenges in this domain. Cancer Centre, Thalassery, Kannur Snapshot of Kerala Cancer Control Strategy: • Enhanced focus on Infrastructure development: 3 Apex cancer centers, 5 comprehensive cancer centers in government medical college and 10 in private sector, 3 cancer hospitals and 21 cancer centers. • Restructuring the infrastructure to create three-level distributed cancer care across the state right from primary health care to advanced and complex care. • Availability of dedicated action plan for the state: This includes formulation of Kerala Cancer Board, adaptation of standard treatment guidelines, Cancer Registry for the state, district level control program and cancer research strategy. • The state has developed a Comprehensive Kerala Cancer Registry and Cancer Care Board under the leadership of the Honorable Minister for Health and Social Justice. • The state is now focused for cancer research strategy by developing Cancer Research Incubation Centre in association with Kerala Start Up Mission. Cancer Care-Kerala Experience, Ernakulam District Cancer, Control Project K Mohammed Y r. Safirulla shared the strategy adopted by the Ernakulum Safirulla IAS District for cancer care. He mentioned that the cancer care Project Director e-Health Dprogram targeted three common cancers namely breast, cervix

88 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 and oral and focused on four key activities – (i) improving cancer literacy among professionals as well as citizens; (ii) awareness of early warning signs among primary care physicians; (iii) empowering specialists in diagnostics; and (iv) integrate cancer surveillance with palliative care network. At the district, each level of care was trained and sensitized about their specific role. A proper patient-management system and referral system was put in place for effective delivery of services. The program successfully trained over 700 healthcare workers and 80,000 members of public; over 600 biopsies were performed in six months and over 85 percent of patients with cancer diagnosis were contacted by community palliative care nurse. The Ernakulum district experience demonstrated that ownership by district authorities is critical for smooth functioning of the program. There is a need to have strong follow-up of patients especially through digital platform which will be critical for linking the diagnosis with cancer registry.

WEBINAR PROCEEDINGS 89 PANEL DISCUSSION

Prevention of Cancer through Primary Health Care

Moderator: Mr. Moni Kuriakose, Director, Cochin Cancer Research Centre Discussants: Dr Sankara Narayanan Senior Visiting Scientist, WHO - IARC Lyon France; Dr MV Pillai Professor of Oncology, Thomas Jefferson University of Philadelphia; Dr. Anil D Cruz President Union for International Cancer Control; Dr Richard Sullivan Professor, Cancer and Global Health, King’s Institute of Cancer Policy and Co-Director of Conflict and Health Research Group; Dr Arnie Purushotham Director Kings Health Partners, Integrated Cancer Centre London The session shared global experiences and learning in strengthening the Primary Health Care for Cancer treatment and prevention. It brought together experts from developed and developing world to cross-fertilize the ideas and learnings for strengthening the cancer care in Kerala.

rofessor Sullivan shared six principles/ learnings that Kerala can take from the experience of UK in tackling cancer. The first Pprinciple was about bring equity in care for cancer; second revolved around understanding the political economy of cancer; third about reducing the out-of-pocket-expenditure on cancer; fourth about planning services and systems on evidence; fifth making investments in strengthening basic health system; and sixth about aligning politics, Professor policies and solutions for building resilient health systems. Sullivan ~

90 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 r. Anil D Cruz shared his thoughts on controlling cancer particularly in LMICs. He mentioned that although global Dincidence of cancer is high, but a large proportion of this is preventable. Early detection and awareness generation is the key for fighting this battle effectively. Strengthening of Primary Health Care (both human resources and technology) System is critical for India to achieve big leap in this area. He mentioned that cancer should not be seen Dr. Anil D Cruz in isolation to other NCDs as the risk factors are common. For cancer ~ screening and early diagnosis Hub and Spoke model is recommended and Kerala has good experience in this area.

r. Arnie expressed that expansion of HRH resources is critical in cancer care specially to strengthen the diagnosis and treatment Dservices. For India there is a need to have a strategic 10-year plan to increase position especially for specialists. The country can also deliberate on extending the role of nurses and allied workers to support the specialists. UK experimented with positions of physician assistant, tele radiology or tele pathology and blended learning approach to counter Dr. Arnie the shortage of specialists in cancer care. Dr. Arnie also reiterated the ~ use of Hub and Spoke model which is being successfully tried in the state of Assam.

r. Sankara communicated the essential role of early detection of cancer in overall treatment protocol. He said that around 60-70 Dpercent of cases are detected in stage 3, therefore early diagnosis is most suitable option for LMIC in their fight against cancer. There is a need to build a referral pathway wherein early diagnosis doesn’t stop with visual detection but is followed-up with proper diagnostics at higher levels of care. PHCs in the country to be equipped with basic Dr. Sankara infrastructure like x-rays or colonoscopy equipments to carry out ~ biopsies. This will help lower the crowding of patients at higher level facilities which can then focus on treatment rather than diagnosis. Subsidizing early diagnosis is another area which may be looked upon by policy makers.

WEBINAR PROCEEDINGS 91 r. Pillai shared innovative ideas in virology and emphasized the role of public-private-partnership to reduce the cost of detection Dand treatment. He mentioned that the country can benefit from centers like TATA Centre of Excellence which is a perfect example of PPP model in healthcare. There are global examples as well which may be looked but can be adapted to suit Indian context. He mentioned that moving forward technology (especially good bandwidth) will play a Dr. Pillai ~ critical role in revolutionizing the health insurance sector.

Challenges in achieving SDGs related to Cancer r. Badwe shared the challenges that the country faces to achieve SDGs related to cancer. He mentioned that 75% of the cancers Din the country are preventable as a large percentage relate to tobacco consumption (40%), obesity (15%) and infections (15%). He shared the example from France where the Government, tripled the price of tobacco which dropped the consumption to half and still due to Dr. Rajendra high taxes doubled the revenue for the government. He mentioned that 19 Badwe cancers are linked with obesity and the rate at which the obesity is rising Director, Tata in India, these will hit the country in next 10-15 years and are expected Memorial Centre to have long term effect on cancer in India.

Key points: • Screening for common cancers like oral, breast and cervix is practical but expanding it for all types of cancer will increase the burden on already stretched healthcare system of the country. • Reduction in overweight and obesity should be focus of all awareness building campaigns. • Hub and Spoke model is an effective strategy in cancer treatment wherein comprehensive cancer centers to act as ‘hubs’ to treat all types of cancers while ‘spokes’ connected to hub to provide treatment to less complex cancer conditions.

92 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 DAY 05

WEBINAR PROCEEDINGS 93 Moving towards TB Elimination–A call for Action

Story of People’s Movement against TB in Kerala Story of People’s Movement against TB was narrated by Team Kerala led by Dr Rajan N Khobragade, Principal Secretary, Department of Health& Family Welfare, Kerala. Team members were Dr Sunilkumar M, State TB Officer, Dr Sairu Philip, State OR Committee Chair, Dr Sanjeev Nair, Chair, State Task Force, Dr Manu MS, Junior Consultant, STDC, Kerala, Dr Shibu Balakrishnan, Regional Team Lead, WHO and Dr Rakesh PS, Consultant, WHO Background Since inception, TB Control is well integrated with the general health system in Kerala. Study done in 2006 (Kumar et al) itself revealed low level of transmission of infection in Kerala-1/5th that of national average. Proportion of TB patients with MDRTB is the lowest in Kerala. Among new it is less than 1% and among previously treated it is 3.5%. Reported recurrence is less than 5% and long term follow up confirms low recurrence.

94 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Milestones in the battle against TB

"Kerala TB Elimination PMDT services state Notification from Scale up of Programmatic Mission" formally wide coverageipsum private sector Management of TB launched Preventive Therapy

2009 2015 2017 2021

2000 2010 2016 2020

Upfront Moleculartests RNTCP state Active Case finding Molecular tests for TB diagnosis to all wide coverage state wide coverage for UDST vulnerable individuals

With a good track record of social development indicators, especially in health and education sectors, Kerala is witnessing a demographic transition with a rise in the proportion of aged in the total population along with declining growth rate. Kerala state is in the third stage of demographic transition. 14% of the people are above the age of 60 years. Good literacy, political awareness, rights-based orientation led to good health seeking behavior among people. Traditionally, education and health accounted for the greatest shares of the state government’s expenditure. Primary Health care services have been systematically organised in rural areas of the state. This ample network that extends to the grass root level must have contributed to less urban-rural disparity. There are 230 community health centers and 845 primary health centers (approximately one per 30,000 population) in the State. There are 5500 junior public health nurses and 3500 Junior Health Inspectors; both being multi-purpose health workers (MPW) for a Health Sub-Centre, serving every 5000 population. Ownership of primary and secondary healthcare institutions is decentralized to Local Self Governments (LSG). Substantial budget provision is ensured to equip the LSGs to assume these responsibilities. This democratic decentralization has led to mass participation in health care activities of the state and increased the public accountability and government stewardship of public health programs. Local Self Government (LSG) which is a form of democratic decentralization by constitutional amendments are empowered in Kerala. Panchayat in Rural Areas (one per 25000 population) and Municipality

WEBINAR PROCEEDINGS 95 & Corporation in Urban Areas are the LSGs. Grama Panchayats are divided into wards and each ward (1500 people) is represented by an elected representative. Altogether there are 941 grama panchayats, 87 Municipality & 6 Corporation in Kerala. 30% of state’s budget is spent through LSG. LSGs act as effective agencies for the implementation of developmental programs. The responsibilities of the LSGs under the Panchayati Raj Act 1994, and later amendments included maintenance of healthcare institutions, providing hygienic drinking water and sanitation, providing medicine and health accessories to the healthcare centers, intervening during epidemics and promoting health practices. Technical assistance for the same are provided by the primary health care team.

Dr Rajan N Khobragade IAS, Principal Secretary, Department of Health & Family Welfare, Kerala presenting the people’s movement against TB in Kerala along with Dr Sunil Kumar M (State TB Officer), Dr Shibu Balakrishnan (Regional Team Lead-South, WHO India), Dr Sanjeev Nair (State Task Force Chairperson), Dr Sairu Philip (Chair, State OR Committee), Dr Manu MS (Junior Consultant, STDC) & Dr Rakesh PS (Consultant, WHO).

Kerala has launched “Kerala TB elimination mission” in 2017 aligning with the Sustainable Development Goals, with objectives to achieve TB Elimination by 2025, zero preventable deaths due to tuberculosis and zero catastrophic expenditure for the families of tuberculosis patients. The mission is envisaged as a peoples’ movement against TB under the leadership of local self-governments. Kerala TB Elimination Mission is being implemented through the LSG Bodies with a theme “My TB free [name of LSG]”. TB Elimination taskforces chaired by the head of the LSG are formed in all the LSG bodies. The LSG Task Force plans and implements local activities mobilizes resources, monitor self, adopts mid-course correction and reports to the district task force.

96 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Organization of TB Elimination tasks at various levels

District

Program Management, Multisectoral Accountability Policy Support Supervision & Monitoring

Block

Care and support for Prisons, NAAT laboratories (Hub) Private Sector Engagement Destitute, Workplaces

Village

Case Finding Decentralised Treatment Airborne Single Overriding and delivering Vulnerability surveillance & Support Infection Communication services at door Reduction Planning Systems Control Objective steps

6 Actions By the People

1. Decentralised TB Surveillance for local actions

Based on village wise thematic maps, village taskforces discussed their presumptive TB examination rates, performances in case finding and lost WEBINAR PROCEEDINGS 97 to follow up rates. They evolved local solutions to address the problems identified. 2. Periodic Repeated Active Case Finding 2. Periodic Repeated Active Case Finding among amongthe vulnerable the vulnerable individuals individuals

Vulnerability Village wise List of Quarterly active case Assessment survey vulnerable individuals finding among [Entire Population] in whole state identified vulnerable individuals

With the help of volunteers from the community, vulnerability to develop TB for each individual were mapped. 3-5% of individuals with high vulnerability to develop TB were followed up quarterly to look for TB symptoms by the primary health care team at village ensuring their confidentiality.

3. Vulnerability Reduction 3. Vulnerability Reduction Addressing Malnutrition at tribal areas & elderly homes

Reducing individuals & society's Reducing individual's & Poverty vulnerability to develop TB NCD society's vulnerability to Alleviation Control develop TB Addressing social & clinical Panchayat vulnerabilities Addressing Social & Clinical Vulnerabilities Better Housing SWAAS

98 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Those individuals who were found to have vulnerability to develop TB, were linked to vulnerability reduction services by the LSG and Primary Health Team.

4. Treatment Support Group

• Non-statutory body of socially responsible citizens • To provide social support to each needy TB patient • Safeguarding dignity and confidentiality • By ensuring supporting and empowering the patient for making decision to ensure continuum of care

Treatment support groups were formed in the community to provide social, emotional and financial support to each person diagnosed with TB safeguarding their dignity and confidentiality.

5. Airborne Infection Control at House, Community & Hospitals

Airborne Infection Control services were systematically organized at household level (domiciliary airborne infection control kit including 5 washable reusable clothed mask, spittoon and disinfectant solution), community level (handkerchief revolution for education regarding cough hygiene) and health facilities (cough corners with system to screen respiratory symptomatic, provide them with masks, separate and fast track those with suspected respiratory disease of infectious nature). WEBINAR PROCEEDINGS 99 6. Single overriding communication objective

"My TB Free Panchayat"

Single Overriding communication objective with the message “My TB Free Village” was repeatedly emphasized.

Summary of Actions By the People in Village

Actions for the People While the people’s movement were happening at village level, people centric systems were organized by the program including decentralized systems for TB diagnosis with a robust specimen collection and transportation systems and decentralized treatment services.

100 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Decentralised systems for TB Diagnosis and Treatment Decentralised Systems for TB Diagnosis and Treatment

Ward 3

Ward 1 LSG1 LSG2 LSG 3

Ward 2 TB diagnostic Lab

CDST Lab District Hub

District level Dr TB Committee meeting, Thiruvananthapuram Specimen Collection & Transportation systems

Patient support systems were set up to reduce out of pocket expenditures, minimize patient inconveniences and provide support to treatment adherence.

Patient Support Systems • Direct Benefit Transfer (Rs. 500/month) • Diagnostic Facility Scale Up • TB Pension - Revenue Department, Government of Kerala (Rs. 160/month) • Specimen collection and transportation mechanism from every health facility. • Decentralised Clinical Services • New Digital X-Ray machines & provision for outsourcing X-Ray • Vehicle Mounted GeneXpert

Similar patient centric systems were established in private sector to ensure standards of TB Care in India through establishment of STEPS (System for TB Elimination in Private Sector). STEPS is a single-window in a private health facility serving as a nodal center to systematically WEBINAR PROCEEDINGS 101 track every TB patient diagnosed by in-house clinical departments, units and clinicians, notify them to NTEP, follow them up during the entire treatment and report treatment outcomes to NTEP in the most patient centric way so that each patient receives highest standards of TB care from the health facility of his choice, protecting the dignity and confidentiality. STEPS centers are established in 380 health facilities. NTEP drugs have been stocked at STEPS centers and linkages to free diagnostics have been established through specimen collection and transportation schemes. STEPS - System for TB Elimination in Private Sector TEPS - System for TB Elimination in Private Sector

STEPS centres Single window system in private hospital Ensuring all Public Health Actions to all

Private Hospital Consortium of Hospital Managements Consortium Establishing STEPS, policy support & Review

Coalition of Professional Medical To sensitise and support specialists Association To advocate with doctors for following STCI

Impacts of People’s Movement Against TB

1. Laboratory testing of Presumptive TB & Number needed to test

102 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 The presumptive TB testing rate /100000 increased and at the same time, the number needed to test to diagnose one case increased from 29 in 2015 to 40 in 2019.

2. Trend in Actual Notification (per 100000 population) of Incident (New Micro-biologically confirmed & Clinical) TB Cases

When each and every cases were berry picked from the community along with strengthening of surveillance in private sector, there was a slight increase in TB notification from 2018 and 2019.

3. Decline in estimated incident TB burden - Kerala

Incidence of TB cases were estimated every year based on 1. Existing Incident TB Notifications & Trends 2. Drug Sales data & adjusting for notified cases 3. Undetected cases based on Delphi

WEBINAR PROCEEDINGS 103 Incidence of TB estimated using epidemiological methods revealed a 7.5% annual reduction in the incidence.

4. Early Diagnosis What proportion of total microbiologically confirmed pulmonary TB cases are diagnosed at tertiary care institutions?

• Cavity, Fibrosis, Extensive lung lesions disappeared • People with typical TB symptoms are not seen now

There were indirect evidences of early diagnosis happening. In 2019, 91% of microbiologically confirmed pulmonary TB cases were diagnosed at primary health care level. In 2015, 21% of microbiologically confirmed pulmonary TB cases were diagnosed at tertiary care centers.

5. Lost to Follow Up after diagnosis

104 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Lost to follow up rates among diagnosed TB cases came down to 1.8%.

6. Improvement in documented standards of care among patients reaching private sector

Indicator 2018 2019 2020 Number of TB cases notified by the private sector 3981 4927 5795 Number (%) of microbiologically confirmed cases 995 1698 2202 among notified TB (25%) (34%) (38%) Number (%) of notified patients offered Universal DST 637 1304 3187 (16%) (38%) (55%) Number (%) of notified TB patients who know their 1672 2236 4809 HIV status (42%) (82%) (83%) Number (%) of notified patients received NPY benefits 1273 1634 3013 in bank account (32%) (48%) (52%) Number (%) of notified patients whose treatment 1393 3364 outcome was reported in Nikshay (39% (99%)

Source NIKSHAY

There were improvements in documented standards of care in patients reaching private sector.

WEBINAR PROCEEDINGS 105 r Ditiu lauded Kerala for their efforts to eliminate TB by 2025 and said this experience would be of great help to other countries on Dthe Sothern hemisphere and go a long way in achieving global health security. Dr Ditiu warned that the world is likely to be frequently confronted with airborne diseases like Covid-19 which “has brought us to our knees,” but such problems can be overcome by using the experience gained from Dr Lucica Ditiu Executive Director, the Tuberculosis Elimination Programme. “The world feels threatened by Stop TB Partnership future air-borne diseases, similar to Covid-19, as we will have this kind of problems more and more,” she said. At present, the world was looking at how it was hit by Covid and how underprepared it was to deal with the pandemic. There was a close link between TB and other airborne diseases such as Covid which were also airborne, she pointed out. “We will try to organize more South-South collaboration so that Kerala and India can share their successful model for elimination of TB,” she said. She also advised Kerala and India to look for donors to ramp up their TB eradication programme for which they had nevertheless allocated huge resources.

r Guy B Marks said global strategies against Covid-19 are working as lessons to control another infectious disease as serious as Dtuberculosis. The way humanity checked the spread of the novel coronavirus reinforces the basic point that infectious diseases are curtailed by reducing or stopping transmission, he told the session. Dr Marks said the efficacy of containing pandemic shows that public health measures do work. “Political commitment and social cohesion really Dr Guy B Marks matter. The places that these two exist have managed to stem the surge of Professor of Respiratory spread of infectious diseases. We know from Covid-19 that it is possible Medicine at to control the virus even without treatment. A vaccine would be helpful, University of but it is not essential.” New South Wales in Sydney & “Many cases of TB are symptomatic and, thus, do not seek care. We the President, must dismantle the barriers on the path to commencing treatment and International Union ensuring its effective completion. Treatment of latent tuberculosis is just against TB and Lung one of many interventions that are available to us to prevent TB.” Diseases

106 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 WEBINAR PROCEEDINGS 107 Panel Discussion

TB Free Islands

Panel discussion was held with TB experts. Dr Sreenivas A Nair, Regional Technical Advisor, South East Asia Region, Stop TB Partnership moderated the panel.

eople has a major role in eliminating TB. That role ranges from providing support to TB patients, fighting stigma against and “Pdo advocacy for TB Preventive Therapy. The fight against TB everywhere shall be for the People, by the people and of the people”

Mrs Divya Sojan TB Survivor

uberculosis remains one of the world’s deadliest infectious killers. While anyone can fall ill with TB, the disease thrives “Ton the most vulnerable—the marginalized, discriminated against populations, and people living in poverty. The Covid-19 pandemic has exacerbated the situation, especially for the vulnerable, where people affected with TB and Covid 19 face dual burdens of stigma or barriers in Dr Teresa accessing their right to health. A people-centered rights-based response Kasaeva is key” Director (Global TB Program, WHO Geneva)

108 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 arned against a complacency that may set in once successes come in the path to eliminating TB. He pointed out that between W1985 and 1992, the US, which thought it had eliminated TB, saw a resurgence of the disease.

Dr Kenneth Castro Senior Scientific Advisor, USAID

elimination needs a shift of focus to prevention and person-centered approach by scaling up of screening “TBand testing.”

Dr Suvananda Sahu Dy. Executive Director, Stop TB Partnership

overnment of India has a clear-cut strategy to incentivize states who achieve various health-related goals including “GTB control. India has developed a protocol for sub national disease-free certification”

Dr Raghuram Rao Deputy Director, Central TB Division, Government of India

WEBINAR PROCEEDINGS 109 esides incentivizing and promoting innovation, Global Fund also supported TB prevention by providing 70 per cent “Bfinancing to TB elimination programs”

Dr. Mohammed Yassin Senior Technical Advisor, Global Fund

ince TB is a social disease with a clinical aspect, it cannot be eliminated without addressing the scourge of poverty and “Sother social determinants of TB.”

Dr Sevim Ahmedov Senior Technical Advisor, USAID

DB provided USD 20 billion last year to fight Covid. ADB’s “A resources can be leveraged for TB Elimination.”

Mr Patrick Oswe Chief of ADB’s Health Sector Group

110 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 (Left to Right) Mrs Divya Sojan (TB Survivor), Dr Reghuram Rao (Deputy Director, Central TB Division, Government of India), Dr Sreenivas A Nair (Regional Technical Advisor, South East Asian Region, Stop TB Partnership), Dr Kenneth Castro (Senior Scientific Advisor, USAID), Dr. Mohammed Yassin (Senior Technical Advisor, Global Fund), Dr Suvananda Sahu (Dy. Executive Director, Stop TB Partnership), Dr Sevim Ahmedov (Senior Technical Advisor, USAID), Mr Patrick Oswe (Chief of ADB’s Health Sector Group), Dr Teresa Kasaeva Director (Global TB Program, WHO Geneva) and Dr Rakesh PS (Consultant, Kerala)

WEBINAR PROCEEDINGS 111 Closing Ceremony

erala has continued its stress on public access to health through its flagship schemes like ‘Aardram Mission’, which “Khas sought to transform outpatient wings hospitals at every level.”

Prof. V K Ramachandran Vice Chairperson, Kerala State Planning Board

uberculosis is going to be the huge focus for the country with the commitment to the goal of ‘End TB by 2025. Kerala is “Tleading in the forefront in containing TB. In addition to many innovations, one initiative designed and implemented well by the state is its vulnerability mapping at individual level. Kerala is moving ahead probably with the lowest TB incidence in the country. But it requires a lot Dr Roderico H of effort to wipe out TB. At state level, WHO will be continuing to provide Ofrin technical support. Programmatic Management of TB. WHO will expand WHO Representative mentor support under its project ‘Gatimaan’.” to India

erala has shown, through its extensive panchayat system as well as the variety of citizen volunteer groups, that “Kin pandemic period these partnerships and citizen engagements are critical. What we really require is people partnered public health. And Kerala has demonstrated how this can be actually developed well. Kerala has shown that it has to be led by a strong and committed public sector while engaging effectively other segments of Prof Srinath Reddy President, Public society in a very efficient partnership more. Therefore, I believe that Health Foundation of we should not be looking at PPPs (Public Private Partnerships) but India partnerships for a public purpose”

112 KERALA HEALTH & FAMILY WELFARE: 1ST INTERNATIONAL CONFERENCE FEBRUARY 14 – MARCH 04, 2021 Acknowledgement

o organize such an event of this scale spanning five days with different sessions and speakers from all over the world, it required a lot of Tplanning and involvement. Tasks were identified and spilt into various actions and was assigned to individual officers in such a way that no one’s main work i.e., focus on the pandemic and pandemic related intervention activities would be adversely affected. It is worth mentioning that the Information Technology committee headed by Shri Safirulla did a stupendous job by providing a robust IT platform so that the Experts from Geneva to Sydney could join the webinar without any difficulties and the webinar could be conducted efficiently. Dr Rakesh Bhat, Dr Tony Lawrence and Dr Aparna worked all throughout the webinar from the pre planning phase, planning and post webinar phases. It is a difficult task to mention all the names to acknowledge the contributions because everyone in the Health Department contributed in their respective programs immensely. We earnestly thank each one of them. The webinar was organized to give confidence to the field functionaries. Without their continuous work neither would there be results nor the events to showcase the same. We thank them for their continuous efforts to achieve the Sustainable Development Goals. We express our sincere gratitude to all the eminent speakers who graciously accepted our invitation and participated in the Webinar. Kerala’s success in the health sector could not have been achieved without the involvement of vibrant private health sector. We thank our partners in joining hands to achieve the Sustainable Development Goals. We are thankful to Dr Roderico Ofrin, WHO - India, Dr Deepika World Bank- India, Dr Kaushik Ganguly, Dr Sugata Roy UNICEF and Dr Devaki Nambiar, the George Institute for Global Health and their teams for joining hands with Kerala Health to organize the webinar. We sincerely thank our Hon Chief Minister Shri Pinarayi Vijayan and Hon Health Minister Smt K K Shailaja Teacher for encouraging us with their guidance and support for taking various initiatives in the health sector.

Dr Rajan Khobragade Principal Secretary Health and Family Welfare Government of Kerala

WEBINAR PROCEEDINGS 113 UHC DAY 1 / 17th February 2021

Time Event Resource Persons

16.00–17.00 Hrs. Inauguration

Welcome Dr. Rajan Khobragade IAS Principal Secretary Health & Family Welfare, Govt. of Kerala

Presidential Address Smt. K K Shailaja Hon. Minister for Health, Social Justice, Women and Child Development, Govt. of Kerala

Inauguration Shri Pinarayi Vijayan Hon. Chief Minister of Kerala

Keynote Address Shri. Rajesh Bhushan IAS Secretary, Ministry of Health & Family Welfare, Govt. of India

Special Address Shri. Vishwas Mehta IAS Chief Secretary, Govt. of kerala

Vote of Thanks Dr. Rathan Kelkar IAS State Mission Director, National Health Mission

17.00–18.00 Hrs. Oration Smt. Sujatha Rao IAS (Rtd.) Former Secretary Ministry of Health & “2021–2030: Challenges in Health Family Welfare, Govt of India Sector & Preparedness” Dr. V K Paul Member NITI AYOG, Govt. of India

Shri. Rajeev Sadanandan IAS (Rtd) Former Additional Chief Secretary H&FW Govt of Kerala

18.00–18.40 Hrs. Kerala Experience of UHC Policy perspective Dr. Rajan Khobragade IAS Principal Secretary (H&FW), Govt. of Kerala

Dr. Dahar Muhammed Medical Officer, Family Health Centre Noolpuzha Wayanad, Kerala

18.40–19.10 Hrs. Progress of UHC in Thailand Dr. Viroj Tangcharoensathien Senior Advisor, Ministry of Health, Thailand

19.10–20.00 Hrs. Panel Discussion Dr. Mala Rao Senior Clinical Fellow, Imperial College London Universal Health Coverage– Outlook for Developing Countries Dr. Yasmin Ali Haque Moderator: Dr. Rathan Kelkar UNICEF Representative to India State Mission Director, National Health Mission Dr. G N V Ramana Ex Lead Health Specialist, World Bank COVID-19 pandemic–Health System Response–Resilience–Preparedness DAY 2 / 18th February 2021

Time Event Resource Persons 17.00–17.50 Hrs. Inauguration Smt. K K Shailaja Hon. Minister for Health, Social Justice, Women and Child Development, Govt. of Kerala

Chief Guest’s Address Dr. Maria Van Kerkhove COVID-19: Health System COVID-19 Technical Lead World Health Organisation Global Response

17.50–18.10 Hrs. India’s Fight against Prof. Balram Bhargava COVID-19–Role of ICMR Director General Indian Council of Medical Research & DHR Govt. of India

18.10–18.40 Hrs. Kerala's Response to COVID-19 Dr. Rajan Khobragade Principal Secretary Health & FW, Govt. of Kerala

Dr. Sakeena K DMO Malappuram

Dr. Raman Swathy Vaman DPM Kasaragod

Dr. R Sandhya DSO Kollam

Dr. Aravind R Head, Department of Infectious Diseases Medical College, Thiruvananthapuram

18.40–19.00 Hrs. Crisis leadership & Dr. Ajit Abraham Workforce resilience Consultant HPB & Trauma Surgeon The Royal London Hospital, National Health Service, United Kingdom

Interaction Dr. Tony Lawrence Asst. Professor, Community Medicine Medical College, Thiruvananthapuram

19.00–19.40 Hrs. Panel Discussion Dr. Gagandeep Kang, Professor,The Welcome Trust Research Pandemic & Preparedness Laboratory, Division of Gastrointestinal Sciences Christian Medical College, Vellore Moderator: Dr. Indu P S Professor & Head Community Medicine Dr. Jacob John Medical College, Thiruvananthapuram Virologist and Professor Emeritus CMC Vellore

Dr. David Wilson Program Director, World Bank

19.40–20.15 Hrs. Pandemic–Response Dr. Navjot Khosa IAS at District level District Collector Thiruvananthapuram Mr. Suhas S IAS Moderator: Dr. Rathan Kelkar District Collector Ernakulam State Mission Director, National Health Mission Dr. Adeela Abdulla IAS District Collector Wayanad

Dr. Raman Gangakhedkar WEBINAR PROCEEDINGSHead of Epidemiology115 (Rtd), ICRM Govt of India Achieving SDG Related to MMR and IMR–Dream or Reality? DAY 3 / 24th February 2021

Time Event Resource Persons

17.00- 17.20 Hrs. Inauguration Smt. K K Shailaja Hon. Minister for Health, Social Justice Women and Child Development, Govt. of Kerala

17.20–17.40 Hrs. Achieving the SDG related to Smt Arti Ahuja IAS Maternal and Child Health Additional Secretary Ministry of Health &Family Welfare Govt. of India

Dr. Paul Rutter Regional Advisor (Health), UNICEF

17.40–18.00 Hrs. MMR Reduction-Kerala Experience Dr. V P Paily State Co ordinator, Confidential Review of Maternal Health & Senior Consultant Rajagiri Hospital, Aluva

18.00–18.15 Hrs. MMR Reduction Field success story to bring in connect of policy with the interventions Dr. Remla Beevi Director Medical Education, Govt. of Kerala

Dr. Krishnaveni RCH Officer, Kollam

18.15–18.45 Hrs. IMR Reduction–Kerala Experience Dr. S S Kamath Former President Indian Academy of Pediatrics

18.45–19.00 Hrs. IMR Reduction Field success story to bring in connect of policy with the interventions Dr. Saritha R L Director Health Services, Govt. of Kerala

Dr. Srihari M State Nodal Officer Child Health, NHM Kerala

19.00–20.15 Hrs. Panel discussion: Accelerating the Dr. Vivek Virendra Singh reduction of Maternal & Infant Health Specialist, UNICEF India Mortality in developing countries Prof. Richard Cash Moderator: Dr. A Santhosh Kumar Harvard T H Chan School of Public Health, USA Professor of Pediatrics & Superintendent SAT Hospital, Medical College Thiruvananthapuram Dr. Rakhi Dandona Professor, Public Health Foundation of India

Dr. Ahmad Reza Hosseinpoor Health Equity Monitoring Lead WHO Geneva Meet the SDG –Beat the NCD DAY 4 / 25th February 2021

Time Event Resource Persons

17.00- 17.20 Hrs. Inauguration Smt K K Shailaja Hon. Minister for Health, Social Justice, Women and Child Development, Govt. of Kerala

Keynote Address Dr. Cherian Varghese Coordinator NCD Management, WHO Geneva

Kerala NCD strategy Dr. Satheesan B Director Malabar Cancer Centre, Thalassery, Kannur

17.20–17.50 Hrs. Achieving the SDG related to NCDs Dr. Thomas R Frieden President & CEO, Resolve to Save Lives, Former Director CDC

17.50–18.30 Hrs. Experience Sharing-Other NCDs Dr. Rajan Khobragade Principal Secretary Health & FW, Govt. of Kerala

Dr. Mathews Numpeli DPM Ernakulam

Dr. Naveen DPM Kozhikode

Dr. Kiran P S State Nodal Officer, Mental Health Programme

Dr. Bipin Gopal State Nodal Officer, NCD Programme

18.30–19.00 Hrs. Cancer Care-Kerala Experience Dr. Rekha A Nair Director Regional Ernakulam District Cancer Cancer Centre Thiruvananthapuram Control Project Mr. K Mohammed Y Safirulla IAS Project Director e-Health

19.00- 19.40 Hrs. Panel Discussion Dr. Sankara Narayanan Senior Visiting Scientist, WHO - IARC Lyon France Prevention of Cancer through Primary Health Care Dr. M V Pillai Professor of Oncology Moderator: Dr. Moni Kuriakose Thomas Jefferson University of Philadelphia Director, Cochin Cancer Research Centre Dr. Anil D Cruz President Union for International Cancer Control

Dr. Richard Sullivan Professor, Cancer and Global Health King’s Institute of Cancer Policy and Co-Director of Conflict and Health Research Group

Dr. Arnie Purushotham Director Kings Health Partners Integrated Cancer Centre London

19.40–20.00 Hrs. Achieving SDG related to Dr. Rajendra Badwe Cancer–Challenges Director, Tata Memorial Centre Moving towards TB Elimination –A Call for Action DAY 5 / 4th March 2021

Time Event Resource Persons

17.00–17.10 Hrs. Dialogue Smt. K K Shailaja Hon. Minister for Health, Social Justice Women and Child Development, Govt. of Kerala

Dr. Lucica Ditieu Executive Director, Stop TB partnership

17.10–18.10 Hrs. Peoples’ movement against Dr. Rajan Khobragade TB in Kerala Principal Secretary Health and FW Govt. Of Kerala

Dr. Sunil Kumar M State TB Officer Govt. of Kerala

Dr. Sairu Philip Professor and Head, GMC Alappuzha

Dr. Shibu Balakrishnan Regional Team Lead (South), WHO India

Dr. Rakesh P S Consultant (TB Elimination) WHO

18.10–18.30 Hrs. Case Finding in Vietnam Prof. Guy B Marks Professor Respiratory Medicine Sydney & President, The International Union

18.30–19.30 Hrs. Panel Discussion–TB Free Islands– Dr. Teresa Kasaeva Way Forward Director, Global TB Programme, WHO Geneva Moderator: Dr. Sreenivas A Nair Dr. Kenneth Castro Regional Advisor, Stop TB Strategy Partnership Senior Scientific Advisor, TB, USAID

Dr. Raghuram Rao Deputy Director, Central TB Division, Govt. of India

Dr. Suvananda Sahu Dy. Executive Director, Stop TB Partnership

Mr. Sevim Ahmedov Senior Technical Advisor, USAID

Mr. Mohammed Yasin Senior Technical Advisor, Global Fund

Mr. Patrick Oswe Chief of ADB's Health Sector Group

Smt Divya Sojan TB Survivor & Staff Nurse, AIIMS, New Delhi 19.30–20.00 Hrs. Programatic Management of TB Preventive Therapy & Multi Sectoral Accountability Framework for TB Elimination in Kerala

Concept Dr. Sanjeev Nair Chair, LTBI Technical Working Group, Kerala

Launch Smt K K Shailaja Hon. Minister for Health, Social Justice, Women and Child Development, Govt. of Kerala

Key Note Address Mr. Vikas Sheel IAS Joint Secretary Ministry of Health & Family Welfare, Govt of India

Special Address Dr. Roderico H Ofrin WHO Representative to India Support for Documentation

State Health System Dr Shinu KS, Dr Rekha Raveendran, Resource Centre, Kerala

Dr Kaushik Ganguly Reeja Jacob UNICEF India Dr.Dhanya Radhakrishnan Sugata Roy

World Bank Mrs Deepika Ananad

Dr Rakesh PS, Consultant (TB World Health Elimination), Dr. A. Branch Immanuel & Organization CVHOs – IHCI Kerala

Dr Devaki Nambiar, Chhavi Bhandari, The George Institute for Misimi Kakoti, Jaison Joseph, Sreejini, Global Health, India Mehar Kakkar, Siddharth

Event Videos are available at: https://www.keralahealthconference.in/ archives/

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