To strategically recognize and manage public health emergencies:

• Public Leaders must realize the importance of 4 Ps - perception, process, people and projection
• India needs national level digital platforms to recognize looming emergencies and manage demand-supply gaps, supported by a dedicated national service for emergency logistics.

When the second wave of the COVID-19 pandemic hit India in March 2021, the entire health system came under tremendous pressure. There was a huge, unprecedented demand for hospital beds, medical oxygen and drugs [1]. Although the government had ramped up health infrastructure during the first wave [2], it was challenged by the demands of the second wave. Consequently, several thousand people died due to COVID-19 in India, within a span of three months [3].

How should we address such a country-wide public health emergency in the future?

Harvard Kennedy School faculty Robert Wilkinson and Kimberlyn Leary have proposed the 4-P framework of Strategic Leadership [4]. The four Ps- Perception, Process, People and Projection, have great relevance for public health emergencies. In this article, we apply the 4-P framework to the two critical stages of mitigating a public health emergency- ‘recognition’ and ‘management’ [5].

Strategically Recognizing a Potential Public Health Emergency

Recognizing a crisis early on is the most important step in mitigating disasters, particularly in countries like India where the size of the vulnerable population is very large.

A public leader must perceive a looming crisis by establishing a process for collecting details of warning signals noticed by the people working in government agencies as well as the general population. People working in government agencies must be trained to identify such signals. For example, if a pharmacist/storekeeper of a community health center notices a sudden rise in the consumption of a particular medicine in the district, it should be immediately notified to the State Health Department. Public leaders also need to build ‘risk assessment teams’ at district, state and national levels to evaluate such signals, analyze relevant data and gauge the seriousness of the situation. Such teams can project how the crisis would evolve and help the leader in designing strategies to mitigate the crisis.

Strategically Managing a Public Health Emergency

A situation becomes an ‘emergency’ when the physical and human resource needs of a population change drastically and the human costs of not addressing those needs are severe. Managing an emergency requires reallocation, creation, and mobilization of resources according to the new needs of the population. During the second wave of COVID-19 in India, the demand for certain drugs grew rapidly [6]. The following graph illustrates how the private sector sales of antipyretics, antibiotics and steroids in India rose during the second wave.

Fig.1 - National monthly private sector sales of 23 drugs (under 10 different categories) which were used for treatment of COVID-19 and allied diseases in India [7], correlated with the count of monthly confirmed cases of COVID-19 in India [3].

A public leader must perceive the evolving needs of the population correctly and restructure the existing administrative processes to reallocate, create and mobilize resources. The public leader must also clearly project the ‘state of demand and supply’ regularly to healthcare providers, manufacturers and distributors of medical commodities, and civil society to help them prepare for a surge in demand.

The biggest challenge posed by a public health emergency is to manage the emotions of people. A ‘tipping point’ lies somewhere in the range of demand-supply gap. If crossed, it triggers a wave of great fear among the people. It activates a ‘feedback loop’- a large gap in demand and supply causes panic among people, which inflates the demand further and increases stress on the staff of government agencies. The stress adversely affects the ability of government agencies to manage and increase the supply. Consequently, the demand-supply gap keeps on increasing, gradually turning a public health emergency into an uncontrollable disaster.

Fig. 2- Range of Demand-Supply Gap and the Tipping Range

A public leader’s emotional intelligence, communication skills and effective action can keep this feedback loop in check. It is important for the leader to be able to estimate the tipping point or tipping range for a public health emergency. Incident response teams across government agencies must be trained to prevent and mitigate the impact of crossing the tipping point.

The Way Forward for India:

Apart from pandemics, many other public health emergencies can be expected in the coming years, especially due to climate change [8,9]. Hence, India needs a digital platform - ‘National Emergency Signal-Incident Reporting (NESIR)’ system - for reporting and analyzing early signals of an upcoming emergency.

To manage the demand-supply gap, India needs to develop a digital ‘Public Emergency Demand-Supply Analysis & Management (PEDSAM)’ system. PEDSAM would:

1. Aggregate, estimate and forecast demand and supply
2. Calculate the tipping point in the range of demand-supply gap
3. Dynamically allocate resources to regions and facilities
4. Calculate logistics required to manage the supply chain
5. Suggest the best routes and modes for transportation.

Existing systems like the Drugs and Vaccines Distribution System (DVDMS) [10] and Oxygen Demand Aggregation system (ODAS) [11] partially accommodate features of PEDSAM. A crucial feature of PEDSAM would be quick and easy configuration of new types of resources and logistics to adapt it to large variety of emergency situations.

India also needs a dedicated National Emergency Logistics Service (NELS) which can quickly mobilize resources across the country for a variety of emergencies. NESIR, PEDSAM and NELS could be leveraged for addressing emergency situations beyond public health as well.

Finally, these systems and services need to be complemented with a transparent and clear public information dissemination portal for providing ‘live’ updates on the demand-supply situation to relevant stakeholders and the common people, by using data from PEDSAM. Such a portal can help build citizen’s trust and confidence in the public leaders, avoid panic, and push tipping points farther.

The 4 Ps - perception, process, people, and projection [4] are critical for public leaders to strategically recognize and manage public health emergencies. To effectively address public health emergencies in the future, public leaders in India must build national-level digital platforms to recognize emergencies and manage demand-supply gaps. They also need to establish a dedicated national service for managing emergency logistics, along with a public information portal.

References:

1. Saurabh Kumar, ‘Second wave of COVID-19: emergency situation in India’, Journal of Travel Medicine, 2021; https://doi.org/10.1093/jtm/taab082
2. ‘Setting up New Hospitals in Rural and Urban Areas’, Ministry of Health and Family Welfare, Press Information Bureau Delhi, 10 Aug 2021. https://pib.gov.in/PressReleaseIframePage.aspx?PRID=1744358
3. National COVID-19 data for India available on https://api.covid19india.org/ accessed on 18 June 2021 at 0109hrs.
4. Wilkinson, Robert, and Kimberlyn Leary. "Leading with Intentionality: The 4P Framework for Strategic Leadership." Harvard Kennedy School Faculty Research Working Paper Series RWP20-029, September 2020.
5. Joshua M. Sharfstein, ‘The Public Health Crisis Survival Guide: Leadership and Management in Trying Times’, Oxford University Press, 2018.
6. ‘Paracetamols, Ivermectin In High Demand As Covid Cases Spiral; Pharma Firms Wary’, Mihir Trivedi, News18, 01 May 2021. https://www.news18.com/news/india/paracetamol-azithromycin-ivermectin-essential-medicines-to-become-expensive-as-demand-grows-manifold-3696131.html
7. Sales by Stockist, Proprietary Data of IQVIA Consulting and Information Services India Private Limited.
8. ‘Climate change and health’, World Health Organization, 30 October 2021. https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health
9. ‘AR6 Climate Change 2021: The Physical Science Basis’, The Intergovernmental Panel on Climate Change (IPCC), August 2021.
10. ‘Free Life-Saving and Generic Drugs’, Ministry of Health and Family Welfare, Press Information Bureau Delhi, 09 July 2019. https://pib.gov.in/PressReleseDetail.aspx?PRID=1577935
11. ‘Upgradation of Healthcare System for Effective Management of COVID-19’, Ministry of Health and Family Welfare, Press Information Bureau Delhi, 27 July 2021. https://pib.gov.in/PressReleasePage.aspx?PRID=1739460