Integrating one health in national health policies of developing countries: India’s lost opportunities
Established mechanisms of coordination and missed opportunities
Given the uncertainty surrounding EIDs and their potential to cause explosive outbreaks, the need for a cogent response, characterised by strong multisectoral linkages, and rooted in transdisciplinary approaches, has been felt for a while now [8–13].
The emergence of the H5N1 influenza, and the resulting policy and public panic, led to the conceptualisation of multisectoral linkages in India, with human health, animal health, and wildlife sectors coming together to combat the problem. The collaboration was institutionalised in the form of an Inter-Ministerial Task Force and Joint Monitoring Group at the national level, with coordination mechanisms established all the way down till the district level [14]. Written standard operating procedures (SOPs), in the form of avian influenza contingency plans, were developed and followed in subsequent outbreaks. The protocols ensured successful stamping out of the virus from most locations, though some of the north eastern states are now endemic, with porous international borders playing an important role in the continued transmission [15].
While the avian influenza preparedness and response have been success stories for India, the opportunity created could not be capitalised on. The scope of these coordination mechanisms remain limited and have not been extended to cover zoonoses and wider sets of issues emerging at the human-animal-wildlife interface. Several subsequent zoonotic disease events, occurring nationally and internationally, such as Crimean-Congo Hemorrhagic Fever (CCHF), Ebola Virus Disease (EVD), Middle East Respiratory Syndrome Coronavirus (MERS-CoV), brought the sectors together briefly, culminating into a national programme for intersectoral coordination. A proposal for the same was submitted by the National Centre for Disease Control (NCDC) to the Planning Commission Working Group on the disease burden of communicable diseases for the 12th 5 Year Plan [16].
Central to this proposal was the recruitment of a veterinarian at the Integrated Disease Surveillance Project (IDSP) State Surveillance Unit (SSU) in each of the states. This functionary is proposed to serve as a bridge between the two sectors, though limited evidence has been produced to support this strategy.
Around the same time, the National Standing Committee on Zoonoses (NSCZ) was activated [16]. The Standing Committee is coordinated by the Ministry of Health. Ever since its activation, apart from facilitating limited academic discussions, it has struggled to ensure ownership by other sectors. Also, the policy relevance of its existence has so far remained uncertain.
Similarly, the Indian Council of Medical Research (ICMR), the research arm of the Ministry of Health Family Welfare (MoHFW), responded by announcing requests for proposals (RFPs) for collaborative research, though it is unclear as to how the disease/s and research priorities had been identified for this research funding. ICMR’s efforts to promote intersectoral collaborative research culminated into discussions around setting up of a Centre for Zoonoses Research, in partnership with the Indian Council of Agricultural Research (ICAR) [17]. Setting up of such an institution will likely lead to duplication of efforts and inefficient utilisation of funds and resources, as preliminary research by our group shows a vast existing capacity for zoonotic disease research in India – over 300 institutions across different sectors/ministries are engaged in cutting edge laboratory and epidemiological research on zoonotic infections (unpublished observations, Manish Kakkar). Given this scenario, mapping and strategic networking of existing capacity could be a more efficient and sustainable solution.
The review of the institutional capacity for research on zoonoses has also shown that a majority of the investments that have gone into building institutional capacity, as well as research output on priority zoonoses from India, have been produced by the human health sector as opposed to the veterinary sector. Thus, it is no surprise that zoonoses research output in India has been found wanting in its policy relevance [18]. A relatively limited focus of the veterinary sector on human diseases of animal origin could be explained in part by competing priorities that are further affected by the limited core capacity of the veterinary and wildlife sectors in India (35 veterinary and 1 wildlife institution versus more than 390 medical colleges) [19]. Moreover, given the likely source of their emergence, the policy disconnect in our preparedness and response to EID threats, as reflected in uneven sectoral investments, is also quite obvious.
Thus, intersectoral mechanisms aimed at operationalising One Health approach based policies appear to be a set of uncoordinated ad-hoc efforts. It is difficult to point out a single factor that has led to this inertia. A multitude of factors may have had contributory effects. EIDs have been perceived as a human health problem, thereby impeding sectorally integrated policies. There is a lack of evidence on operational frameworks, largely driven by a disconnect between research output and policy needs. A mismatch in sectoral capacities, against the backdrop of vastly stretched existing human, animal health and wildlife disease management systems, has resulted in competing priorities and reactive actions in the event of emergencies. This interplay of multiple factors has led to a lack of appreciation of the benefits of the One Health approach, failing to trigger investments, and appropriate effective intersectoral action. However, the biggest missing link has been an overarching One Health policy, or at least a One Health orientation of existing sectoral policies.