As the Pandemic Accelerates, How Equipped Is India's Healthcare System?

As per recent data, India now has 1,117 active COVID-19 cases and 32 deaths due to the outbreak of coronavirus in the country. Quite alarmingly, the known respiratory disease COVID-19 cases have increased exponentially in the last couple of weeks. Even in a mild scenario with an attack rate of 5-10% and a case fatality rate (CFR is the number who die relative to the number infected) of 1% (At this point, CFR is 2.9%), the number of deaths would jump to a thousand soon. The total number of deaths due to novel coronavirus is doubling every two days in India.

The pertinent question is how do we deal with this COVID-19 epidemic? What policy options do we have? A few short term and long term strategies have already been at work. First, testing would help detect the virus at source, prevent secondary infection and reduce mortality. After facing severe criticisms for,, the government has decided to extend testing to all pneumonia patients.

But the number of government labs (only 117) conducting tests for COVID-19 continue to be grossly inadequate. Although a few private facilities(43) got approval in some states it is anybody’s guess that how many from the lower socioeconomic strata would turn up for testing at private labs, given that the cost of a test would require at least three days of wages for an unskilled worker in India, even if indirect costs are ignored. The problem is that unless we get population level figures i.e., the true number of cases in the population, it is hardly possible to make reasonable policy decisions. It would be therefore highly desirable that tests are conducted free of cost among a sufficiently large random sample of people to estimate the prevalence of coronavirus disease. To start with, the exercise can be carried out first in Kerala and then in Maharashtra, states with most number of confirmed cases of COVID-19. This would enhance our understanding of the disease transmission.

Second, by quarantining people for three weeks, government is hoping to slow down the spread of the virus. However, the national lockdown, at this stage of disease transmission, may backfire in some sense. According to the latest research based on the data from Australia, if 70% or fewer people comply with the advice of ‘physical distancing’, this strategy simply does not work, implying that the spread of the virus will go unabated, regardless of how long 70% of the population keeps itself ‘self-quarantined’.

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Researchers from CDDEP and JHU did a similar simulation exercise on the Indian population and concluded that the gains would be significantly smaller in case of insufficient ‘physical distancing’. Now consider two important facts. Unlike its counterparts in the developed world, India does not have the infrastructure to deliver necessaries at doorsteps and therefore, shops/markets dealing with food, groceries, fruits have been exempted from the lockdown. Two, as per census 2011 data, almost 40% of the Indian households live in one room house and conditions are so cramped that, on an average, five persons share a room in the name of a house. Thus, one cannot help but wonder how effective the strategy of ‘physical distancing’ will be in a socioeconomically and culturally diverse country like India. There is a growing belief that the economic cost of this pan India lockdown might actually outweigh the health benefits.

On day three of the lockdown, a video showing children eating grass with salt in a village in Varanasi went viral. The impact that three weeks of lockdown will have is unimaginable. Aside from economic woes, the wide-spread panic caused by the lockdown and misinformation might see patients with serious ailments avoiding hospitals for the fear of contracting COVID-19. Further, the non-availability of transport may also prevent people from accessing medical treatment, particularly in rural areas.

Let us look at other deterrents – vaccine and drugs. The vaccine can prevent one from getting infected but it is still quite some time away (at least 12-18 months). This means that we need to focus on the health care system, which can save millions of lives by using an aggressive treatment approach in dealing with COVID-19 affected patients. The evidence on coronavirus epidemic indicates that the case fatality rate varies considerably across countries and over time, ranging between 0.37% and 11.23% and some of the factors that affect the higher death rates are coexisting diseases, low quality health services and patient demographics.

According to a report based on 72,314 COVID-19 cases by the Chinese Center for Disease Control and Prevention (CCDCP), the age distribution of the infected persons is as follows: between 30 and 79 years accounted for 87% of the cases, ≤9 years for 1%, 10-19 years 1% and aged 80 years or older 3%. There were a total of 1,023 deaths out of 44,672 confirmed cases. In other words, the overall CFR was 2.3%. However, the reported CFR differed significantly by age.

Evidently people from the older cohort (60+) are highly susceptible  to coronavirus and have higher mortality rate. Importantly, China is not an exception as similar mortality patterns were observed in other coronavirus affected countries including India. In India, out of 25 deaths, 80% were aged between 60 and 85 and the average age of the deceased persons was 64 years.

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Worryingly, there are 117 million people in this country who are aged 60 and above and about one-fourth of them, according to National Sample Survey 2017-18 data, are having at least one chronic disease.  As the epidemic intensifies, there will be a spurt in demand for hospital care, particularly from older Indians, with an estimated 5-10% of total cases needing critical care with invasive and non-invasive ventilators, advanced radiology, ICUs etc.

In absolute numbers, in the worst-case scenario, there could be anestimated 2.2 million severe hospitalisation cases by May 15. This is a disturbing figure, because the health care system does not have the capacity to deal with such a large number of cases. According to one estimate, India has only 3.63 public ICU beds per 100,000 population  and the per capita availability of ICU beds varies tremendously both between and within states.

For instance in Madhya Pradesh, out of the 50 districts, as many as 30 districts had no ICU facility in 2015 (Saigal et al 2017), and more than two-thirds of the facilities were concentrated in just four districts. MP had only 2.5 ICU beds per 100,000 population, and 83% of these were in the private sector and almost 9 out of 10 facilities were of low quality, implying that they either lack sophisticated equipment, such as non-invasive ventilator, facility for ABG etc., or qualified medical doctor.

It is evident that there would be a significant short-fall to match the intensive care need, even under an optimistic scenario (where there will be less number of hospitalisation cases). To put in perspective, Italy, which is similar in size and population density to Madhya Pradesh, has 26 ICU beds per 100,000 population. Yet, the pandemic has overstretched its health system, forcing it to delay non-urgent surgical operations and free up ICU beds for patients infected with COVID-19.

Besides, low number and quality of ICU beds, the skewed distribution and private ownership of facilities are going to be the key barriers to patient care access, specifically for the middle and lower middle-class population in India. The access related issues are similar across India, barring one or two southern states where the health care infrastructure is relatively better. This is the direct fall out of the relentless persuasion of privatisation in health care and weakening of the public health system, which has put millions of older people at danger as they are highly susceptible to COVID-19 and have higher mortality rate. Although any death is unwarranted, the deaths due to avoidable reasons are more painful than the unavoidable ones.

In terms of the health system’s capacity, India is among the least prepared countries to deal with the pandemic. Currently, almost all COVID-19 positive patients are being treated at public hospitals. The Centre’s provision of Rs 15,000 crore for infrastructural upgradation is going to be too little to make any major impact. For example, the estimated total number of ventilators in the country is between 30000 and 50,000 whereas we would need at least 200,000 ventilators.

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Both the Centre and states must find additional resources, which can be used for creating isolation wards, expanding the existing ICU facilities and for purchasing critical care equipment like ventilators. Media reports suggest that in many public hospitals doctors, nurses and frontline workers who are putting their lives at risk for the rest of us are yet to be provided with respiratory masks, surgical gowns and protective eye gear. The neglect of healthcare providers can prove to be very costly. If we do not protect them, how will they protect the patients? Regardless of technical equipment,  shortage of healthcare workers would remain a significant area of concern. The issue of not having enough qualified doctors, trained nurses and support staffs such as physiotherapists, ICU technician etc., would severely undermine efforts to treat COVID-19 affected patients. Years of neglect cannot be overcome overnight.

In states like Bihar and UP, the public facilities would have to manage with 30% human resources of what ideally is required, even after pooling the medical and paramedical staff from the private sectors. This would obviously affect the performance of these facilities and in turn, treatment outcomes. To address this issue, West Bengal decided to recall the retired doctors. This would give them some breathing space. We can take a few more steps.

There are at least ten thousand medical and paramedical students who are currently studying management programmes (including hospital and public health management) in different institutions across India. They should be brought in. This would be an excellent internship opportunity for them.

In addition, another few thousand public health and hospital administration graduates with training in different streams of medicine currently engaged in administrative works in NGOs may also be called in. Finally, we have more than 100,000 registered dental graduates in India, who could prove to be an excellent resource. All of them should be recruited and trained at an early stage so that they can also be used in crisis situations.

It is likely that the demand for hospital care, in particular, advanced care will overwhelm the public health system soon and therefore, tapping the private sector to fill the gap may be a good idea at that point, but it should be treated as a stop-gap solution and treatment must be provided free to all. It is important to remember that the private sector actually has very little to offer in resource-poor settings, where it is actually needed, if one were to work with the private providers for improving access.

For example, in Bihar, there is no registered private provider (i.e., no hospital was empanelled with insurance companies) in 14 out of the 38 districts, according to the analysis based on data from Insurance Information Bureau of India data (Choudhury and Dutta 2019).

In such locations, the public hospital is the only provider and public-private partnerships such as PMJAY play a very insignificant role. Therefore, instead of using PMJAY and other PPP routes to nudge the private sector to capture greater space in health sector, resources should be channelised to augment the capacity of the public health care system to deliver care.

Soumitra Ghosh is Assistant Professor at the Centre for Health Policy, Planning and Management, Tata Institute of Social Sciences.