Dr K Madan Gopal
Senior Consultant
NITI Aayog

Strengthening Indian healthcare post COVID-19

India witnessed an outbreak of the coronavirus in late January 2020, and as of September 30, 2020, India has the second-highest number of confirmed cases in the world with ~6.3 million cases and ~98600 deaths. Despite stringent lockdown measures, India still has the highest daily increase in positive cases and deaths.

Besides, the shortcomings of the healthcare ecosystem have been laid open with continuous reports of bed and ICU shortages, overbilling, non-standardized treatment, and non-coherent policymaking at the top levels with different organizations releasing different advisories (ICMR, NDMA, State Government, MoHFW, etc.)

It is a pressing case of both an opportunity and a need to transform or run the risk of increased inaccessibility, unaffordability, and poverty. It is a case of strengthening across its entire ecosystem for fulfilling its objective of Universal Health Coverage.

These reforms need to be carried out on the backbone of some of the known strengths of Indian healthcare, with excellent performance in the areas of pharmaceuticals and human resources in particular. India continues to be the largest provider of generic drugs and vaccines globally and has also launched a new scheme to boost the production of active pharmaceutical ingredients (API) that are currently dependent on the Chinese supply chain.

India boasts of the world’s highest number of medical schools, and has become a leading source for nurses. Doctors and nurses from India have excelled and distinguished themselves across the US and Europe. India has become the single largest source of emigrated physicians in the world.

However, the public healthcare agenda remains largely unfinished. The buildings of most state-run hospitals and health centers are in a neglected state and unhygienically maintained. Even medical equipment at the hospitals is poorly maintained. COVID-19 treatment is currently focused in government hospitals and apathy toward the public healthcare system poses a challenge to India’s COVID-19 containment plans. Increasing public healthcare spending to 2.5 percent of GDP as a vision in NHP can help solve some of these challenges.

India has among the lowest percentage spending of GDP on public health among the 10 countries of its geographical region. Limited funding for the health sector coupled with low efficiencies in public spending by the government for years has adversely impacted the quality, reach, and provisioning of adequate healthcare services.

Further, there is an acute shortage of the absolute number of medical manpower. The COVID-19 pandemic has added to the stress of an overburdened healthcare workforce. India’s doctor & nurse to population ratio are lower than the World Health Organization benchmark. The long queues, and in some cases, the absence of the required specialists has led to a trust deficit in the public health system in many parts of the country. Primary health centers are facing a severe shortage of resources like skilled medical and para-medical workforce. Reforms in medical education and national medical commission should be expedited to help increase the absolute capacity of Indian healthcare. Further, due care should be taken to adequately deploy these workforces and prevent over-concentration in urban areas. Despite the rapid addition of ~67000 MBBS doctors to the healthcare ecosystem, the urban concentration of health services and medical professionals remains a challenge in a country where two-thirds of the population still live in rural areas. The service of doctors in local/rural areas could be incentivized.

The private sector provides 70 percent of the country’s healthcare services. However, it is largely unregulated. Further, very few PPP models of excellence have evolved in the last 70 years. While the private sector can duly help on various fronts like COVID testing, critical care beds, ventilators, manpower, treatment, and PPEs among other aspects, the action on the ground was somewhat wanting. There is evidence of patients expressing unhappiness over high costs of treatment in the private sector. This public-private participation should be undertaken in a more mission mode basis with dedicated financing and governance reforms associated. For ~3.2 beneficiaries of CGHS and 550,000 of ECHS, bills of over `1,000 crore remain pending. An immediate case in reform is the release of pending dues from the private sector to bridge the trust deficit. COVID presents an opportunity for the government to rekindle discussions about Universal Health Coverage and strengthen accountability and the relationship between public authorities and private providers. Instead of forcing the private sector, there can be a formulation of a stable policy-based strategy to get the private sector on board.

The performance of some of the health insurance schemes also needs to be improved. For example, ESI, with ~130 million beneficiaries, had only ~2400 isolation beds, 550 ICU/HDU beds, and 200 ventilators for COVID management. Further, there is a lack of uniformity about the pandemic in India across states in almost every healthcare metric. There are variations across state government policies on bed management, therapeutic management, data management, private hospital contracting management, and management of payments/reimbursements.

Alongside insurance schemes, there is a need to rekindle the focus on preventive healthcare. The creation of 150,000 health and wellness centers by 2022 by transforming existing sub-centers and primary health centers under the Ayushman Bharat scheme is a major move in the direction of primary care. The upskilling of nurses and Ayush doctors for larger roles in the community (like in the UK, Thailand, etc.) can be explored. The focus of primary care can be modified to a more comprehensive and community-integrated approach. In COVID also, there is overwhelming scientific evidence of adopting preventive care like masks. However, in India, there is evidence to show that educated civilians are not wearing masks and are having a casual attitude with strange excuses. This poses a serious threat to India’s COVID struggle and ultimately to the healthcare system. Hence, alongside a push to increasing the supply of primary care, a cultural change needs to be brought in the society to support the demand for primary care also.

One of the levers for achieving some of the above reforms is digital health, however, it remains largely untapped. The Internet has penetrated 50 percent of India and more rural areas than urban. This presents a golden opportunity to develop telemedicine, patient monitoring, health awareness, and especially electronic health records.

Similarly, on the MedTech front, there is an urgent need to upscale the capacities, especially in the high-end business. In testing alone, India currently conducts ~1.4 million COVID tests a day of which ~40 percent are RA tests which have a high false-negative rate. India has 1039 NABL accredited diagnostic labs which are mainly private labs, of which 462 private labs are approved to conduct RT PCR tests (481 government labs are also doing RT PCR tests). The majority of these 462 labs are doing only ~100 RT PCR tests a day.

Many of these reforms have been iterated time and again by different committees and forums, However, the present crisis has presented a window of opportunity with unprecedented unanimity in initiating reforms in this sector. There must be a positive change in India’s healthcare system to be constituted, by inviting a coordinated action from all stakeholders to continue to provide affordable, accessible, and acceptable quality care.

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