The year that was

The emerging second peak needs to be checked firmly. It could derail India’s fragile economic recovery.

In less than a year, nearly every industry has been touched in one way or another by COVID-19, and the healthcare market has perhaps experienced one of the most direct impacts.

Initial signs of the tumultuous year ahead began to take hold a year ago this month, with the World Health Organization’s pandemic declaration and a wave of regional lockdowns.

In India, it all began when a student from Kerala tested positive for COVID-19 after returning from Wuhan in China, the global epicentre of the virus.

As the virus gripped the nation, the vast majority of people realized that it was about to change their way of life, at least for a while. Working from home became the norm, stay-at-home orders came down and, eventually, mask mandates started appearing.

To arrest the spread of the virus, the Indian government imposed a nationwide lockdown on the 1.3 billion population, late March. Domestic and international travel was banned and factories, schools, offices, and shops other than those supplying essential services were shut, crippling India’s economy. Since then, India has been facing a huge decline in government revenues and growth of income, and is set to contract 7.2 percent in the current fiscal year to March 31.

But it is not just the Indian economy that felt the impact. No one has been spared. Economies of about 100-plus countries have been destroyed, out of which some of them have asked for monetary help from IMF, ADB etc. Businesses across the world, particularly hospitality, entertainment, and aviation have seen a major negative impact. Various sports events such as IPL and Olympics and industry events as Medica Trade Fair have been postponed or conducted online. Schools and colleges have been closed. The virus has also disrupted the functioning of various online giants.

With accurate testing among the most immediate public health and market needs, medical giants jumped into new markets of PCR, antigen, and antibody tests. When the pandemic hit the country, there was only one testing centre, National Institute of Virology (NIV). The testing facilities have now increased to 2410 testing centres across the country and over 22.4 crore samples have been tested, with a daily count of 700,000 tests. These include the RT PCR, rapid antigen, and antibody tests.

As hospitals halted elective procedures, MedTech companies took big financial hits. COVID-19 cases were beginning to mount, stoking concerns about adequate supplies and hospital resources such as bed capacity and ventilators. Providers were forced to shutter some services, cancel OPDs and surgeries to preserve precious resources.

While much has changed, life for many has yet to return to normal. And some of those alterations may be permanent. The crisis has forced the healthcare providers to rethink how they operate. They have learned a lot over the past year, including how to improve systemwide communications and work on more efficient patient flow strategies.

Physicians say harnessing data was a game changer in combating the novel coronavirus. At the time, there was no tool that allowed physician leaders to see real-time metrics of operations such as capacity levels within each hospital, or even in the ICUs. That required text messages and calls to individual hospital leaders, an inefficient process.

Now, there is a dashboard of information at the fingertips of those who need to make timely decisions. It is referred to as the COVID intelligence. Many health systems have adopted similar dashboards. For example, the dashboard illustrates overall hospital strain and is color coded; green and yellow is good, red is bad. This dashboard enables decision makers to immediately see ICU capacity across hospitals so they can better allocate resources.

The biggest lesson was learning how it could leverage the huge repository of patient data. Doctors across the system are now devising their own projects to see how they can utilize the data to improve patient care beyond COVID-19. The analytics team is assisting them to mine the data for trends and insights.

It enabled tell which patients are most likely to end up in the hospital, need a ventilator, or, in the best case scenario, sail through without complications. One of the most compelling uses of the data is turning it into actionable information and automating it.

The pandemic has forced hospital leaders to rethink the way they operate in all sorts of ways from the mundane to more critical elements.

As the coronavirus wildfire raged, hospitals faced continued shortages and supply chain issues that needed to be addressed rigorously. For instance, they quickly exhausted PPE supplies, a critical resource to keep front-line workers safe.

The onslaught of the virus also forced hospitals to rethink the most basic elements of how they operate: how patients flow through a hospital. It is not uncommon for patients to have to wait for a bed once admitted. Numerous factors influence the trend; for example, Mondays can be a difficult day as surgeons want to schedule surgeries and patients tend to wait to come into the emergency room (ER) until after the weekend. Now, the goal is to immediately move any patient who is admitted up to a bed instead of waiting in the ER.

It is easier now than it was before to monitor chronic patients remotely. So instead of waiting for the patient to come on the next visit, their doctors continuously monitor their vitals and intervene sooner to prevent hospitalization.

Hospital executives increasingly found the focus shifting to automation. Growing in importance, it pointed to the need to curtail wasteful spending, especially in light of the pandemic’s negative financial effects. It is expected that providers could continue to be swamped this year by higher than normal expenses following a surge in cases again.

Concerns about ongoing expenses could lead executives to look for tech-driven ways to cut costs. They anticipate an RoI of two times or higher on their AI technologies. However, despite the growing interest, actually getting the technology in hospitals continues to be a problem in an industry often criticized as being behind the digital curve.

Resource constraints, such as not having enough staff to support implementation, along with difficulty identifying best processes for automation are the two biggest implementation challenges. Additionally, the concept of applying AI in healthcare has given rise to myriad concerns, especially when the software is applied to clinical applications.

The frontline caregivers had other challenges to face. The pandemic has claimed the lives of more than 160,000 Indians and more than 2.6 million around the globe.

A year of working on the frontlines brought a heightened focus on the challenges on the workforce. Nurses and physicians especially are reporting increasing rates of burnout, and a lack of trust and engagement with the organizations employing them. Turnover has long been a problem for the industry, though some fear the pandemic is exacerbating it.

The call to duty never seemed to reach a lull. For many months, nurses and other clinicians worked extended hours as the surge of cases stretched resources. Nurses were in such high demand that hospitals were willing to pay significantly more to bring in additional traveling nurses. They have been pushed to their limits, and some are now considering a change in profession or setting as the country marks one year into the pandemic. After a year of working on the front-lines of a pandemic that took many nurses away from their specialties, dissatisfaction about advancing in their careers has become a problem.

Some are accelerating their retirement plans, or simply looking for other work outside of clinical care. Scheduling conflicts are another challenge drawing nurses with families to other jobs. Some have had to cut back so that they can home school, some have had to make changes, maybe into a different type of schedule where previously they could work a night shift at the hospital and now they need to work remotely, say for an insurance company.

Hospital leaders seem to be grappling with how to adequately address the needs of co-workers. Hospital staff faced unprecedented levels of stress and burnout, leading to concerns about hiring enough people and keeping them well in the future. When they returned home from work, they kept awake at night with the emotional and mental toll the pandemic had. Their colleagues sometimes lost their lives to the pandemic and some had to watch an unfathomable number of their patients pass without family members nearby, but over video calls.

Undoubtedly, the pandemic has caused massive short-term disruptions to the economy and labour market, and the healthcare industry was no exception. And, while some industries may never completely recover from those losses, healthcare will. But burnout could strain supply, and demand for healthcare workers will only grow post-pandemic.

In other parts of the industry, changes in care delivery, including the rapid adoption of telehealth, could alter post-pandemic employment, specifically for physicians’ offices and dentists. Beyond increasing demand, a need to replace workers who leave for different jobs or retire will contribute to the boost.

Independent doctors are now more financially stable. The year saw major health systems and community doctors alike scrambling to ramp up operations to care for the growing tide of COVID-19 patients.

But unlike large hospitals, which have remained on relatively stable footing, the competition for scarce supplies and federal aid, paired with a catastrophic plummet in patient visits early in the year, left independent primary care practices—many already operating on razor-thin margins—wheezing.

After a year of COVID-19 and months of struggling to make ends meet, many independent practices report they are no longer facing an immediate financial cliff. Although expenses, including pricey personal protective equipment, are still high, volumes are almost entirely back to normal, aided in large part by telehealth, primary care physicians say.

Despite the optimism, however, independent practices are still very much in a holding pattern following months of depressed revenue and sky-high expenses. And though data is spotty on medical closures during the pandemic, it is estimated that 7-10 percent of all physician practices nationwide, independently-owned or have closed due to COVID-19.

But even as volumes recover, front-line doctors are facing fresh challenges, including rising frustration that they have been excluded from the vaccine distribution process and worries about downstream effects from delayed care.

Vaccine quagmire aside, primary care physicians are also airing concerns about the ramifications of medical care delayed during COVID-19, saying they are already seeing some detrimental effects crop up. Mental health needs in particular have seen the greatest near-term rise.

One in five adults report pushing off medical care during the pandemic, and of that group, more than half said they experienced negative health consequences as a result.

Independent primary care physicians are reporting a similar emotional toll, as they have for a year now continued to deliver healthcare while facing grave financial pressure and little-to-no direct government aid. The doctors are all suffering from COVID fatigue in some way. Everybody is.

On top of that, the doctors have had to combat rampant misinformation and educate their patients around thorny issues like testing, masks, and now vaccinations—often to intense pushback. Despite the frustration and fatigue, physicians are in a prime spot to address vaccine hesitancy.

As we are at the one-year anniversary of the emergence of this elusive and lethal virus, most parts of the world continues to face its wrath, more so as it has been mutating, multiplying and some variants even more contagious than before. Currently, WHO along with its partners, is currently tracking three virus variants, from the UK (B.1.1.7), South Africa (B.1.351), and Brazil (P.1).

Scientists and pharmaceutical companies worldwide have worked round the clock to get the right molecule for an effective vaccine against COVID-19. A vaccine that takes at least 10 years has been developed within a year. There are 181 vaccines in pre-clinical development and 81 in clinical development. And a handful of them, including vaccines from Astra-Zeneca-Oxford University, Pfizer-BioNTech, Moderna, Gamaleya Institute, Sinopharm, Sionvac, CanSino, and Bharat Biotech are being administered in various countries.

Now that the vaccine has been developed, countries including India are facing the risk of their vaccination process getting derailed. Adar Poonawalla, chief executive officer of the Serum Institute of India Ltd, which is making the shot developed by AstraZeneca Plc and Oxford University in India has expressed concern that countries are holding tight to their supplies and restricting access to materials needed to make more. Serum is responsible for providing more than half of the shots used so far. They, alongwith many other manufacturers, have already missed timelines and commitments. The manufacturer is already two to three months behind schedule and reaching the 2021 target of 2 billion doses will be challenging. The world is facing a continuing challenge of vaccine inequality that threatens to prolong the pandemic after richer nations race to stockpile supplies. Few African nations received a single shipment of shots before March, while more than 20 percent of the population in countries including Israel, the UK, Bahrain, and the US have received at least one shot.

As a manufacturing giant, India has sought to portray itself as a generous benefactor through targeted vaccine diplomacy, while seeking to outdo regional rival China. At the same time, the Centre has tightly controlled the deployment of the doses it has, mostly supplied by Serum.

The Serum CEO is pushing for a fully privatized vaccine market across India. Currently private hospitals and clinics are allowed to charge `250 a dose, but they have to purchase those vaccines directly from the government and can only inoculate people aged 60 and above or those 45 and older who are high risk.

Serum wants a liberalization of the rules to allow corporate clients to negotiate directly and potentially buy supplies at a higher cost, as its vaccines are now being provided through the government at very low subsidized price.

Though opening up the private market would help accelerate India’s vaccination effort-it is only administered about 32 million doses so far, behind the pace needed to reach a goal of 300 million people by August-there are concerns that doing so will lead to price gouging and unequal access across a country with enormous wealth divides. Having said that, a free market would allow corporations to immunize their workforces quickly and speed up the opening of the economy.

The government will speedily need to take a call on this. No doubt it is a tough call, but the recent spike in COVID-19 cases is not looking pretty. It could derail India’s fragile economic recovery. The emerging second peak needs to be checked firmly. The risks of a second wave are already weighing on the equity markets, which fell the most in over two weeks!