Opinion: How can India address big surge for health care after coronavirus lockdown?

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Photo by: Madhukar Pai

India’s COVID-19 lockdown bought valuable time. Infection rates are only now starting to increase, and case fatality rates have remained lower than in many other countries. But how the health crisis plays out in the future depends critically on what is done with this borrowed time — and how effectively planning is done for the future.

This is not only in terms of expanding hospital facilities for managing COVID-19 and increasing capacity for testing, but also ensuring that the millions who have not received care during the lockdown do not contribute to a sharp rise in mortality and morbidity from illnesses not related to the coronavirus.

The numbers are frightening. The National Health Mission’s year-on-year comparisons of — mostly — public sector clinics show that vaccinations for measles, mumps, and rubella are down by 69%; outpatient treatment of acute heart conditions is down by 50% and oncology by 70%; inpatient treatment of hepatitis is down by 59% and malaria by 33%; and even the number of lab tests for tuberculosis is down 34%. Other disruptions to TB services have been widely documented as well.

These are probably underestimates. About 70% of primary care and over 50% of hospital care in the country are provided by the private sector, which is massively underrepresented in the data. Many private establishments have shuttered their operations during the lockdown or chosen not to manage patients due to a lack of personal protection equipment or the fear of contracting COVID-19.

If these deficits in care are not addressed soon, we are likely to see a resurgence of vaccine-preventable illnesses, thousands of deaths from chronic illnesses, and a rise in mortality due to infectious diseases such as tuberculosis, which kills over 1,000 Indians every day. Mathematical models suggest that each month of lockdown in India could cause an additional 40,000 TB deaths over the next five years.

As the lockdown lifts, two kinds of challenges will emerge.

First, as lockdowns are eased, there will be a massive surge in demand for care for all conditions. Patients who were receiving TB treatment and have run out of drugs and those who need dialysis or cancer treatment will desperately try to get the care they need.

But they will find it challenging. The public sector will need to continue dealing with COVID-19 — India now has about 200,000 cases, with numbers rising every day. Public sector capacity will be saturated quickly. The private health sector is nowhere near normal capacity, and it will take time for it to restart operations — some closures may be extended due to coronavirus cases among hospital workers or even made permanent.

A surge in demand for private care, combined with a decline in the number of private health facilities, is a recipe for price gouging and short-term profit making, which will further exclude the poor from accessing health care.

Second, for other types of care such as childhood vaccinations, we may see permanent deficits. Research has shown that missed vaccinations are not “made up” at a later time. Even something as small as a nurse being absent on the day that an expectant mother visits a clinic leads to a permanent deficit in care.

We need to have a plan to address these shortfalls today. The key to ensuring that the COVID-19 pandemic does not leave a long shadow on our health depends on our ability to rectify the deficits in care that have emerged during the lockdown while reconfiguring our systems to successfully maintain physical-distancing requirements and other proven interventions such as increased testing capacity, targeted isolation, and contact tracing. A plan that successfully addresses these challenges requires three components.

Money. The pandemic is clear proof that if we do not invest today, we will have to spend a lot more tomorrow. A child who is not vaccinated against measles may contribute to a measles epidemic down the line. TB patients who have received intermittent treatment are at risk of developing drug-resistant disease that requires spending 10 to 100 times as much per patient in the coming years.

We need to earmark these funds today. It will not be easy, given multiple demands from every sector on the government budget, but there is no choice. At a minimum, India needs to increase health expenditure to reach 2.5% of the gross domestic product.

Care delivery innovation. As multiple studies show, financial investment in health is necessary, but it is far from sufficient, even in normal times. In these extraordinary circumstances, addressing pent-up demand while maintaining physical distancing requires great imagination and innovation. But it is not a hopeless task.

For instance, a little-known fact about our public health system is that our community and district hospitals are bursting at the seams but our primary health care centers in rural areas spend an average of only 20 to 30 minutes with patients daily, leaving most of the day free. We can “spread the load” by reconfiguring patient pathways optimally and ensuring that more care is delivered in primary health care centers and at home rather than in a limited number of facilities.

One option, for instance, is to use mobile vans to deliver vaccines and medicines in villages throughout the country. Telemedicine, e-pharmacies, and phone-based consultations must be leveraged, even if this might only reach those in cities and those who can afford internet services. India could also harness the large number of nongovernmental organizations and community-based groups to enhance capacity for grassroots-level health care.

The key to ensuring that the COVID-19 pandemic does not leave a long shadow on our health depends on our ability to rectify the deficits in care that have emerged during the lockdown.

Partnerships and training. We have to make the private sector a partner in these unprecedented times.

Take, for instance, the fact that in rural India, providers without any formal medical training provide 60% to 70% of all primary care. We have shown that although the care provided by these informal providers is worse than what patients receive from formal, qualified doctors, it is not as bad as we may believe, especially if they receive added training. Further, it is a realistic option for the vast majority of the rural population, and structured training can improve care in a cost-effective manner.

Programs that allow private and informal providers to engage in vaccination efforts and the monitoring and management of chronic illnesses and minor acute conditions with clear referral pathways can help us reconstruct our systems in a way that is consistent with the long-term physical distancing that COVID-19 will require.

Structured purchasing agreements are not easy to set up and regulate — and this will almost certainly require a significant effort in training and providing PPE to thousands of health care workers. But the pandemic requires India to better regulate the private health sector and ensure national needs are met, without expecting the private sector to do things for free.

Partnering with the private health sector does not imply abandoning the public health system. India needs to strengthen the public health system while simultaneously regulating and engaging with the private health sector to deliver quality, affordable care. It is not an either-or situation. India needs to leverage both sectors to meet the surging health needs of over 1.3 billion people.

Everyone’s bandwidth is currently focused on the pandemic and its immediate effects — as most of it indeed should be. But we need to recognize that this is only the first phase of the crisis. A second phase requires India to provide the care that was missed in the last few months and rebuild the fragmented health system. This is the best way to prepare for the next pandemic.

About the authors

  • Madhukar Pai

    Madhukar Pai, M.D., Ph.D., is a Canada research chair in epidemiology and global health at McGill University, Montreal. He is the director of McGill Global Health Programs and associate director of the McGill International TB Centre. Madhu did his medical training and community medicine residency in Vellore, India. He completed his Ph.D. in epidemiology at University of California, Berkeley, and a postdoctoral fellowship at the University of California, San Francisco.
  • Jishnu Das

    Jishnu Das is an economist, a professor at Georgetown University in Washington, and a senior visiting fellow at the Centre for Policy Research in New Delhi.