The Private Sector Response to COVID-19 in India
This is the second in a series of blog posts by ACCESS Health India Country Director Dr. Krishna Reddy. Dr. Reddy is a board certified cardiologist with a long and distinguished career, marked by his leadership of the CARE Hospital Group which he helped create. The hospital group is now recognized as the most advanced, complete cardiac care center in the country. In this new series of posts, Dr. Reddy will reflect on the impact of the novel coronavirus outbreak on health from his perspective as the director of ACCESS Health India and as a healthcare provider. To access other blog posts click: Part 1, Part 2
Ever since China reported on the growing respiratory epidemic, the response to Covid-19 has been dominated by the public sector response. India has been witnessing continuing growth in the number of new infections, albeit at a moderate doubling time, despite the national lockdown. The current growth rate, coinciding with a graded exit from lockdown, means that the country is preparing itself for a new normal. In India, the private sector meets nearly two-thirds of healthcare needs of people. In addition, most of the healthcare goods—drugs, vaccines, diagnostic tests, biomedical equipment, among others—are supplied by the private sector.
The public health sector includes national, state, and district level governance systems across the country. It enables a coordinated response across the system. The private sector, on the other hand, is highly fragmented and has no such governance system to mount a coordinated response. There are multiple representative bodies for hospitals, nursing homes, general practitioners, specialists, diagnostic chains, pharma and biotech companies, and device manufacturers. A coordinated response from these bodies is not yet evident.
The following brief outlines a few action plans to help mount an effective and coordinated response from the private sector.
How should healthcare providers prepare themselves?
As we enter the new normal of living with Covid-19, healthcare providers will be required to reopen medical services to all people. Until there are vaccines or drugs for Covid-19, people have to continue with non-pharmaceutical interventions (NPI), such as face masks, hand hygiene, social distancing, and isolation. Hence, clinics and hospitals have to make necessary modifications in their facilities to screen and triage people as they enter, provide segregation facilities for suspected or proven Covid patients and others, provide adequate personal protection equipment (PPE) to healthcare workers as per scientific guidelines, train the staff in the new methods of managing patients, and assign at risk staff to non-frontline functions.
While bigger hospitals have built in safety and quality systems—especially with regards to antisepsis—primary care physicians, nursing homes, and small hospitals which account for more than 90% of private healthcare providers require rapid orientation courses to manage themselves, to protect their workforce, and to protect their patients. e-Learning tools can be rapidly developed and disseminated to these providers across the country. Concerned associations can play an important role in this aspect.
Healthcare providers can adopt innovative methods—telemedicine, mobile clinics, home visits, remote monitoring systems—for mild to moderately ill patients to provide services remotely in order to avoid crowding healthcare facilities. Payments systems for these remote services should be designed and put in place. Healthcare provider associations should interact with health insurance players to evolve appropriate guidelines considering the new normal.
Private providers in cities and towns can share details of the resources they have – single room beds, intensive care beds, ventilators, syringe pumps, dialysis machines, ECMO machines, PPEs, nursing and medical staff with expertise in ICU management and ventilator management. They can also agree on charges for sharing these resources. Hospital associations can interact with supplier associations for better coordination in sourcing critical material. Online platforms can connect healthcare providers with suppliers. Similar efforts can also be built for sharing diagnostic tests.
Embrace public health responsibilities
Private healthcare is not well geared to take on the full responsibility of containing the epidemic. Ill prepared hospitals, clinics, and healthcare professionals have become a major source of spread of the virus in many countries. The majority of healthcare providers in India – both public and private – do not have a robust antiseptic culture of wearing masks, gloves and sterile gowns, or even basic handwashing before and after touching ill patients or surface cleaning techniques. Very few private sector facilities monitor hospital-acquired infection rates. Very few understand the need to notify concerned authorities about communicable diseases, thereby shirking their fundamental responsibility to the public. Covid-19 should change the prevailing culture towards a more responsible culture. Basic quality certification should be made mandatory to all providers in order to protect the public from healthcare-acquired infections, medication errors, and wrong site procedures or other dangers.
Gain public trust
While people, even those who can’t afford private healthcare, have lost trust in public healthcare facilities, there is a growing disillusionment among people with private healthcare as well. Sensational media reports on hospital bills for dengue cases, suspicion of doctors’ recommendations high cost tests and procedures, fast rising bills that even the middle class is finding unaffordable have dented the public trust in private healthcare. There is a risk of that mistrust deepening further during times of Covid as they are either denied care or charged exorbitant prices for care. The private sector should reflect on their role in diminishing public trust and come up with solutions that sustain them financially while demonstrating their social responsibility.
Health financing solutions for accessing private healthcare
Out of pocket expenses (OOPE) account for nearly two thirds of health expenses in India, despite growing protection being offered by various public, private, and employee health insurance programs. Representative bodies should coordinate with insurance providers to bring clarity to the reimbursement process. Since many hospitals are facing acute cash flow issues, these insurance players can make advance payments to their empaneled hospitals, based on average bills raised during the corresponding period for the previous year.
Consumer financing has been growing rapidly, leveraging innovative and emerging fintech solutions. While consumer financing focused mostly on goods, there is a great opportunity to finance healthcare service needs, akin to financing education needs. People finance their OOPE through their individual or group savings, sale of their precious assets, or by borrowing money from lenders at exorbitant interest rates. Self Help Groups (SHGs) have been undertaking cooperative financing of their members’ unexpected needs. A case can be made to influence public policy to earmark lending to SHGs.
Private sector response to supply goods
There is a need to create a platform where data can be provided with regards to products, stocks, and their prices for specific Covid-19 products. The platform will be able to connect healthcare providers with suppliers. That way limited supplies can be made available most efficiently.
There is an intense competition across the globe to capture the new market for Covid-19 related products, including tests, drugs, vaccines, critical care equipment, and PPEs. India is trusted globally to supply quality goods at affordable costs – it supplies the bulk of vaccines and drugs for viral infections like hepatitis C and HIV. Private manufacturers should leverage the large research and development capacity that exists in public sector. The innovations need not be in developing new products. They can look at repurposing existing drugs or innovate on processes that reduce the cost of production. They should also partner with international universities and multilateral bodies who are looking at bulk manufacturing partners to ensure equitable supply to low and middle income countries.
Public Private Partnerships
Over a period of time, public and private healthcare systems diverged from each other so much that there is an evident distrust between them. While the private sector focuses on individuals, public healthcare looks at the whole population. There is a need to change the prevailing mindset in both systems – the private sector should also be accountable for population health, while public sector should not neglect individual basic health needs like safety, quality, and experience. While medical professionals have drifted more towards the private health sector, nursing and allied healthcare professionals and ASHA workers prefer the public health system. While public healthcare is overburdened in terms of bed occupancy and consults per doctor, much of private healthcare has underutilized capacity, be it beds, high-end equipment like CT scans and MRIs, or doctors or teachers. There is a strong case to be made for nurturing the public private partnership with a shared goal of better population health.
Unleash Digital Health
We have been hurtling towards the digital age over last few years. While many sectors are eagerly embracing the new technology revolution, healthcare has been hesitating to take the plunge. Health systems across the world needed the push of Covid-19 to enter the new world of digital health. India is at the cusp of pole-vaulting on the shoulders of digital health to transform its health system and achieve the goal of universal health coverage for all to access quality and accountable care. The ground is getting well prepared – there is a policy push, be it in National Health Policy (NHP-17) approved by the parliament, or be it in National Health Stack published by Niti Ayog, and the recently published National Digital Health Blueprint (NDHB) by the Indian Ministry of Health; there is a convergence of mobile and internet penetration, high-speed data bandwidth reaching the remotest part of the country, and the cheapest rates in the world; and the explosion of the start-up ecosystem in the digital health space. Covid-19 has the potential to ignite and open up unimagined opportunities for the private sector in digital health, not only to meet domestic needs, but also to meet global needs.
While Covid may be devastating every aspect of life, we should not lose the opportunity to learn and grow. This is the time for the private sector to evolve strategies to think in terms of the whole health system—not just their own sector—in terms of population health and not just individual health.