Ishan Talukdar
(ishantalukdar666@gmail.com)
Over the years, the healthcare system in India has been largely centralized, expensive and impersonal. In a country where expenditure on healthcare is low, most healthcare expenditure is out-of-pocket and where most of the population continues to live in rural areas or on urban fringes, such care is inaccessible, unresponsive and unaffordable. COVID pandemic exposed these realities further. Based on experiences of directly managing health services during the COVID-19 pandemic in different settings and across different levels, the authors of this paper argue for a decentralized, distributed and responsive health system for India, that is likely to be more effective and sustainable in normal times, and in times of crisis.
Following the recognition of COVID-19 as a pandemic and its rapid spread, the Government of India announced a nationwide lockdown in March 2020. Restriction of movement and fear of contracting COVID-19 made it difficult for families to access healthcare for non-COVID illnesses. Many private healthcare providers closed their facilities to them, and government health facilities significantly reduced the scope of their services.
In the first few months of lockdown, safe management of childbirth, immunization services and notification of tuberculosis reduced significantly. Far fewer patients presented themselves at cancer hospitals for treatment, and patients requiring eye care stayed away from hospitals. In the second wave of the pandemic as well, access and availability of healthcare other than for emergency treatment of COVID reduced significantly.
There are settings, however, where the provision of healthcare was either less affected, saw increased demand, or bounced back quickly during the pandemic and consequent lockdown. We are associated with three such organizations in India, cutting across levels (primary, secondary and tertiary), domains of healthcare (eye care, cancer care and primary healthcare) and geographic settings (remote rural, rural and urban). Based on these experiences, we argue for a decentralized and distributed healthcare system in post-COVID India.
The lockdown demonstrated a critical need for teams across the healthcare spectrum to be prepared and encouraged toward task reorganization. The experience drives lessons for a decentralized system in which tasks redistribution and shifting of roles from sub-specialists to specialists, specialists to generalists and from generalists to non-physicians are critical. It requires investments in equipping, skilling and supporting cadres of health workers and professionals to perform the entrusted tasks. In such a distributed network, the use of technology is essential to ensure coordinated care and maintain the quality of care. Tele-ophthalmology, for example, enables the delivery of high-quality care even in distant vision centres, and in ensuring continued care.
Over the last few decades, India has made significant advancements in the way healthcare is delivered in the country. In terms of employment and revenue, it has been one of the largest sectors and is growing at a brisk pace. Healthcare in India is delivered mainly either by public or private providers. Public healthcare focuses on delivering primary healthcare through community-level health programmes mainly focusing on reducing mortality and morbidity caused by various communicable and non-communicable diseases. It follows a tiered system of infrastructure wherein basic health services are provided through sub-centres and primary health centres, while secondary and tertiary care is delivered at better-equipped establishments such as community health centres, district hospitals and medical colleges that are mostly at district headquarters. The private sector largely has its presence concentrated in tier I and II cities. The disparities and the challenges to equitable, accessible and quality healthcare get exposed when compared geographically. The National Health Policies over the years have served well in guiding the approach toward a more inclusive healthcare system in the country and aim at achieving a Universal Health Coverage (UHC) following a graded manner.
With the COVID-19 pandemic testing of even the more developed healthcare systems globally, the foundations of India's healthcare system have naturally also been shaken. The overall response to the pandemic witnessed both the private and government sector working in tandem. The private Indian healthcare players rose to the occasion and have been providing all the support that the government needs, such as testing, isolation beds for treatment, medical staff and equipment at government COVID-19 hospitals and home healthcare.
India's private healthcare sector has contributed significantly and accounts for about 60 per cent of inpatient care. Most private facilities initiated their plans in response to the COVID-19 pandemic, which involved significant investments to prepare facilities for controlling and preventing the infection, building infrastructure for quarantine and treatment, and equipping the facility with suitable medical supplies and additional workforce. Additionally, hospitals and labs witnessed a sharp decline in revenue due to delayed medical tourism and elective processes (the pandemic is speculated to trim the private hospitals' operational profit by approximately 40 per cent this fiscal year). The OPDs (outpatient departments) had also been closed almost throughout the year as per the government advisory.
The healthcare industry, along with the Central and State governments, undertook a robust response plan to tackle the pandemic by setting up dedicated COVID-19 hospitals, isolation centres and tech-enabled mapping of resources. To effectively manage the outbreak, the Indian government also leveraged technology and developed various applications both at the central and state levels. The Aarogya Setu mobile app which assisted in syndromic mapping, contact tracing and self-assessment were widely used throughout the country. Such technology platforms were used to supplement the response management, which included delivery of essential items in containment zones, teleconsultations with patients, bed management and real-time monitoring and review by the authorities. Over the years, the healthcare system in India has been largely centralized, expensive and impersonal. In a country where expenditure on healthcare is low, most healthcare expenditure is out-of-pocket and where most of the population continues to live in rural areas or on urban fringes, such care is inaccessible, unresponsive and unaffordable. COVID pandemic exposed these realities further. It has also made it urgent to redesign the system that is more decentralized, distributed and responsive.