How Ill Is India’s Health Sector?

Till about the end of June, Dr Tanaji Lakal would look out nervously from the window of his office in Osmanabad Civil Hospital and feel grateful. By that time, the Covid-19 pandemic had swept through Maharashtra’s large cities, such as Mumbai and Pune, and begun to make inroads into the state’s smaller cities and towns. But somehow it seemed Osmanabad was being spared. “The whole city was in a green zone for a very long time. And even when the virus was spreading into nearby districts, we were getting only a few cases,” Lakal says.

And then came July.

The number of cases began to grow rapidly across the district from then on. Osmanabad, to the south-eastern end of the state, consists of many small villages. While there are a few minor private hospitals in the city of Osmanabad, for both the city and the entire district, the Osmanabad Civil Hospital, with its over 400 beds, remains its most vital healthcare set-up.

When the sudden surge began, the hospital didn’t just get cases of patients who had either travelled from cities such as Mumbai and Pune or had relatives visiting from those areas, Lakal says. There were also farmers who had remained aloof in their fields for months. Soon, the hospital was close to breaking point. Even when a centre came up nearby where the mildly symptomatic patients would be sent, there were not enough beds in the hospital. There were shortages of drugs and oxygen cylinders, the nursing staff was untrained in procedures such as when and how to use nasal cannulas to deliver oxygen to patients, and perhaps the most crucial, there were just two doctors for the entire hospital. Lakal and his colleague Dr Pravin Dumne divided their duties between themselves in 24-hour-long shifts. “That was the only way. One of us would do a 24-hour-long shift and the other would take the next shift,” Lakal says. “We would spend almost our entire shift drenched in sweat in PPE suits. It was exhausting because we had to be everywhere. And so many were dying too.”

In July, Lakal’s colleague Dumne became infected. The following month, Lakal himself had to be admitted to the ICU with the infection.

Much of the focus during the pandemic has been on large cities where the disease first appeared and continues to take a heavy toll. But in less urban areas, especially those which lie close to these big cities, the pain has been no different. Here, the shortage of doctors and trained healthcare workers becomes more glaring, the paucity and inadequacy of healthcare centres starker. For instance, in the state of Maharashtra, which continues to lead in total number of infections so far, it is estimated that there is a need of 19,752 doctors, nurses and paramedics to fight Covid. According to an Indian Express report, as of September 15th, 12,574 of the posts were vacant. Of the 1,700 Class I doctor posts (including specialists) that the Public Health Department needs to fill, only 538 have been.

In many of the more rural areas of India, such as the district of Osmanabad which lies close to cities like Mumbai and Pune, the healthcare system has come close to collapsing. There has been a respite in the last few weeks, but many worry that there could be another wave of large infections, brought on by the coming festivals.

The surge lasted right up to the beginning of October in Osmanabad. But over the last few weeks, in a pattern mirroring the rest of the country, infection numbers have begun to come down in this district too. Help has also arrived. Two private doctors and a few AYUSH doctors have been contracted at the hospital. The care of patients has now been divided among the doctors in a better manageable four units, with a single doctor having to pull a 24-hour shift just once in four days.

“It’s become much better now,” Lakal says. “But I still worry what might happen if things went bad again.”

The healthcare set-up across cities and rural areas, both government and private, is currently in disastrous shape. While the rush of patients has laid bare the inadequacy of government hospitals, most private hospitals are in a financial mess. While the costs of running a hospital during a pandemic have shot up, revenue streams, especially from international patients and complex surgeries such as organ transplants, two categories that make up the bulk of private hospitals’ revenue streams, have nearly collapsed. To add to the chaos, there is a tug-of-war going on between insurance companies and private hospitals over what should be the adequate pricing of treatment protocols for Covid patients. There have even been instances of doctors threatening to go on strike over unpaid salaries.

Dr Rohinton Dastur, the medical director of Bhatia Hospital, a well-reputed private hospital in South Mumbai, told Open a few months ago that many private hospitals are close to shutting down. Costs from the need for frequent testing, PPE suits, and higher financial incentives for healthcare staffers to continue working in the pandemic have shot up, while revenue remains low. “I know a lot of hospitals which won’t be able to sustain this way beyond two months,” he said.

IndiaSpend, studying the balance sheets of some of India’s leading private hospitals, found many of them were bleeding. The total income from operations of Fortis Healthcare, for instance, had fallen 46.8 per cent or Rs 532.4 crore when the April-June quarter of 2019 (Rs 1,138.3 crore in income) was compared to the April-June quarter of this year (Rs 606 crore in income). The company reported a Rs 178.9 crore net loss in the quarter compared to the Rs 67.8 crore net profit for the same period last year. Narayana Hrudayalaya saw a Rs 383.9 crore dip in total income from operations (from Rs 777.4 crore to Rs 393.5 crore), with a reported net loss of Rs 119.7 crore for the same period compared to a Rs 30.3 crore net profit in the same quarter of the previous year. ‘The trend persists for smaller and mid-sized listed hospitals such as Kovai Medical and Artemis Medical Services,’ IndiaSpend reported. ‘Kovai Medical saw its total income from operations fall from Rs 165.4 crore to Rs 129 crore, while Artemis Medical Services posted a Rs 73 crore drop in revenue year-on-year from Rs 135.7 crore to Rs 62.7 crore.’

According to Dilip Jose, Managing Director and CEO of Manipal Hospitals, while the biggest impact to their hospitals’ revenue stream was in the early months of the pandemic when the lockdown was enforced, even when more people are visiting hospitals for non-Covid treatment, normalcy hasn’t yet returned. “The biggest impact on patient footfalls was in April, when the fear of the virus was probably at its highest and travel restrictions were near-total. Overall, OPD (out-patient department) visits fell to about 20 per cent of pre-Covid levels and consequently there was a similar decline of in-patients too. Both reflected in the revenue, which dropped to about a third of that in January or February,” he says. “Elective procedures constitute a significant proportion of the work in hospitals and almost every patient opted to postpone such interventions. Sadly, even lifesaving procedures like organ transplants or treatments for serious conditions like cancer were delayed in the early months of Covid. Even now, well over six months into the pandemic, such elective interventions are yet to return to earlier levels. Keeping aside its impact on the income of the hospitals, the tragedy is that lives that could otherwise have been saved or had a better quality, are being lost,” he adds. Pointing to the higher costs most private hospitals now incur, Jose says, “The increase in operating costs are on account of cost of PPEs, additional cleaning cycles and sanitisation, reduced work hours for healthcare professionals as well as special allowances for staff engaged in caring for Covid patients. Further, there are significant costs incurred on quarantine, alternative accommodation and other facilities for employees. Capital expenses were also incurred to set up fever clinics, testing facilities and to make changes to the hospital infrastructure to treat Covid patients.”

By the end of last month, more patients had begun to visit hospitals. In the Manipal Hospitals’ chain, most of their hospitals have seen OPD visits at about 80 per cent of pre-pandemic levels and in-patient occupancy at near normalcy by September-end. “However, these include Covid patients, who form a sizeable proportion of both. Elective procedures remain below normal trends and these are visible in specialties like orthopaedics, neuro sciences and cardiac sciences. Avoidable morbidities and perhaps deaths too are occurring even today. Regretfully, that would be very disproportionate to the risk of contracting the infection from a hospital, if that is what is preventing patients from accessing treatment,” Jose says.

Various state governments have responded to the pandemic by clamping down on prices and forcing private hospitals to reserve beds for Covid-19 patients. These, hospital representatives claim, have also hurt their bottomline. There is currently a PIL in the Supreme Court that seeks to curb the prices private hospitals can charge for treatment of Covid patients. The General Insurance Council responded to this issue by releasing an indicative rate chart for Covid treatment, but private hospital associations, such as the Association of Healthcare Providers (India), have come out with their own charge structure which is far higher.

Dr Alexander Thomas, the president of the association, did not respond to requests for an interview, but he has told a media outlet that they have shared their rates with the council and are trying to reach a consensus.

Many patients have also found it difficult to get their Covid-19 treatment expenses covered by their health insurances. While the Insurance Regulatory and Development Authority of India (IRDAI) has issued circulars instructing insurance companies to cover Covid-19 if an existing policy already covers hospitalisation, and also pushing them to process Covid claims expeditiously, problems have persisted. One such has arisen over price caps on private hospitals—with the hospital insisting these caps do not extend to those with insurance while many insurance companies refuse to pay anything in excess of that.

According to Bejon Kumar Misra, an international consumer policy expert, while many state governments have introduced price caps, these do not have any legal standing. “These would come under the Clinical Establishments (Registration and Regulation) Act, 2010, but so far no state government has implemented it. Some 18 states have just notified it, but the implementation hasn’t happened. So even if hospitals do not adhere to the price caps, there is no regulation really that can check them from doing so,” he says. Misra points out that much of the blame for the current impasse between insurance companies and private hospitals lies with IRDAI. “The body is too beholden to insurance companies. They will often meet insurance companies, but as a policy holder (or activist) it is impossible to meet them even with genuine concerns,” he says.

In such a situation, it is not a surprise, he says, that insurance companies have refused to completely honour their policies during the pandemic. One of the results of the impasse, Misra points out, is that many private hospitals have stopped taking cashless options for policy holders, and when patients seek to reimburse their costs, they are told they have been overcharged.

When asked about the price caps introduced by various state governments, Jose says that private hospitals stepped up to take on the challenge and to work with governments during this pandemic. “While in many instances, the price caps that were fixed were seen as not taking into account the actual cost of care, hospitals went ahead with providing treatment, separating their duty from the dialogue on the prices. Major hospital groups have the ability and balance sheet to tide over resulting losses, but there are many instances of standalone facilities or nursing homes closing down as they were unable to deal with such a situation. The larger distress is losing hospital capacity at a time when the country requires every possible bed to be available,” he says.

According to Jose, of the nearly 15 lakh hospital beds in India, over 60 per cent are in the private sector, and smaller facilities account for a bulk of that. “Revival of stressed hospitals needs to be a priority, so that investments already made are not lost. Larger hospital groups may be able to play some role in that direction, but a lot would depend on the steps that government(s), regulatory bodies and financial institutions take,” he says.

In Poladpur, a remote taluka at the southern end of Maharashtra’s Raigad district, Rajesh Salagare mans a tiny hospital of about 30 beds. This is like the many small centres that dot India’s countryside, unremarkable in appearance but serving as a vital link.

Salagare is an AYUSH doctor and at night he is relieved by another. For years, there has been a vacancy for three specialised doctors but this has never been filled. Until Covid-19 hit this remote hospital, a majority of Salagare’s patients were people who had been bitten by snakes or scorpions, or women at childbirth. Occasionally, people who had injured themselves in accidents on the nearby Mumbai-Goa highway were brought in. But patients with severe cases used to be mostly sent away to distant, bigger hospitals.

When Covid hit the area, this small hospital was made to double up as a screening centre. “RT-PCR results take three days here. So we would have to keep the suspected Covid patients here with the others until the result came,” he says. “Plus there was the regular work. It just became very difficult,” he adds.

“I am an AYUSH doctor. I can treat snake bites and things like that. All this is beyond me,” Salagare says. For now, this AYUSH doctor and his unremarkable but vital hospital in the countryside are soldiering on.

CoronavirusCovid-19health sectorhospitalspandemicpreparedness