In January 30 2020, India recorded its first case for Corona Virus popularly known as Covid19. Since then India has seen a series of lockdowns and as we inch towards somewhat of a partial recovery, the question around the state of our healthcare system has become centre stage again.
Since the 1940’s where the Bhore committee gave its recommendations for developing the healthcare structure in India, as a nation we have been playing catch up with demand far exceeding the supply in terms of doctors, diagnostic equipment, hospital beds and medicines.
In addition the wellness programs have been struggling and preventive measures have not been very successful. In this context the corner stone of the healthcare system in India has become the hospital.
What determines a successful healthcare intervention is patient experience. Today with the advent of telehealth and the guidelines given by Medical Council of India, it becomes even more important for hospitals to focus on patient experience and add to the growth of the industry.
What is Patient Experience?
Private hospitals have long tracked patient satisfaction ratings, but they didn’t always carry great significance. While all hospitals want happy patients, most hospitals have been historically plagued with the “doctor knows best” mentality — a mentality where clinical outcomes outweigh “touchy-feely” indicators such as patient satisfaction or overall patient experience.
However, in recent years, some leading institutions in India have begun to focus more heavily on providing an outstanding patient experience. Drivers for this include growing consumerism and transparency for healthcare services and increased interest from both consumers and providers in patient-centred care.
Why Patient Experience is important to Hospitals?
Healthcare consumers increasingly view their experience with a provider as a key consideration for determining if they’ll return to or recommend the provider, largely because it remains one of the few ways consumers can differentiate providers. Over the past few decades, clinical outcomes have improved dramatically, and patients no longer view favourable outcomes as a key differentiator as these are expected. What remains is the patient’s overall experience, which encompasses everything from customer service to patient-centeredness and care coordination among providers. Also given the growth of Tele Health, it would become even more important for hospitals to focus on patient experience in order to create a favourable experience and create the hook that would bring patients and others in the community back to the hospital.
We are working on a report on understanding the current digital levers to manage patient experience. We will be releasing the report soon.
Yoga has been India’s gift to the area of preventive health for centuries. Though the practice of Yoga has seen its ups and downs, in popularity, there is no denying the benefits that it brings to us. So on this International Day for Yoga, let me look at three key areas that Yoga helps us.
Strengthening the back
One of the biggest challenges of this lockdown in the quarantine due to Covid19 is a sedentary lifestyle. This has impacted our backs, especially lower backs. As the back and spine carry the entire load of the body it becomes important to keep the back straight and strong. Yoga practices can help. The one asana or practice that I can recommend from practice is the Bhujang Asana or commonly known as Cobra Pose. Highly recommended for those in sedentary jobs and that practically the whole country these days. This is a useful link, that one can use to learn more about the practice.
Strengthening the lungs
One of the biggest impacts of Covid 19 is on the upper respiratory system. As there is no cure for the virus, and no vaccine in sight, the best defense is strengthening the immune system. One of the ways to strengthen the lungs is by the practice of Anulom Vilom Pranayam. The practice as it helps the lungs to grow the size of the lungs and strengthen the upper respiratory system. This is a very important practice and this link is a good example of how to practice Anulom Vilom effectively.
Calming the mind
The other big casualty during Covid 19 is our mental health. Before the lockdown, it was estimated that by 2020 almost 20% of Indian citizens would require mental counseling. My estimate is that number would be close to 50% today. Financial uncertainty and almost no social contact has led to a situation in which many people are feeling the anxiety and slippi9ng into depression. The recent suicide by actor Sushant Singh Rajput has again brought the spotlight on how we as Indians are exposed to mental illnesses. The yoga practice of meditation really helps in fighting depression and strengthening our mental health. A practice daily of 5-10 minutes has had a huge impact on the mind and productivity. Here is a link that can help you get started on this practice.
I hope these links and practices are useful to you. I have been practicing Yoga for the last 4 years and this has really helped me make most out of my day and time. Here is wishing a very International Day for Yoga.
Recently, Dr Devi Shetty, the founder of Narayana Hrudayalaya, authored an article in the Times of India Sunday Edition where he said that healthcare will become a poll issue in the future. Given the historically low percentage of budget allocated to public health in India, can Covid19 realistically push the government to prioritise this area?
An analysis of select 2014 election manifestos indicates that we may be woefully behind on the path to a more comprehensive health plan for citizens.
India spends about 1.2% of its GDP on health services and in 2018 this number went up to 1.4%. However, this is still significantly lower than the time and efforts allocated to areas like physical infrastructure development and jobs.
Women Led parties had more space dedicated to healthcare in their election manifestos (AIADMK – 6% and TMC – 5%). AAP follows closely with 4%, whereas national parties BJP and Indian National Congress (INC) dedicated around 2.3% and 2.1%, respectively. Interestingly, the AIADMK appears to have been implemented given that Tamilnadu leads on several health parameters, the TMC in West Bengal needs a stronger implementation policy to suitably action on its promise.
Most parties tend to pay little attention to preventive health. There is almost no mention of areas like nutrition in election manifestos and while the BJP manifesto does talk about Swachh Bharat, there is no mention of ways to tie that back to measuring health outcomes. The INC manifesto talks about malnutrition and mentions Anaemia and HIV but does not spell out anything concrete in terms of action plans to prevent or tackle the disease.
All election manifestos considered for analysis missed addressing non-communicable diseases and the measures to tackle them. Given the high incidence of non-communicable diseases such as diabetes and hypertension in India, this is a glaring miss.
Most of the focus on health in manifestos is on building hospitals – more beds and more clinics and so on. But there is no focus on the quality of care provided at these centres or the variety of ailments they can treat. One cannot provide hospitalisation and expect improvement in the state of health without tackling the underlying social and sanitation causes for the ailments.
Strangely, while the focus remains on building new facilities, there is no mention of improving existing primary health centres and community health centres that have suffered from decades of neglect. Even in Ayushman Bharat these have not been addressed. While the insurance part of Ayushman Bharat is doing well, the wellness program can be significantly improved.
There is no mention of disease surveillance in any manifesto. This is surprising considering most developing countries in the world have some semblance of proactive disease surveillance to curb the spread of disease and manage its citizens’ health.
In summary, even if all that has been promised in the election manifesto is delivered, it would not even make a dent in the state of health in the country.
Why is this so?
Historically India missed the boat in prioritising healthcare reforms recommended by the Bhore committee in 1946 (See box in the next page), particularly the delivery of health at the grass root levels through primary health centres (PHCs).
Further, religious beliefs that tie poor health to karma and a generally fatalistic outlook have ensured hospitals and external care providers are seen as the last resort for patients. Preventive healthcare was largely provided at home. In line with this, the government has not undertaken research connecting the health of its citizens to their productivity. For instance, a study in the UK found that those who smoked were twice as likely to take time off work. Another study found that workers with obesity (BMI over 30) annually took an average of three sick days more than those with normal weight (BMI less than 25), and those with severe obesity (BMI over 35) took six days more. In India, a large population and limited availability of jobs means employment remains a bigger issue than health for the government.
The relatively affordable cost of healthcare so far has also meant citizens have remained negligent about lifestyle diseases. Until recently health insurance wasn’t understood and perhaps without the tax exemption many citizens may not opt for it.
Until the time healthcare is viewed as a discretionary spend, political parties may see no value in contesting elections on the plank of better healthcare for citizens. Citizens themselves need to demand for better health from its government for parties to take the issue seriously. A possible reason why some of the Southern states have overall better health indicators is the relatively high proportion of senior citizen population that resides alone, without support from younger people who tend to live outside the state/ country. This changing demographic of voters may have prompted political parties in the region to place greater emphasis on public health and deliver results.
In addition states like Karnataka and Kerala have prospered from the investments from the princely states. Tamilnadu alone benefitted by keeping public health distinct from Health Services, this is one of the few states that implemented this recommendation from the Bhore Committee recommendations.
The following part manifestos were considered for the analysis – Bhartiya Janata Party (BJP), Indian National Congress (INC), All India Anna Dravida Munnetra Kazhagam (AIADMK), Trinamool Congress (TMC) and Aam Aadmi Party (AAP). The rationale was to consider national level parties and those led by women, as it is widely acknowledged that women tend to prioritise health. (We wanted to include the Bahujan Samaj Party (BSP) but we couldn’t find the manifesto in the public domain). AAP was considered in the analysis as it was a recently formed political party that emerged from a citizen movement demanding a corruption free India. All manifestos from 2014 were considered for the analysis.
The following parties have not been considered as their manifestos were unclear on the healthcare aspect – JDS Karnataka, Shiv Sena, Shiromani Akai Dal, and Biju Janata Dal. The communist parties are also missing from our analysis. We are planning a follow up report on the analysis of the 2019 manifestos and we plan to include more parties there.
Late January, a medical student fleeing from Wuhan became the first confirmed cases of SARS-Cov-2 in India.1 Couple of her classmates also contracted the virus and India made its initial entry into a leader board no country wants to lead. The three students largely remained asymptomatic and recovered with a month, ending India’s first tryst with the virus.
The second wave started at the end of February. By now, SARS-Cov-2 had spread to 64 countries / regions across the world, with South Korea and Italy reporting over 1,000 confirmed cases. But it is quite possible there were cases in India long before that. It was only in in May that we found that the virus had already reached France in late December itself.2 It is quite possible that the virus had reached India from Europe long before we started screening the flights coming from Europe.
Nevertheless, as confirmed cases started gradually increasing in India, the Central Government took a bold step in locking the country down for three weeks to prevent the spread of the virus. Many countries were opting for lockdown to tackle the virus, but the step by India was a bold one for two reasons:
Lockdown is a strategy for the rich. It meant many will have to live off their savings and those who can’t will have to be protected by the government. US alone has provided for over 3 million via unemployment benefits.3 India, with perhaps the largest number of poor people in the world, would have struggled to provide for those getting unemployed due to lockdown.
It would have taken a phenomenal effort to enforce the lockdown given the size of the country and population density in certain parts. The only comparable country is China, which can rely on heavier surveillance than India could enforce.
By 14th April, Goa, the North East and East India excluding West Bengal were largely unaffected by the virus and had limited the number of cases to less than 100. States like Haryana, Karnataka and Kerala had managed to control the spread as well and showcasing more than one-fourth recoveries.
But it was already evident by then that many places in the country where the infection had reached the community.
Though India officially denied community reach of the virus, on 10th April, Indian Council of Medical Research (ICMR), which was coordinating India’s Covid19 response (Which in itself was odd since there was already another organization fitted for it – Integrated Diseases Surveillance Programme (IDSP) 4) had recommended 36 districts be prioritized to target Covid-19 containment activities. This was based on the Sentinel Surveillance study done till 2nd April.5
By 3rd April, India recorded a little over 3,000 cases of SARS-Cov-2. This was spread across 255 districts in 30 states and union territories. Incidentally, only 66 districts had reported more than 10 SARS-Cov-2 cases then.
And ICMR was recommending stricter containment in 36 districts.
As the economic cost of the lockdown became more apparent, India went on a period of staggered release of lockdown after 14th April. But as expected from a country with community transmission of a virus, India showed a consistent increase in cases as norms got relaxed. What was 104 districts on 24th March, when lockdown started, it became 379 on 14th April, 489 on 4th May, 564 on 17th May and with the last release on 31st May – 654 districts have seen confirmed cases of SARS-Cov-2 across the country.
The Road Ahead
Image 1 – Italy
Image 2 – India
After a long three month struggle, Europe is finally starting to hope they can move beyond Covid. While most of the European countries peaked in cases late March, they have seen a gradual decline in cases over two months.
This long tail foreshadows what we may see in India. But for that, we have to reach the peak first. So, we can expect considerable pain, both from Covid and the economy, for at least the next two months before things start to get better.
The 66 districts that saw more than 10 cases on 3rd April, now account for 66% of the SARS-Cov-2 cases in the country.
As cases increase, hospitals get stressed and treatment gets delayed. This leads to an increase in fatality rate. While India is doing remarkably well with around 7,500 dead from 267,000 SARS-Cov-2 cases (2.8%), there are over 100 districts with a fatality rate of 3.7% and above. The ones to watch out for over the coming weeks:
All these districts have shown consistent growth the past week and has high fatality rate. With more testing, it may be possible to weed out the SARS-Cov-2 carriers and catch patients early, although districts like Kolkata and Nashik may already be stressed, given the high number of cases there.
Ujjain (Madhya Pradesh), Anand (Gujarat) and Panchmahal (Gujarat) have seen low growth in cases recently, but has an overall high fatality rate. Increasing testing in such places may reveal the extent of the spread, since high fatality rate may be due to late stage discovery of the disease.
On a positive note, there are 48 districts that show a high growth rate in cases with a less than 1% fatality rate. This would indicate better testing and good potential to keep a check on the virus. These include Chennai (Tamil Nadu), Chengalpattu (Tamil Nadu) and Gurugram (Haryana). All of the three districts have recorded over 1,000 SARS-Cov-2 cases
Among the 25 districts that have over 1,000 cases, Indore (Madhya Pradesh) and Jaipur (Rajasthan) have shown the slowest growth rate the past week, indicating a positive road ahead.
Late March, George Gao of the Chinese Center for Disease Control spoke to Science Magazine about the road ahead with SARS-Cov-2 – Trace all SARS-Cov-2 carriers with mass testing, Isolate the carriers and trace out their close contacts, Quarantine and isolate the close contacts.6 As we officially start to slowly unlock our economy in June, despite the numbers on the rise, it will be a difficult road ahead for all of us in India.
A century ago, the Indian subcontinent was the biggest graveyard for the Spanish flu virus. In all probability, we are again headed there and the only way to have some form of control is to trace the infected early by mass testing and ensuring strict quarantine of the infected and their contacts. We also need a workable serological test7 to determine who have already been infected (and not initially traced) so that they can get back to work.
By Ranjith Kollanur
Bout the Author
Ranjith Kollanur is the Managing Parter with the Unseen Ink,
India has always been a spiritual nation. For the last 5000 years, we have believed that the source of our mental happiness and wellness is based on our spiritual way of life.
But the modern mechanical world has in a way disrupted that pattern and in the last 50 years, we have seen an increase in cases requiring mental wellness intervention. We also see an increase in cases where patients need counseling and therapy. While this is still an emerging trend it is believed that this year 2020, more than 20% of our po[ulation needs mental wellness interventions.
Covid19 has exposed the need for the same. It is believed that the number of people requiring treatment is almost 25% more than previously anticipated. Also, the infrastructure in terms of doctors, psychiatrists, and counselors is just not there. To discuss this and more Dr Sumeet Kad and I took up this issue in our third episode of India Health Talk. The link is below.
On the positive side, there is an increased awareness of the situation, also due to the rise of telemedicine, we would see an increase in the number of teleconsultations. However, the key is to increase awareness and not take your mental wellness for granted.