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.
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[1] 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.
In the last week of April 2020, a septuagenarian in the state of J&K who was a renal dialysis patient for 2 years, was asked to get his next round of dialysis from a private nursing home as the hospital where he normally went for treatment refused the dialysis procedure since the entire hospital was converted into a COVID care center. The nursing home neither had the apt infrastructure nor the skilled personnel to handle any kind of complications that is common during a dialysis. Unfortunately, the patient died in less than a week. Another dialysis patient in Mumbai had to wait for 7 hours for treatment as he was not carrying his covid test result report. Around 1,30,000 patients are on dialysis in India and most of them depend on private dialysis centers.
In another caustic case, last week, a 25 yr old pregnant woman in Delhi, visited 2 of the leading government hospitals in Delhi for antenatal care. Both the hospitals denied her admission as she was not Covid-19 positive. As a result, she visited 6 hospitals and maternity clinics in next 48hrs before giving birth outside AIIMS. Many hospitals and nursing homes are completely shut even if one case comes up in them.
There are a plethora of such cases rising across the country as our healthcare system is under stress from managing the contagion outbreak. This is despite the fact that the Government of India has asked state chief secretaries to ensure that hospitals and clinics do not ask for a Covid test report from every patient who requires medical treatment. This raises red-flags and serious questions on the local authorities and regulatory bodies who have also threatened to cancel the operating license of hospitals and clinics if they turn away any non-Covid patient. Patients also fear the escalated economic cost if their treatment cost is not claimed or reimbursed as not all nursing homes and clinics fall under health insurance policies.
Similar danger mounts on Cancer and TB patients. India has the world’s largest TB load of 25%. In Mumbai, due to COVID, lack of adherence to TB drug regimen has risen to 40% from 15%. A significant decrease in TB notification has been witnessed which indicated that access to a TB center and subsequent diagnosis and reporting has been severely hit. These are dangerous signs which are being ignored. A TB patient can infect 10-15 more, and such patient can become a breeding-ground of new Coronavirus cases as Covid hits hard on low immunity patients. Many senior oncologists have claimed that due to difficulty in travelling during lockdown, many hospitals not providing regular treatment, hospitals shutting down and fear of contracting covid, have resulted in a delayed diagnosis of cancer patients which can push them to an advanced stage of cancer.
There has to be clear and stringent guidelines by MoH to each state health authorities highlighting the delirious effect of not providing critical care to non-Covid cases. State should ensure that no patient is denied treatment for any ailment by a hospital (government or private). Instead of shutting down the entire hospital even for one covid case, a wiser approach of creating zones within the hospital can be implemented. Online, phone consultation and Tele-medicine modules should be made widespread thorough proper communication channels.
Our healthcare infrastructure is one of the weakest in the world with a lack of adequately qualified health care professionals adding to the woes. We certainly can’t afford to inflict more burden on the already fragile healthcare services by denying treatment to those who are in need.
About the author
Dr Sumeet Kad is a Healthcare and Artificial Intelligence Leader, focusing on leveraging technology to create a model for affordable care
The world is grappling with the stark implications stemming out of the uncontrolled coronavirus pandemic. Healthcare infrastructure is under severe stress. Precious lives are being lost in large numbers (over 143k fatalities so far). Economic fragility is peaking, unemployment rate is mounting, and supply chain breakdown is hurting millions across the globe. With no sign of cure or vaccine being available in foreseeable future, nations are deploying strict and discrete measures to arrest the impact of this unprecedented crisis.
In this digital age, populations are benefitting from the constant flow of information related to covid19. Social media and instant messaging platforms are buzzing with videos, memes and trending hashtags, print media is being flooded with opined articles and by-liners from pundits, and news channels inundated with harried correspondents trying to bring every piece of information at your fingertips is quite common.
However, it becomes an arduous task for an individual to sift authentic and trustable information from the copious stream of content. As a result, a myriad of myths related to coronavirus has surrounded all of us. These myths incorporate multitudes of aspects connected to coronavirus – etiology, symptoms, vulnerability, treatment by home remedies, drugs/vaccines available, food habits, immunity boosters, effect of weather on virus potency etc. – which could be equally dangerous as the coronavirus itself. In a recent incident in Iran, more than 600 people died from the consumption of high-concentrated alcohol based on a rumour that it could prevent infection from coronavirus. The severity of these misplaced myths/fake news about the hazardous cures and viral hoaxes can be judged from such unfortunate episodes.
Based on my expertise and knowledge in medicine and healthcare, I have made an earnest attempt to dissect many of these myths in a 2-part video series (links below). The realities busting these fallacies that you see in the videos have been factchecked and corroborated through reliable and bona fide resources like WHO. I firmly believe that we as individuals need to play a much bigger role in this fight against the coronavirus and we can begin by putting a stop to misinformation about the contagion being circulated online.
Links to the ‘Coronavirus-Myths vs Reality’ video series:
It’s been two weeks since India took a step towards a historic lockdown which effectively put 1/6th of the world’s total population in their home prison. Using the data that is available in the public domain, we have tried to evaluate the last 14 days.
The Effect of “India Lockdown” – India is doing much better
On 25th March, when we updated the Covid19 Projection Model (CPM19) with the latest data, the projected number for India according to our CPM19 was around 31.6K cases. With the lockdown, as on 7th April, the number for 15th stands at 15.6K cases. It’s been 24 days since India reported its 100th case. India seems to be doing much better when compared to other countries on their 24th day after reporting the 100th case. (CPM19 Performance numbers are shared at the end of the article)
Country
Date of (100th Case)
Date24 days later
Total Cases on 24th Day
Daily Avg Growth%
India
15 Mar
7 Apr
5,351
17%
Italy
23 Feb
17 Mar
31,506
20%
USA
2 Mar
25 Mar
68,367
33%
Iran
26 Feb
20 Mar
19,644
12%
South Korea
15 Feb
9 Mar
8,086
9%
Spain
1 Mar
24 Mar
49,515
26%
Germany
1 Mar
24 Mar
32,992
25%
France
29 Feb
23 Mar
19,856
21%
In the next seven days most of the countries doubled their cases with the exception of Korea and the US. If we take that trend we should be around the 11k mark. When we take the worst case scenario by extrapolating the US trend we could be at around 16K cases.
Countries
Date of (100th Case)
Date 31 days later
Total Cases after 7 days
Multiplication Factor
Italy
23 Feb
24 Mar
69,176
2.2
USA
2 Mar
1 Apr
215,215
3.1
Iran
26 Feb
27 Mar
32,332
1.6
Korea
15 Feb
16 Mar
8,799
1.1
Spain
1 Mar
31 Mar
104,118
2.1
Germany
1 Mar
31 Mar
71,808
2.2
France
29 Feb
30 Mar
44,550
2.2
India seems to be well placed even after a month of declaring 100 cases. Besides, even with higher testing our positive % results have not been that high. This has already been discussed in a previous article.
The India Story – Case Drivers
There are eight states that contribute to around 76% of the total cases detected in India so far.
States
Total Cases
Contri%
Delhi
576
11%
Kerala
336
6%
Maharashtra
1018
19%
Rajasthan
343
6%
Tamil Nadu
690
13%
Telangana
404
8%
Uttar Pradesh
332
6%
Andhra Pradesh
314
6%
Other States
1338
25%
Total
5351
100%
Amongst these states the positive news is that two states have started showing a downward trend in the lockdown. Two other states seemed to have flattened the trend. The problem is the remaining 4 states that are showing an upward trend even during the lockdown. We take a look at these states individually
Maharashtra – Maharashtra is a prime driver of cases in India. It’s doubling the cases at the fastest pace amongst all states. Even if we look at the daily growth rate of cases, it shows a very clear upward trend.
Tamil Nadu – Tamil Nadu had one big spurt during the lockdown which has really increased its numbers. But overall the state has managed to reverse its growth trend and now seems to be slowing down the trend.
Delhi – Delhi seems to have been impacted adversely because of the religious event and has seen two peaks in the lockdown period. Last few days Delhi seems to be reversing the upward trend
Telengana – Like Maharashtra Telengana is also showing multiple peaks since the lockdown which has resulted in an upward trend line for the state
Kerala – Kerala was the first state that reported Covid19 cases. Kerala was also affected by a huge expat gulf population coming back. But during the lockdown Kerala has actually slowed down and is now showing a downward trend.
Rajasthan – Rajasthan seemed to be managing well until the religious event in Delhi started affecting the number and changed its trend to an upward trend.
Uttar Pradesh – Uttar Pradesh seems to be slowing down after the religious bomb.
Andhra Pradesh – This state had one day when the number grew by more than 2.5 times and post that it seems to be correcting its trend.
The Bad News
Besides these eight states, Gujarat, Haryana, West Bengal and Jammu & Kashmir are the states with more than 100 cases and they are showing an upward trend.
6 out 10 most populous states (UP, Maharashtra, MP, Rajasthan, WB, TN) in India are still showing a growing trend. The combined population of these 6 states is 582 million which is more than the population of the US, Italy, France and Spain combined.
The Good News
Madhya Pradesh and Karnataka are the two states with more than 100 cases that are showing some signs of a slowdown. Though there is a super spreader in Madhya Pradesh who can still wreak havoc.
We have avoided looking at the pre-lockdown period because the real growth in the discovered cases has happened during the lockdown. This may work to India’s advantage as the growth spurt has happened during the lockdown period. In other countries this happened before the lockdown. The time taken for the lockdown to have an effect, the base had increased so much that even a small percentage increase meant a significant strain on the health services.
In conclusion even though India has been doing much better than some of the other countries during the same period, we are still sitting on a timebomb. India may be better off not removing the lockdown completely. A better strategy would be to start opening states where trends seem to be in control in the lockdown.
CPM19 Model Performance
As on 8th April the Model is performing well. With the exception of India, the model has correctly predicted for the other countries. For India, it is currently predicting higher numbers due to the spike in cases due to “The religious event in Delhi”. We are hoping that spike is an aberration rather than the norm and are pleased to be predicting a higher number for India.
Country
Predicted
Actual
Error Rate
India
5769
5351
7%
Italy
135890
135586
0%
USA
397701
400412
1%
Iran
62377
62589
0%
South Korea
10382
10384
0%
Spain
141040
141942
-1%
Germany
106607
107663
-1%
France
108104
109069
-1%
About the Author
Sanjeev Prakash is an Analytics and Marketing professional with more than 12 years of experience in Analytics, Data Management, Sales, Brand Management, Corporate Communications, Market Research and Customer Relationship Management. Sanjeev has an MBA from IMT Ghaziabad and a degree in economics.
Collaborators – Parinay Pande
Sources
Worldometer.info
Covid19india.org
(Views expressed in this article are the author’s personal views and need not represent the views of Healthcare India)
