A 14-year-old, young boy was brought into an ICU in a north Indian state with acute respiratory syndrome, a severe lung disease. His oxygen saturation levels were less than what was compatible with life and his chances of surviving this were slim. He was put on a ventilator, a breathing machine, however, he continued to deteriorate by the minute. This ICU was supported by a team of qualified critical care specialists based out of Bangalore who were helping the bedside doctors manage patients through a tele-ICU network. The specialists at the command center in Bangalore were alerted about this critically ill patient and through audiovisual assessment and remote live monitoring, the on-ground team was able to institute advanced ventilator management strategies. When he continued to worsen further, it was decided to institute a strategy called prone ventilation which had not been tried there before. The critical care specialists and their nursing team guided the ground team on treating this patient. The young boy was liberated from the ventilator on the seventh day and is now doing well and back in school. This was an example of leveraging technology to make quality care accessible to a remote location. There exist myriad avenues for using technologies in medicine.  Artificial intelligence and machine learning for example can aid clinicians in diagnosing and treating  patients while decreasing complications. Healthcare as such has been slow to adopt technology for public health, however, the current COVID19 pandemic beckons many such measures to find wider acceptability. This article has a brief introduction to COVID19 and also attempts to ideate some healthcare reforms in India.

What is COVID19

The COVID19 ( Coronavirus disease 2019) pandemic has afflicted 213 nations currently with over 4.4 million cases worldwide leaving more than 302 thousand people dead in its wake. ⁽¹⁾ While advanced nations like Italy and the UK with mature healthcare systems have been unable to efficiently cope with the magnitude of the problem, what lies in store for countries like India is as of now a matter of dire epidemiological speculation. The human coronavirus was first described in the early 1960’s and for many decades the betacoronavirus class out of the four types identified, seemed to cause only minor respiratory illnesses in man. In recent decades however more virulent beta coronaviruses such as SARS and MERS have emerged causing restricted pandemics.

COVID-19 is caused by SARS COV2 which seems to be more closely related to the SARS virus which had caused a pandemic in 2003.The origin of the virus has been currently postulated to be out of a wet market at Wuhan,  China. The closest RNA sequence similarity is to two bat coronaviruses. Bats are known reservoirs of coronaviruses and as such are immune to the virus. Whether the Virus was transmitted directly from bats or some other mechanism is unknown as of now. ⁽²⁾

There are several drugs that are under investigation, however, there is no medication that has high-quality data supporting its widespread use. Barring convalescent plasma, even the medications which have shown some promise in preliminary data like Remdesivir and tocilizumab are either not available in India or are too expensive to procure. ⁽²⁾  A race for manufacturing a viable vaccine is on, however, we are several months away from commercial production. Even if a vaccine does become available, we are too early in the pandemic to even predict how long a person would remain immune post-vaccination. This therapeutic lacuna is further compounded by the lack of a robust critical care healthcare infrastructure in our country.

While the strain on the healthcare system and lack of personal protective equipment, ventilators and other equipment are universal, first world countries like the USA do have a robust healthcare system and excellent financial resources. An exponential rise and spread of COVID19 in resource-limited countries like India however may have far more disastrous consequences. The biggest lockdown in the history of humanity is currently underway in India and has helped mitigate the relentless progression that we have seen in other countries to a large extent.

Epidemiological data however does suggest that lockdown strategies while effective in flattening the epidemiological curve, are not a permanent solution to an epidemic. Easing of mitigation strategies such as lockdowns are an eventuality for the economic sustainability of a nation and this is probably the time a second wave can be expected. ⁽³⁾

The Indian Situation

The constitution of India has a directive in the preamble directing the government to ensure the right to health to all. The draft national health policy prepared in 2015 proposes that health be made a fundamental right. ⁽⁴⁾

India’s net GDP expenditure on health is 1.15% which is lower than even a lot of low-income countries. Government health services are available free of cost to all citizens, however, there are severe limitations in quality and infrastructure. This has resulted in a majority of patients relying on out of pocket expenditure at private hospitals. Health insurance covers only about 20% of India’s population. While there has been some positive progress in healthcare indices recently, we are still a long way from having quality-centric, equitable, and affordable healthcare. ⁽⁵⁾

The current pandemic is an eye-opener and an opportunity for introspection into the way healthcare is delivered and positioned in our country. Public health reforms now are no longer a problem of only the poor, it has ramifications even to the privileged. Many areas such as but not limited to overall healthcare infrastructure, manpower, sanitation, accountability, economic feasibility, supply chains need a revamp. These problems are further compounded by an absence of linking quality and patient outcomes to medical care in general. A lot of these are not limited only to government institutes but also private medical institutions. ⁽⁶⁾

Healthcare  reforms

The beginning of reforms in healthcare would have to start with increased resource allocation and improving overall GDP expenditure on healthcare. There are multiple precedents across the world ranging from all citizens being insured by law in Germany, state-sponsored public health distribution like the NHS in the United Kingdom, or a  semi-autonomous structure of health infrastructure in some other countries. The complexity of our nation, culturally and economically and the large population, does not allow a one size fits all solution. Amalgamation of various models with enough flexibility would likely be a better way forward and will need extensive participation by all stakeholders.

1. Primary Healthcare

Primary healthcare at grassroots form the backbone of any healthcare system and is perhaps the single most important aspect to ensure the health of the population. Robust primary healthcare systems would be a layered decentralized people-centric system. This is often considered a luxury only first world countries can achieve, however, some states like Kerala despite resource constraints have led by example for many decades. The state is leading in almost every health index for the last few decades. Even during the current pandemic and the recent Nipah virus epidemic, Kerala state’s public health sector has provided a paradigm for efficiency in limited resources  ^{(7 )}This model may not be replicable in all states since local socio-economic milieu in the state play a role, however, there lessons to learn in public health which can be replicated elsewhere.

2. Infrastructure and manpower – Stopgaps and long term vision

a.Decentralization

While the revamp of the entire system is not only time and money consuming, but also labor-intensive and will need obsessive levels of perseverance from many machinery.

Using a relatively robust private healthcare system in our country to help the less privileged would be a reasonable stopgap measure. While schemes like Ayushman Bharat, Employee state insurance, and various state and central government insurance schemes do offer accessibility to healthcare in private institutions, their reach and scope are limited. Incentivising private institutions with subsidies, loans, and waivers may allow us to have a more active participation in implementing public health insurance and disbursement schemes.

There are autonomous/semi-autonomously functioning institutes of excellence that have been able to maintain quality and care better than federally controlled hospitals. These autonomous institutes such as AIIMS, Jayadeva Institute of Cardiology, and NIMHANS are large specialty centers and institutes of excellence. Such autonomous and semi-autonomous structures can be implemented at district hospitals and tier 2 and 3 cities. If these hospitals can be on par with a well equipped multispeciality corporate hospital, they will not only provide access, but also decompress larger institutes. A people-centric decentralized structure of these hospitals which encourages local aspirations and accountability would be a step towards filling in the lacunae in the pyramid between primary health care and large institutes.

b. Quality Centric healthcare-Incentivising performance and accountability

Medical care globally is delivered in an evidenced-based manner and doctors in India have the same aspirations. There are however severe limitations of resources that have led to a culture based practice and partial adherence to guidelines and protocols in many institutes. There is an urgent need to move towards outcome-based and quality-centric medicine rather than a culture and experience-based medicine. ⁽⁹⁾ There are accreditation bodies such as NABH and JCI, which ensure the quality of infrastructure and care in our country. There are however only 666 NABH accredited hospitals in the country of which government institutes are only a handful. These accreditations are desirable by private institutions since it is linked to indirect revenue generation through insurance empanelment.  Similar accreditation machinery is needed even in the public health sector. Active participation by hospitals and workforce in this regard can be ensured only if there are incentives linked to success  ⁽¹⁰⁾

There is a huge disparity in the availability of good quality lab data in most civil hospitals as opposed to central institutes. Tests such as automated blood cultures which is the standard of care is unavailable at most civil hospitals. This disparity results in inferior care by physicians across the country owing to the absence of much-needed tools. Tests such as cartridge-based nucleic acid assays and line probe assays are available even in remote locations with the help of Bill and Melinda Gates Foundation. More involvement of such philanthropic organizations will go a long way in improving medical laboratories. This needs to happen beyond larger institutes to have a significant impact at a community level.

c.Manpower

Manpower shortage at every level in the public health system needs no introduction. Though the reasons for government medical employment to be considered less desirable are multifactorial, work compensation and quality of care delivered are possibly the two major factors. Some of this can be tackled by providing compensations equivalent to their private practitioner counterparts, better equipment and facilities, and merit-based incentives.  Most doctors with niche expertise will be happy to serve the poor as long as their salaries are reasonable and they do not have to work under severe resource constraints. ⁽⁸⁾ Modern hospitals will also need maintenance crews, active operations machinery, quality control departments, and biomedical engineers. Some of these can be either outsourced or disbursed contractually with a centrally controlled accountability system.

3. Technology in medicine

Technology percolates slowly into the field of medicine and this is a universal problem. There are many technological advancements that have helped in providing better access, improvements in outcome, and quality of care in the field of medicine. India as a nation is yet to adopt most of these on a large scale. While technological advancements such as robotic surgeries may not be a feasible option in most public or even private hospitals, adoption of electronic medical record systems, telemedicine, tele-ICU, tele-cardiology would lead to getting specialized medical care to the peripheries. Frugal innovations need to be examined, tested, and deployed in the field of medicine much faster than it is happening.

Adoption of electronic medical records will lead to a seamless system obviating the need to maintain paper records at multiple areas, prevent loss of patient data, provide instant access, and also will lead to a centralized access system across hospitals and doctors. This is easier said than done and has many obstacles including but not limited to healthcare professionals generally being averse to technology in India.

Solutions like telemedicine have come to the forefront of patient care with the advent of COVID19 and is gaining wider acceptance amongst practitioners in India. Tele-radiology for example, is being widely used and is servicing remote locations across the country. The use of telemedicine platforms in India definitely has got a push owing to the COVID19 pandemic, the Ministry of Health has issued guidelines in this regard. ⁽¹¹⁾ A detailed draft bill with regards to telemedicine is on the anvil, however, some startups are already in compliance with widely accepted patient and data privacy laws.

A Tele-ICU is a more advanced level of telemedicine that leverages technology to deliver access to highly trained critical care specialists to small to medium-sized hospitals where such specialists are not present. There is a good amount of evidence that this improves patient outcomes in the ICU and improves the overall quality of ICU care at the peripheral centers. Innovative solutions and locally sourced technology has enabled some players to deliver tele-ICU services at an affordable cost^{.(12, 13, 14).} Experienced and successfully running telemedicine organizations can be roped in to help manage ICU’s across public hospitals. These processes take time and effort and will need long term focussed leadership within the healthcare bureaucracy for implementation. ^{(13, 14)}

^{4. Research}

Scientific research in general is an ignored field in India and needs a comprehensive overhaul. Though it’s often opined that it is the lack of funding that is a deterrent to research in India, the absence of inquisitive scientific culture, in general, seems to be a much larger issue. Gaining a publication in a journal is often equated to research, however, this is a very narrow view of a larger picture. Scientific advancement in any country will bear fruit only when goal-directed innovations are encouraged. Identifying local problem statements and incentivizing innovative solutions through dedicated funding mechanisms, thus making scientific research a tangible career option is the solution. This interest in innovative science, not limited to medical schools, needs to be started in our schools and colleges. Financial resources as well as knowledge incentives need to be a part of general academics. This needs a structured mentorship program from actual innovators and scientific organizations in various fields. The medical field in India per se has plenty of indigenous problems that beg for solutions. For example, there needs to be an understanding that pioneering research in tropical diseases needs to be done by tropical countries such as ours. Undergraduate and postgraduates would need to have dedicated research time and curriculum not limited to just a dissertation as a part of their curriculum. Mentors of such students would also need to be trained and have to be assessed if they can indeed train students in research methodology. There is thus a need for long term commitment from the academic community and the government machinery, albeit it is no longer just an aspirational goal but a necessity for scientific advancement in countries such as ours.

Dr Sanu Anand
Dr Sandesh Kumar K J
Intensivists @Cloudphysician Healthcare

References: