Many Indian States have low beds-patient and hospital-patient ratios. This raises a question mark over India's strategy to address the CoronaVirus crisis.
A look at India’s health affairs
- Highly privatized: India’s health system is highly privatised and most of the country’s health-care capacity in terms of human resources, hospital beds, laboratories, and diagnostic centres is in the private sector.
- State of testing centres: While Maharashtra has the highest number of testing centres and relatively better coverage, the State is still under-equipped to detect cases as one testing centre is available for 1.02 crore people.
- Beds and hospitals: Andhra Pradesh had the lowest hospital-population ratio while Bihar had the lowest bed-population ratio. Many big States also have poor bed and hospital ratios.
- Poor doctor to Patient ratio: According to WHO, there should be one doctor for 1,000 people.
- India has around 3.4 qualified doctors and 3.2 nurses and midwives per 10,000 population; in contrast, China (Italy) has 18 (41) doctors and 23(59) nurses per 10,000 population.
- India has around 70 hospital beds and 2.3 ICU beds per 100,000 people.
- Rural-Urban disparity: Moreover, health workers in India are mostly concentrated in the urban area.
- There are huge disparities between States (Bihar has 0.3 and Kerala has 3.2 doctors per 10,000 population).
Less number of people tested: We do not really know how widespread the epidemic is in India because such a small number of people have been tested and many mild cases go undetected.
- The higher number of confirmed COVID-19 cases in States such as Kerala and Maharashtra suggest this (though this could also be due to more testing).
- Poor ICU facilities: If the Covid positive cases rise, the ICUs will fill up in six weeks and hospital beds in about eight weeks from now in States with lower hospital capacity.
- Threat to health workers: Estimates from China’s National Health Commission show that more than 3,300 health-care workers have been infected as of early March and, by the end of February at least 22 had died; in Italy, 20% of responding health-care workers were infected, and some have died.
- Countries with far better health infra than India have suffered: China & Italy have 420 & 340 hospital beds respectively. They have 3.6 & 12.5 ICU beds per 100,000 people, and both these countries struggled to care for the severely sick.
It is important to remember that the vast majority (80%) of COVID-19 cases will be mild. The estimated mortality rate varies considerably between 3% to 0.25% of cases, and is much higher among the elderly.
- State-to-State coordination: It is critically important to put in place well-functioning between-State and within-State coordination mechanisms that enable efficiently leveraging resources such as doctors, nurses, equipment, supplies from elsewhere and direct them to regional/sub-regional hotspots.
- Ramping up hospital capacity: Making more ICUs and procuring ventilators should be prioritised. Alternatives, such as, extending current hospital capacity, hospital trains that can easily move from one location to another, or converting university dormitories into treatment centres should be considered.
- Tapping the resources in the private sector: Recognising this, several State governments have initiated action, such as enlisting private laboratories for testing and using the private hospital bed capacity to treat positive patients.
- Leveraging alternative medicine health workers: it is important to consider task shifting and multi-skilling strategies where a variety of health-care workers (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy doctors, nurses, as well as general and specialist doctors) are engaged.
- Leveraging primary-care providers: The formally trained (e.g. medical officers, nurses, auxiliary nurse and midwives, pharmacists), or lay workers (accredited social health activists) or informal workers (rural (not registered) medical practitioners, or RMPs, drug shops) are the first contact health workers for COVID-19 patients.
- Primary-care providers will encounter patients in early stages or with mild forms of the disease, they play a crucial role in treating and referring patients.
- Health worker safety: Procuring and ensuring the widespread use of personal protective equipment (e.g. masks, gloves, gowns, and eye wear) in the care of all patients with respiratory symptoms needs to be prioritised.
India, like other countries, faces important health system challenges in mounting a credible response to COVID-19. How India deals with these health system issues in the days to come will make all the difference.
Current best practices
- In both China and Italy, hospitals were rapidly constructed to accommodate infected patients.
- The success of countries such as South Korea and Singapore in controlling the spread and mortality due to COVID-19 has been credited to the ability of health workers to locate, test and treat cases.