Epidemics teach us many lessons on how we can strengthen primary healthcare within a nation. The key is that disease management and effective primary care should be an everyday protocol and just be part of disaster management. Dr Narottam Puri, Advisor-FICCI Health Services Committee and MVT Committee; Former Chairman- NABH; Advisor-Medical Operations and Chairman, Fortis Medical Council, Fortis Healthcare explains various aspects of India’s response to COVID-19 in a chat with Raelene Kambli
Dr Puri, you have been in multiple roles – a doctor, strategist, journalist and more, and have seen and have evaluated India’s healthcare system in many ways. Tell us from your experience, how have you read this current pandemic impact for Indian healthcare?
The effect of the current COVID-19 pandemic is cataclysmic for the entire world, its social order, its economy, healthcare systems and an entire generation is preparing to pay its price for quite a while to come. Hence, it is only natural that healthcare, not just in India but all over the globe has been affected and shall not be the same in future. Indian healthcare has been badly dented – the public healthcare system has been swamped, particularly in some pockets of our country and the private sector is working in tandem with the policymakers and public healthcare system to provide succour in terms of manpower, beds, lab tests, training and skill development, to name just a few.
Economically, the Indian healthcare industry stands in a precarious position as has been so well brought out in the FICCI-EY Report on Economic Assessment of COVID-19 on private healthcare providers. Smaller medical establishments have, and are closing down; bigger players have taken a massive hit to their balance sheets and cash flows are a huge issue. Dwindling footfalls in OPD and stoppage of all elective surgeries, zero medical tourism has hurt the industry. It was never an industry which was in the pink of health all-round, COVID has really put it on the canvas, to borrow a boxing term. Hospitals and laboratories have lost about 70-80 per cent of their revenues – administrators and doctors have accepted reduced pay packages, no variable payment and the question of bonuses and yearly increments have just flown out of the window. At the same time, all efforts are being made to ensure that nurses, technicians, resident doctors and colleagues in junior places in hospital administration retain their salaries and jobs. Indian healthcare, thanks to COVID, is itself sick and is crying for help.
Strange to say, there is a positive impact of this pandemic too – badly required beds, equipment and personnel are being bought and brought in at public health systems – moribund hospitals are being opened and equipped now and the realisation of the importance of enhanced spending on health as a percentage of GDP is being realised at state and central levels.
From a historic point of view, do you think India’s response to COVID-19 is better than before or the lack of infrastructure and a proper system still exists?
If there was ever a time when I blessed rather than cursed (usual) the political class and bureaucracy, it is now. Whilst I would not like to be in their shoes at this moment, given the fact that they are having to make decisions quite like what we as doctors have to do in our daily lives, as their policy decisions can make a difference between life and death. So far, by and large, they have come out well – calibrating India’s response has been quite adroit, flexible and on the job at all times. Timely steps in terms of screening of incoming passengers at the airports, lockdown and then its extension, creation of hotspots, a calibrated opening up of the economy appear to have been taken at the right time and even as we still do not know the trajectory of this disease in India, appear to be the right steps. Most importantly, the intention behind these seems to be right. It is inevitable some may feel—‘x’ should have been done this way, ‘y’ should have been delayed –possible, but in my mind, the intention has always been right. And they have, unlike some high ups in other countries, listened to the healthcare experts and paid heed to science.
This alacrity has been necessitated because India has been tardy in spending a decent sum on healthcare – a measly 1.2 per cent or so and is amongst the laggards in the world in terms of public spend. It has struggled to support the preventive and primary healthcare system and emergency and disaster medicine has never been in the syllabus of post-graduation till lately. Hopefully, post-COVID, this lackadaisical approach to healthcare will change. I feel political will bends to public demand and the public, and henceforth, will hopefully demand better healthcare.
From a quality perspective, what is your opinion on accreditation being a barrier to the right response to epidemic management? Because in the times of crisis, tough choices need to be taken and following protocol could sometimes be a barrier?
Accreditation is an enabler, not a barrier. It is a WHO-approved method of quality measurement and improvement. It encourages patient safety as its primary objective. How can that be a barrier? High quality always costs less, ultimately. Take the example of Chinese companies supplying PPE and kits, since they have received a lot of publicity from across the world the Chinese government is forced to enforce quality control. Why should quality (accreditation is merely a quality tool) and accreditation be seen as anything else but a system and protocol that wants that the patient is safe and tries to ensure this through external checking of systems and policies? Who wants a defective kit or an N95 mask that does not do its job of filtering 95 per cent pathogens?
Now you know in an epidemic, most people at risk are the providers. We have seen that in earlier epidemics too. In fact, if we gather lessons from the Ebola outbreak in Western Africa, we see that many healthcare providers lost their lives. In India too, we fear that because we see a lot of our nursing and doctor resources being infected while providing treatment. How do we protect our providers?
It is true that healthcare workers are being harmed the most by COVID management. Whilst the percentage of mortality is high, morbidity and psychological damage are also very high. They are, as a BBC documentary I saw, said – ‘The only line’ not just the front line. You have only got to see the visuals of the mayhem in Italy (Lombardy), New York and the UK hospitals to realise this. In India, sadly these “warriors” and their “henchmen” (police, ambulance drivers and safai karamcharis) are also subjected to violence, derision and derogatory comments. I have very little doubt that the Indian healthcare worker will triumph – initially, they managed without or less of PPE, masks, goggles and gowns but they never gave up. Frugal healthcare and jugaad is a way of life for them but is it humane to expose them with improper gear, training and derision and violence?
What are the major changes that India will need to do to be epidemic-ready in future?
Hope springs eternal. What helped Singapore was that SARS had helped create a state of preparedness in terms of manpower, training, processes and infrastructure to better tackle the COVID epidemic. The Nipah virus disease outbreak helped Kerala to be better acquainted with managing epidemics. I am quite sure lessons will be learnt, in fact, are being learnt as we adopt best practices from one state to the other and from one country to the other.
The key will be not to forget these lessons and not to allow a chalta hai approach pervade our psyche nor allow a bureaucratic approach to overcome the scientific vigour. The cooperation among technocrats, bureaucrats and politicians will determine the fate in future too and when it comes to managing healthcare in India in a judicious way, public and private distinctions will need to drop. All hands on deck have to be the approach.
Technology and science must be the way finders and be relied upon increasingly in a changing landscape of healthcare that is in the offing.
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