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Monday, June 15, 2020

Covid-19 in India in the coming months: The puzzles faced by leaders of health care organisations

by Ajay Shah.

Peering into the next six months

How might the pandemic play out in India in coming months? There are newspaper reports about some important statistical evidence from ICMR about the spread of Covid-19 in 70 districts of India (caveat). Based on antibody testing, it appears that about a third of the people in containment zones in some large cities had antibodies in late April. We can cautiously expect significant progress towards herd immunity, in containment zones, by today, i.e. mid-June. Recent stories from Dharavi in Bombay are consistent with such an argument (while also being a testimony to the public health capability of the municipal authorities).

In most of India, however, the picture is quite different. E.g. while about a third of the people in the containment zones in Bombay had antibodies in end-April, the fraction of persons in Bombay as a whole who had antibodies is small. In most of India, the bulk of the epidemic lies in the future.

There is a public health problem (how to slow down the spread of the disease) and there is a health care problem (how to care for the people who get sick). In this article, we focus on the health care problem. For the leadership of health care organisations in most of India, this is an extremely important moment, when they need to plan for this coming surge. In this article, we think about the pandemic from their point of view. A given facility might appear to be relatively unruffled today, but it is important to envision the coming surge of demand for health care, and to lay the groundwork for faring better at the peak of the pandemic in the catchment of the facility. What are the issues, and what are the potential actions that can be taken?

About 70 per cent of health care in India is in the private sector. In this article, we place ourselves in the shoes of the leaders of health care organisations of all kinds, but we have an accent on private organisations as this is where the bulk of the action will lie.

Equipment

Oxygen therapy is a key element. There has been a lot of talk, internationally, about ventilators. However, from the viewpoint of both efficacy and cost, ventilators are a poor solution. The skill required of health care workers, to use a ventilator, is substantial and this will limit scale up. It is more useful to develop a strategy that involves oxygen cylinders and oxygen concentrators. The former is associated with the problem of managing the supply chain for oxygen cylinders. All hospital beds should be equipped with oxygen ports.

In many hospitals, there is a need to introduce physical isolation and establish a dedicated wing in which Covid-19 patients will be treated.

Beds in the ICU are a scarce resource. It is useful to establish `step down beds', where patients exiting the ICU can be safely placed, when they require a high standard of care but no longer require to be in the ICU. This will improve the extent to which the ICU is available to the patients who need it most.

Internal management

The medical community in each city needs to debate and agree on the clinical protocols that will be put into play, that are feasible and cost-effective under their local conditions. This will reduce fumbling and recrimination in the surge. Conversations and documents around rules of triaging will help.

Economies of scale and cost reductions can be obtained by establishing `eICUs', where a central command centre has skilled staff which monitors the data coming in from a remote ICU. This is a more feasible path to scaling up ICU capacity, particularly in places when the skilled staff in ICUs is hard to find.

When the surge comes, the management processes of the hospital will be tested. Every element of the process requires analysis from the viewpoint of coping with a surge environment. Enhancing non-medical staff and processes, ahead of time, will help cope with the surge.

Health care workers

A key problem concerns health care workers (HCWs), who face the risk of high dose exposure to the virus. While some HCW are driven to serve the community, many may retreat from work when the surge gathers momentum. At precisely the time when the most capacity is required, the capacity could degrade, thus increasing the chances of an organisational rout.

The leadership needs to undertake many measures which will be fair to HCW and reinforce their commitment to hold the ranks:

  1. It is penny wise, pound foolish, to skimp on the quality and quantity of PPE. If a few ward boys get sick, word of this will leak to other ward boys. For ward boys to feel safe, their training and consumables have to be of high quality.
  2. HCW and their families need to be reassured that there will be ample effort on giving them treatment if required.
  3. PPE and training is required not just in the ICU but also for the primary care providers, who are the first point of contact for patients when they reach the facility.
  4. Periodic antibody testing for all HCW will be particularly useful: (a) In assessing the extent to which infection and immunity has come about, (b) Generate metrics of the class of situations where new infections are coming about and feed back to process improvements, and (c) Increase the confidence of HCW as a stream of process improvements are visible, and when it is seen that the infection rate and severity of the disease is low.

Community initiatives

These elements (equipment, management, HCW) constitute a reasonable work plan to gear up for the surge. But many or most hospitals today are beset with difficulties. In the best of time, their management bandwidth was limited. Covid-19 has induced a financial crisis with a decline in non-Covid revenues, and the Indian financial system is not able to engage effectively with most hospitals. The thin capabilities have been adversely affected by the retreat of HCW. The puzzle lies in finding the energy and resources to actually pull off a significant amount of preparatory work.

There are many problems which are hard to address at the level of one hospital. Consider a city like Nagpur. There is significant value in constructing a Coalition of hospitals and of the local business community, which can work towards many initiatives -- without any government involvement -- which will reduce the damage caused to the city from the epidemic. Examples of such collaborative initiatives are :

  1. Nagpur requires facts, through random sampling, about the state of infection and antibodies in Nagpur. The weekly or monthly construction of these facts is vital for health care organisations to know the planning horizon that they face, before the surge. The citizenry requires these facts to make decisions about the economic and social activities that are safe. The Indian state does not produce this information. Better planning by health care organisations is good for them and for the citizenry and economy of Nagpur. It would be valuable if such a work program can be put together by the Coalition.
  2. The Coalition can collaborate with the medical testing industry to establish capacity, and negotiate bulk rates.
  3. The Coalition can establish a process of discussion and drafting of appropriate clinical protocols which can then by used by all HCW in the city.
  4. When an individual requires health care or a bed, there is chaos during the surge, with patients running around across multiple facilities looking for spare capacity. The Coalition should establish a shared information system and call centre for patients to use. This will reduce the operational overheads and queues outside facilities. This will increase bed utilisation and improve the allocation of facilities based on the condition of the patient.
  5. The Coalition can pool resources to do bulk buying and inventory management on medical supplies such as PPE or oxygen cylinders, and dynamically respond to the shortages of consumables that are discovered at future dates.
  6. There has been significant friction between health care organisations and the government. The Coalition could be more effective in addressing inappropriate behaviour of various arms of the Indian state. The Coalition is a natural locus for addressing bad behaviour by some health care actors, and can head off such problems so as reduce the probability of the state getting involved.
  7. The Coalition can be more effective in overcoming the frictions faced by hospitals in empanelment with the various government sponsored health insurance schemes (GSHIS) and address frictions associated with dealing with health insurance companies.
  8. Some health care organisations may falter in their commitment to stay in this fight. The Coalition will be valuable in exerting peer pressure, and in helping transmit management knowledge to some organisations who are sitting on the fence.

To the extent that the health care problem in a city like Nagpur is worked out well, individuals will feel more safe, and will get back to working and consuming, thus bolstering the economy. If the health care system gets crushed, there will be greater reticence on the part of the citizenry to spend or work, and the economy will be more adversely affected. Supply chains will get disrupted if there is a lockdown in the future in Nagpur. There is thus ample self interest which should drive the business community, and the health care community, to come together, and expend financial and management resources on building such a Coalition.

There are severe financial problems in many health care organisations today, as the traditional revenue stream has dried up as a consequence of fearful households. The leadership of many health care organisations is firefighting a financial crisis, which is exerting a tax upon their management bandwidth, at a time when they should primarily be working on laying the groundwork for the surge. The Indian financial system works poorly and is not able to perform its role, of efficiently supplying capital. There is a need for owners to bring in equity capital to alleviate this problem. It is also in the self interest of business interests in a given city, to offer loans to health care organisations, so as to diminish the organisational rout of health care organisations in the surge, which would adversely impact upon the economy of the city.

Conclusion

The bulk of the discussions surrounding Covid-19 in India are focused on public policy. But state capacity in India is low, and we should have low expectations for what the state can do. As the de-lockdown progresses, the pandemic will accelerate. We are now at the last barricade: Health care.

How things work out in 2020 will now be shaped by the sagacity and leadership qualities of the senior managers of health care organisations across the country. There are about 10,000 important hospitals in India, and about 50,000 key persons who make up the leadership of these hospitals. All eyes are on the actions of these 50,000 people, which will have an impact upon millions of lives. Seldom has so much depended on so few.

In this article, we have shown some areas of planning and preparedness that are required in health care organisations. All large hospitals in the country, private or public, need to plan for the surge. A key theme we have emphasised is negotiation and collaboration between private persons. The Indian state is generally not able to usefully intermediate in the interactions between private persons. A key feature of the way forward lies in organising communities, in privately negotiated local solutions. It is in the best interests of the citizenry and the health care community of (say) Nagpur to take their future in their own hands, to plan their best way forward.

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