Transforming Indian healthcare

The indisputable message from this pandemic: India cannot lose citizens to any disease for want of adequate infrastructure capacity.

Bengaluru: India is facing a crisis of unprecedented magnitude. The second Covid-19 wave is devastating families, communities, and societies all across the country. The fear created due to the sudden spike in deaths and lack of response infrastructure is forcing India to re-examine its health strategy. A previous article on a Grand Reconstruction Budget for India (published 4 April 2020 in The Sunday Guardian) to drive post-pandemic growth and investment included recommendations for revamping healthcare infrastructure. The second wave has abundantly clarified how to transform India’s healthcare system to ensure the population is better protected against both acute and endemic diseases.

LACK OF INFRASTRUCTURE

The second wave has underscored the lack of health infrastructure to cater to India’s 138-crore (1.38 billion) population. Moreover, the scarcity of public infrastructure is driving more people to private hospitals even when they cannot afford it—further straining already constrained finances due to the economic fallout of 2020. Various research reports indicate 40% of the population may enter poverty due to sudden and protracted healthcare expenses. Even though the Prime Minister’s Ayushman Bharat scheme is helping remedy this, there is a long road to improve healthcare access to all at affordable costs.

The inadequate medical infrastructure system in India contains four facets:

1. Lack of access and capacity: The country has not installed sufficient hospital capacity to cater to 138 crore people. The rural economy is notably lacking. A recent Housing.com report shows India has only 0.5 public hospital beds per 1,000 population. With the inclusion of private hospitals, the number merely moves from 0.5 to 1.4 beds. World-class infrastructure only exists in the few urban conglomerates like Mumbai, Bengaluru, and Delhi, and is sparse elsewhere.
2. Lack of inputs: The supply of essential inputs to the health system like oxygen, medicines, ventilators, and other equipment needs to be scaled up. As the oxygen crisis has demonstrated, this is not just a production problem but often a distribution problem. India must secure both supply and distribution, alongside building diversification, emergency stockpiles, and redundancies.
3. Inadequate human capital: Poorly-designed policies coupled with low spending on medical education over the last 70 years has created a severe scarcity of doctors, nurses, technicians, and support staff. Per WHO recommendations on doctor-patient and nurse-patient ratios, India has an estimated shortfall of six lakh doctors and twenty lakh nurses to serve the population adequately.
4. Low spending: The health system requires consistent spending budgets to build, maintain and upgrade. This was never a priority in the last 70 years, with low budget allocation, and India is suffering the consequences today. Since its inception, the Ayushman Bharat scheme has enabled more than 1.8 crore hospitalizations and is slowly remedying this situation. Revamping healthcare infrastructure on the momentum of this scheme will accelerate access to all Indians.

Covid-19 has irrevocably cemented the importance of health in Indian minds and hearts. Citizens have long witnessed the vulnerable succumbing to lack of affordable care and attention. Today, the 30-crore middle class also suffers the consequences of being unable to access timely help in a medical emergency. Now, citizens know that nobody can escape a virus. Most importantly, they feel abandoned by an administrative and governance system that did not protect them at their most vulnerable time. They have suffered irrecoverable loss. There is an urgent need to allocate a comprehensive budget and deploy a three-year response strategy to remedy this situation and prepare for a more resilient system in the future. Indians cannot and must not face calamity like this again.

HOW TO TRANSFORM HEALTHCARE

1. Expand capacity: Each district needs a 500-bed multidisciplinary tertiary hospital to cater to the needs of the district’s citizenry, complete with the necessary equipment, infrastructure and an ambulance service. In case of emergency, it must have the physical capacity to expand to 1,000 beds with oxygen in general wards. The administration must survey and identify which of India’s 700+ districts need this; the number may run to 500, largely in the rural areas. Assuming it costs Rs 1 crore per bed excluding land but including equipment and expansion capacity, for 500 districts, the capital outlay is Rs 2,50,000 crores. This must ideally be funded and constructed over three years, with the Central Government giving a grant of 75% to the states. As a special grant, states in the Northeast might require 90%. The states must put up the balance to have a stake in the enterprise and oversee execution.
2. Human capital: It is imperative India creates a robust human capital pipeline for medical staff. MHRD data shows India currently has 88,000 seats for MBBS degrees which needs to increase to at least 1.5 lakh per year. The biggest challenges are the long periods it takes to set up teaching college infrastructure and the shortage of high-quality teachers—the result may be doctors who may not meet the requirement. Instead, brownfield expansion may be ideal. India has around 600 medical colleges, out of which roughly 300 (both government and private) are 20+ years old. It is suggested that these colleges with 20-year track records of demonstrated proficiency be allowed to expand by 50% over the next two years, which could add around 20,000 graduates every year. They already have good infrastructure, reliable brands, and entrenched faculty and have the resources to expand capacity quickly. The 500-bed district hospitals discussed above can be attached to medical colleges for staffing on rotation, and students can build hands-on clinical experience.
3. Primary health centres (PHCs): Hospitals can provide advanced medical services while PHCs can provide basic services. India has roughly 5,600 taluks/tehsils, on average consisting of 2.5 lakh people each. To fully serve the population, each taluk/tehsil would require at least 5 PHCs. Assuming 60% of taluks—mainly in rural areas—need PHCs, at Rs 1 crore per PHC, the total capital outlay is Rs 16,800 crores. PHCs can also be attached to medical colleges for staffing. For example, in the Dakshin Kannada and Udupi districts in Karnataka, Kasturba Medical College has secured PHC facilities to such an extent over the last fifty years that the district HDIs exceed that of even developed countries.
4. Post-graduate (PG) medicine degrees: There are roughly 54,000 post-graduate medicine seats available in India, having increased from 24,000 in the past five years. Since MBBS degrees alone are deemed inadequate by graduates, the largest migration of doctors from India is after the MBBS degree when they do not obtain PG seats. It is suggested that PG-medicine capacity is expanded to 1,00,000 a year by involving corporate hospitals in teaching programs and increasing the capacity of existing MD and DNB programs—especially in high-demand areas like internal medicine, emergency medicine, trauma surgery, anaesthesia and radiology. Improvement of capacity will also decelerate the brain drain of the country’s top medical talent.
5. Nursing colleges: The current strategy of training nurses at independent nursing colleges has led to corruption and inadequate quality of nurses. Each medical college must be incentivised to start an attached nursing college, if they do not already have one, and train 500 nurses per year. This strategy will ensure high-quality nurses with hands-on clinical training. India must aim to produce 2.5 lakh nurses every year. Assuming 50% of the 600 medical colleges undertake this strategy, it will add 1.5 lakh nurses per year to the existing 80,000 graduate rate, bringing the total to 2.3 lakh per year.
6. Critical medicine supply chain: During the pandemic, Indians noted with horror that even though India has built the capacity to produce world-class medicines and vaccines, a whopping 70% of APIs (Active Pharmaceutical Ingredients that form the core of the medicine) come from China. The nation has to ensure that strategic inputs into the pharmaceutical chain is protected and indigenously produced. Staying dependent on China and other external players can leave India vulnerable. The government has created a PLI scheme for drug inputs which will hopefully make India self-sufficient. The country must spare no cost to shift the manufacturing of critical inputs back to India.
7. Adequate research and administrative capacity: The country needs an integrated Centre for Disease Control like CDC in the US with a national centre in Delhi and state centres in every state capital. Each district can have a small centre reporting to the state. This CDC network can continuously monitor medical threats and pandemic vectors, enable the government to take precautionary measures ahead of a calamity and establish protocol during one. The network will require adequate human capital, infrastructure and administrative capacity to stay up to date on disease vectors, infection spread factors and testing and validation efforts of new drugs and vaccines. In addition, India needs world-class research centres for virology, genetics, and medicine to ensure a quick response to any medical calamity. Government must lead the investment into building credible and resilient institutional capacity along these lines.
8. Pandemic planning: The National Disaster Management Authority must also be included and mobilized in case of a medical calamity to oversee management and ensure critical goods and services are rapidly sent to areas of need. The country also has to build a National and State-wise Stockpiles of critical equipment and medicines for emergency deployment. The Armed Forces must also increase emergency reserves as this also forms a vital part of the country’s defence. Capital pools must be designed and held in reserve to be able to supply critical response and advance procurement without red tape and unnecessary optimisation of prices or margins. When lives are at stake, no cost is too high to bear.
9. Annual grant to states to manage infrastructure: The Centre can give annual grants of Rs 10 lakh per bed for a minimum period of five years to maintain the new infrastructure until the healthcare system becomes viable. Taluk/tehsils can also be granted Rs 50 lakh per year for PHC maintenance to ensure they are well-stocked to serve the citizenry. The maintenance amounts to Rs 25,000 crore (for district hospitals) and Rs 1,680 crore (for PHCs)— a total of Rs 26,680 crore per year for five years by the Centre.

IMPERATIVE TO STRENGTHEN HEALTH SYSTEM

The message from the Covid-pandemic is crystal clear. India cannot lose citizens to any disease or pandemic for want of adequate infrastructure capacity. The total cost of revamping the medical infrastructure network, training of human capital and establishing Centres for Disease Control could amount to Rs 3 lakh crores over three years. The centre must be in a position to spend Rs 75,000 crores a year, amounting to Rs 2.25 lakh crores, with the balance coming from the states. The country must use the lessons from the pandemic to build a world-class healthcare system that provides access at affordable costs to its 138-crore population. Never again must Indians suffer as they are during this pandemic.

T.V. Mohandas Pai is Chairman, Aarin Capital and Nisha Holla is Technology Fellow, C-CAMP.