Inadequacy of public health system

Stung by scarcity

Print edition : April 24, 2020

Medical staff of Guru Nanak Dev Hospital in Amritsar protest against the supply of alleged low-quality of PPE. Photo: PTI

As the Indian health-care system is up against many odds in its struggle against COVID-19 with shortage of health care professionals, protective gear and ventilators, the relatively low rate of mortality may not be a cause for cheer.

AT a routine briefing, representatives of the Union Ministry of Health and Family Welfare, Union Home Ministry and the Indian Council of Medical Research (ICMR) on health preparedness and the implementation of the nationwide lockdown, sought to give an impression that things were under control, that directives to State governments were being regularly issued and that there was little cause for panic. The Health Ministry, which had been in a bind over the spurious distinction it had made between local and community transmissions, sought to dispel the notion that the virus was spreading virulently by comparing the rate of increase of cases and case fatalities in India with that of developed countries. Until April 4, a total of 2,088 cases had been confirmed and 56 people had died.

There was, however a marked difference in the nature of the press briefings held in April and in the period soon after the start of the lockdown. In the latter case, questions from the media were encouraged. The briefings in early April were exceedingly brief, with officials taking very few questions from reporters, most of whom happened to represent the official media. This marked shift was perhaps because questions have been regularly directed at the government regarding the prevalence of community transmission, the low rates of testing, the availability of personal protective equipment (PPEs) for health workers, the availability of ventilators, and the attacks on health workers.

There has been widespread acknowledgment that public health systems the world over have been woefully inadequate. Acute shortages of almost everything, especially PPEs, have been a feature of this epidemic. This situation is not unique to India. In every other country, even in the United States, which has higher public spending, there have been shortages of ventilators and PPEs. The situation in the United Kingdom is as bad. One reason for these countries not going in for a complete lockdown is their concerns about its impact on the economy. Now it is felt that the “stay at home” policy might relieve the overburdened health systems a little.

Health workers, who have been called “warriors”, are in a particularly difficult situation. There have been reports of attacks on health-care workers in Indore, Haryana and a few other places and of the protective gears provided to them not being up to World Health Organisation (WHO) standards. Some 50 health workers in India have been confirmed to have tested COVID-19 positive by the Health Ministry. Health workers in developed countries have faced similar risks. But the problem is potentially far more serious in a country with a high population like India where the ratio of beds to patients and doctors to patients is low and medical equipment is in short supply. It has a ratio of one doctor to 10,189 persons against the WHO recommendation of 1:1,000, which amounts to a deficit of six lakh doctors. The nurse-patient ratio is 1:483, indicating a shortage of two million nurses.

On March 30, the government announced that factories producing essential items and ordnance factories were working “round the clock” to make PPEs for medical personnel working in isolation areas and Intensive care units (ICUs). These were apparently always imported for hospital use in the country before this crisis. Given the global shortage of PPEs, the government involved the domestic industry, shortlisted 11 manufacturers and placed orders for some 21 lakh coveralls. The government also said that it had approached companies in Korea, Singapore, Vietnam and Turkey to supply PPE kits.

Despite these measures, the immediate needs of medical personnel were not being met. About 3.34 lakh PPE coveralls were available in all the hospitals taken together. Some 10,000 PPEs had been received from China, which had also supplied them to Spain and Italy.

The country faces acute shortage of ventilators, crucial for patients with Acute Respiratory Disease Syndrome. The government had commissioned Bharat Electronics Limited (BEL) to address the problem. As of March 30, 20 people with COVID-19 infection were on ventilators. Some automobile majors offered to produce ventilators, and the government planned to source 10,000 ventilators from China. It has asked one company in Noida, Uttar Pradesh, to manufacture ventilators, which were supposed to be ready in the first week of April.

N-95 masks were also in short supply. The government contacted two domestic manufacturers to produce them, and the Defence Research and Development Organisation (DRDO) is collaborating with them. Some 11.95 lakh masks are now in the possession of hospitals. Drug companies have said that there would not be any shortage of drugs. But apparently they faced transport hurdles, which the manufacturers association reported to the media. The government has not been candid about the nature and extent of shortfalls in medical supplies in the event of a more serious outbreak.

The Jan Swasthya Abhiyaan (JSA), a public health campaign, estimates that only 20 to 30 per cent of the hospitals had Infection Prevention and Control Guidelines in place. The Delhi government had requested the Centre for PPEs. As of April 3, 809 persons had been admitted in the nine hospitals equipped for COVID-19 treatment, and 369 people had tested positive. The hospitals had a total capacity of 1,545 beds. Some 3,120 samples were collected for testing, and reports were received for 2,745 of them. The Delhi government had at its disposal a total of 243 ventilators, 3,261 PPE kits, 4,63,450 surgical masks, 20,566 N- 95 masks and 22,366 sanitisers.

The JSA pointed out that despite guidelines issued by the ICMR and the National Centre for Disease Control (NCDC), hospitals had never invested adequately in PPEs. Given the global shortfall of PPEs and India’s import dependency, the supply of PPEs to all health workers is facing serious challenges. The JSA has urged the government to step up production of PPEs by involving manufacturing units in each State. The Central government-owned HLL Life Care is the central procurement and distribution agency for PPEs. The JSA said the government could also consider deploying more public sector units as procurement and distribution units.

The JSA acknowledged that the National Pharmaceutical Pricing Authority’s (NPPA) move to control prices of products such as sanitisers and masks and declare them essential items was a good step. The NPPA also issued an order declaring all medical devices as drugs, thereby bringing them under the ambit of the Drug Price Control Order.

The lockdown has prevented overcrowding of public hospitals. But this also means that those who are in need of medical attention may not be able to visit in time because of non-availability of transport. Another reason for the relatively low pressure on hospitals is the relatively low morbidity and limited testing.

The efforts by State governments in Rajasthan, Telangana, Andhra Pradesh, Punjab, Chhattisgarh and Madhya Pradesh to “take over”, either partially or completely, private hospitals have been widely welcomed. The conversion of existing hospitals into dedicated COVID-19 treatment and isolation centres has given rise to concerns that regarding routine procedures and treatment of non-COVID patients may be affected. An advisory was issued to hospitals not to conduct routine and elective surgeries. The anxieties of patients seeking treatment for other communicable and also non-communicable diseases have not been addressed sufficiently. Likewise, the government’s decision to allow Central government employees to access the Central Government Health Scheme (CGHS) facilities has been met with criticism as that same leverage has not been extended to other patients.

ICMR’s new directive

After some initial criticism of inadequate testing, the ICMR issued an order stating it had no objection to testing being done by government institutions such as the Department of Biotechnology, Department of Science and Technology, Council of Scientific and Industrial Research and Department of Atomic Energy, as long as they took up the responsibility for it. It said that it would “not provide diagnostic kits/reagents to these laboratories” and that samples referred by State health officials or State Integrated Disease Surveillance Programs should be the only ones to be tested. Yet the ICMR note cautioned them about SARS COV-2 being a “high risk pathogen with high transmissibility and infectivity. Sample handling at too many points and by inadequately trained staff can lead to high spills and laboratory outbreaks”. The ICMR has listed out a series of safeguards that the laboratories managed by these institutions need to take.

Yet the total number of people tested is small for a population size of 1.3 billion. The Joint Secretary, Health Ministry, admitted on April 3 that testing for confidence-building could not be done as test kits were limited. Testing in India is at present confined to a defined category of persons with travel histories and their contacts and people with Acute Respiratory Infections and Influenza Related Illnesses. This covered health workers as well. As of April 2, 66,000 samples had been tested so far in 150 government and 52 private laboratories.

Malini Aisola, co-convener of the All India Drug Action Network, said: “The delay in the procurement of PPEs has already irreversibly jeopardised the public health response to COVID-19. While some positive measures have been initiated, such as involving Invest India and enlisting of the government’s e-marketplace platform, the chances of their success remain limited owing to challenges arising from the lockdown. There has to be more concerted and co-ordinated effort by the government and its agencies.”