Healthcare in pandemic: Private versus Public

As COVID-19 infects more people, the role of the private hospitals in meeting challenges is coming under increasing scrutiny.

The human cost of the coronavirus outbreak continues to mount, with more than 1.35 million cases confirmed globally, and over 75000 people known to have died from the contagion. It is worth examining how the healthcare systems world over are coping with the virus.

No one predicted the outbreak of a pandemic so expeditiously, to the extent that it upended global healthcare services. However, what has emerged clearly is that, in times of emergencies, the delivery of healthcare, either by the private sector or the state-run system, is a national priority and all such resources are "public goods" to be shared equitably for the common weal. A pertinent question is whether the private sector hospitals have the bandwidth and intent to handle such exigencies or are they more compelled to achieve corporate objectives.

The toll on healthcare systems

Most countries in the world have a dual system of private and public healthcare, yet the public system is one that is most accessible to those who have lower income levels. It is not surprising that public hospitals get quickly overwhelmed trying to cater to all segments of society in one go. On the other hand, the private health care institutions are regarded more as super specialised and expensive, and may not be well equipped to intervene during times like what we are experiencing now. Responding to public health emergencies is resource-intensive and is also not commercially attractive, and this could be another reason why it does not resonate with the private sector who have to be sensitive to their bottom line demands.

In coping with the pandemic, China, Italy, and Spain have been the worst affected so far, with now the U.S. following. While Italy and Spain have excellent public healthcare systems in place, it wasn't equipped to handle an epidemic of this proportion. The Chinese authorities, on the other hand, operating under a centralised system took quick decisions to stem the tide by building almost overnight new purpose COVID-19 hospitals, strictly monitoring people and their movements, and ramping up manufacture of personal protective equipment (PPE) and ensuring its supply to the frontline health workers. This leaves the U.S., the new epicentre for COVID-19, which depends largely on a private healthcare system finding itself poorly equipped to deal with a medical situation of this magnitude. Deterred by the expensive healthcare system and no adequate insurance cover, reports admit that people chose not to go to the hospitals. This has compounded the infection rates and stretched the public health system beyond its limits.

In India, the response to the pandemic has so far remained confined largely to the public health care system. Yet, government hospitals already struggling with the number of patients seeking medical treatment, are burdened with shortages of ventilators, ICUs, and rooms. Private hospitals have been directed to treat symptomatic patients, but due to limited testing facilities and higher cost, the number of such patients has so far been low. In semi-rural areas, the private sector hospitals are not comparable to those in the cities. They only have basic infrastructures and limited medical staff. It is also worrisome that many smaller private hospitals and nursing homes in cities have closed down their out and inpatient facilities.

A robust public healthcare sector, on the other hand, would ensure proactive responses to dynamic situations in health care at the national and local level, making it easier to handle crises at this scale. For example, in Kerala, the government has taken to testing, screening, and providing rations to people through a multi-pronged public sector approach. In Germany, testing has gone up to 50,000 a day, while it has some of the lowest mortality rates. The public health system in Rajasthan too has responded with a clear plan of containing the spread and has tested the population in large numbers.

The counterpoint

The very structure of super speciality hospitals is to offer services in a restricted domain. Though 'team practice' (several specialists working together in addressing the overall health and recovery of patients) is gaining momentum, they are still restricted by the speciality they operate in. A hospital offering cardiac services may not have the wherewithal to offer regular secondary care services or have only limited support to other disciplines like respiratory medicine or neurology. Public health response usually demands a multi and interdisciplinary approach to management and many times it goes even beyond a medical approach to the problem.

Addressing social determinants of health will need more convening power and bandwidth, and these have traditionally been vested in public agencies. Private hospitals usually operate on commercial principles and may not have the financial space for them to provide care at little or no cost during public health emergencies. That being said, it is not as though private hospitals and clinics have no role to play during epidemics. They need to continue to address the regular health issues the citizenry will be facing. Currently, the closure of several private centers is adding up to the pressure on public hospitals and further strain existing resources.

While the public healthcare system is undeniably beneficial in cases of pandemics, in the overall scheme of health care, private hospitals do have an important role to play. The range and depth of specialists available in the private sector are traditionally not available in the public health system, except in a few super speciality hospitals run by the government. During times of crisis like now, the public health system can co-opt and use doctors who are either willing to volunteer or agree to be contracted in temporarily. Some private hospitals have also volunteered to be reclassified as COVID-19 hospitals and have expressed their intent to function as public hospitals until the crisis tides over. Finally, we need to understand that while governments are best placed to respond to epidemics of this magnitude, it needs to build complementary partnerships with people from the private and civil society space. It is only when all players willingly and intentionally work together, forgetting traditional boundaries can situations like the current COVID crisis be managed and contained.

Assessment

  • Governments have to be vigilant of the magnitude of the crisis that a country would face once the pandemic spirals out of control. All healthcare facilities, public/ private/ armed forces/ paramilitary will have to be brought under one command and control and their resources deployed from one hotspot to another. A flexible, well-coordinated and forward-looking plan has to emerge with matching logistics in terms of land and air mobility ( to be provided by the armed forces) and PPE in sufficient quantities to every frontline health worker. The recently passed National Medical Commission Act should be amended to include coordinated responses in a crisis like this and could function as this command center. All other central and state agencies during such times need to be placed under this commission which reports directly to the Union Health Minister.
  • The private sector should voluntarily step in for handling of the COVID-19. However, for the future, it should be ensured that regulatory authorities incorporate mandatory provisions for private hospitals to have the inbuilt capacity to switch roles and support the public system in case of war or worse a pandemic. A good way to regulate the private sector would be to bring it under stricter regulations to oversee costs that the hospital charges for its services.
  • Pandemics are no longer mere public health problems. The current crisis has demonstrated that they have a much wider social, economic, trade and security ramification. Inter-ministerial teams (similar to the Cabinet Committee on Security) representing all these sectors need to be formed to respond with a short term and long term strategy addressing all the complexities arising out of the crisis.

Authors : Tobby Simon – Founder and President, Synergia Foundation & Dr R Balasubramaniam - Founder, Swami Vivekananda Youth Movement and GRAAM Mysuru

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