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

Comments

Dr Suku George, Gastroentrologist, Atlanta USA
May 3, 2020

I know Tobby from St. Thomas well. Nice to know he is well placed in the think-tank business. Nice write-up. I wrestle with following questions in India 1. How can you force private hospitals to provide covid care without reimbursement. Med care is expensive and cannot bankrupt patients and hospitals. 2. Private hospitals have a social responsibility to provide care — has to have a legal requirement to provide COVID care. — have to be realistic with cost. Once someone gets on a vent there is at least 50% fatality rate. To maximize benefit with limited INR could make a decision that they don’t have to provide mechanical ventilation. This is the most expensive part of the care since covid pts esp if they survive tend to spend more time on the vent than other pts with ARDS. Sound cruel but that is reality —some tax write off (instead of substantial immediate payments by govt) for unreimbursed care but this is an area that has potential to be scammed. Have to trust someone and so consider with heavy fines if misused. They have to eat some of the costs in this exceptional circumstance —I cannot fully agree with the statements under ‘counterpoint’ that speciality hospitals have limited domain. A cardiac hospital structured to take care of post surgical cardiac patients have more than enough capability to take care of COVID patients — in the U.S., insurance pays per diagnosis (DRG).Not too complicated to calculate and likely Indian drug costs known in the Indian medical insurance industry. Some limits on charges in pvt hospitals based on cost structure in govt hospitals. The actual costs once controlled for doctors reimbursements should be close. (Excluding big fixed costs such as buildings). Charges have sig more variability than actual costs Cannot compare with western systems In US - almost all hosp are private and patients have to be treated by law irrespective of ability to pay but they get paid by insurance and write off the rest In UK- NHS enlists all private patients but govt pays them to treat covid19 pts In Australia also govt pays pvt hospitals to provide care for covid pts. Have been out of India for 27 years now and not very sure of business aspects of health care in pvt sector there

Sunil Rajshekar - CEO, IPSMF, Former CEO Times Group company
April 28, 2020

I read the article. While various pros and cons have been stated particularly wrt Pvt hospitals, what is not clear is whether a concerted strategy can be put in place where Pvt hospitals are able to balance between the regular health issues and the pandemic. Just yesterday in Bombay a friend’s close friend’s wife succumbed to a heart attack as Bombay Hospital’s Emergency Services we’re closed due to the Pandemic. By the time she reached JJ, the lady died. I understand the Karnataka Govt has a well thought out plan to integrate Pvt Hospitals as and when the PHS finds it difficult to handle the load. At this time people should know where to head in case of both Covid and non-Covid emergencies. This is not clear.

Sanjay Mitra - Former Secretary of Defence , GOI
April 28, 2020

Almost all private hospitals have clear mandates for free or subsidised beds, in exchange for free or cheap land allotments. It is not their choice. Whatever be their specialty, basic ventilation support can be easily provided. Except niche areas like eye. The states can issue orders based on the MOUs. Ditto for medical colleges that have state quota seats. The armed forces should be kept out as far as possible. Also, paramilitary. A single case could render our carriers or submarines or planes or tanks inoperative. Look at the Ladakh Scouts problem. Look at the USN carriers. We could see public unrest of the sort we just saw in Mumbai. The paramilitary should do its own assigned tasks and do them well. The apex coordination mechanism works well. All the stakeholders are involved. Additional structures may not be useful.

ESL Narasimhan
April 24, 2020

Education and health care are core responsibilities of a government while public- private partnerships can be considered to a limited extent. Look at the NHS in the UK -Why not try that as a pilot project. Costing in private care is high and unaffordable to normal people. Also, the code of ethics for the medical fraternity needs to be refined and implemented. A visionary approach and more funding for research is called for

Sridhar
April 24, 2020

It is nicely written and has neatly presented both sides of the public vs private argument. I also agree with your assessment points. I have a couple of thoughts: One is, the government needs to have a National Pandemic Response Repository, where adequate numbers of ventilators and PPEs are maintained. The repository should also maintain adequate quantities of all antivirals for early-stage treatments in hotspots. If it is restricted to hotspots in early stages, the quantities required may not be too high. The other is our government seems to be preternaturally incapable of coming up with good regulations and our private hospitals seem to be incapable of acting with self-restraint. Whenever the government comes out with a regulation, it always seems to be heavy-handed. On the rare occasion when they come up with reasonable regulations like the pricing of Covid-19 tests in private hospitals, our courts don’t seem to like it. To ensure a good balance in regulation, the regulatory authority needs to have some private representation maybe from hospitals in the private sector that are not too avaricious. Overall, I really enjoyed reading it.

Harish HV
April 24, 2020

Lessons learnt from this should be internalised and systems put in place for building inventory of PPE, medicines and best practices and these should be coded so that next time one does not need to reinvent the wheel. Also important that one lays down protocol for vaccine administration once it is available NOW itself so that once vacccines come there is no chaos .

SRK Nair
April 17, 2020

The scale and spread of Covid 19 is unprecedented and no country can truthfully claim to have the wherewithal to handle this pandemic. In the Indian democratic approach, public health system has not got the required attention from the government, both in terms of funding and infrastructure. Hence it not fair to expect the public health system to support such a pandemic. Whereas, private health care hospitals have flourished, especially in urban areas, riding on the wealthy few and the modern insurance system, where huge and often inflated bills ,have no adverse bearing on the patient. In our context, full use of government hospitals and armed & paramilitary medical assets can contribute significantly to such a crisis both in terms of scale and quality. Several other governmental organisations like railways, HAL etc have healthcare facilities which can be brought directly under government control. It is absolutely necessary to make it legally binding for private hospitals and doctors to function under the government whenever there is a calamity, with compensation as decided by the state. This will need a strong hierarchy established under the health ministry to enforce the will of the government through laid down operating procedures. In short, do all that we need to do int he health sector when at war.

Anil Chopra
April 16, 2020

Perfectly argued. We do need a mix of public-private services. However, I believe all governmental machinery, including hospitals, are far more focused in crises than in normal periods— during which time their functioning is lackadaisical and even dystopian. The Achilles Heel of all public services is lack of motivation and accountability. Sab chalta hai- Taxpayer’s money!

Dr. P K Srihari, PhD, IRS
April 16, 2020

Well timed article articulating the need to take serious look on the health systems holistically in the back drop of COVID19. India always had public hospitals and private in charitable platform. While public institutions suffered from bureaucracy and inefficiency but best skill still available, the private sector has slipped from charity to MBA managed performance based bottom line and top line models. Corporate vehicle instead tax benefits embedded trusts in recent decades signify the new ideology.The input cost on account of Human Resources basically super skilled medical graduates makes it almost impossible for the present private hospitals to join the Government efforts to contain the COVID 19 type epidemic which will be frequent if not rare in the future times. So what is to be in short and long run. 1) Reduce the cost and years of medical education. Modern medicine is no more a skill except surgical intervention, but test driven diagnostics. 2) Promote cooperative sector based hospitals along the side of hospital corporates. 3)WHO should actually partner the build and operate international hospitals partnering with countries. 4) Let corporate hospitals exist to prevent the rich and powerful cornering the public facilities. 5) Immediately establish an apex national regulatory body for hospitals. Above are some of my thoughts. Post Covid I expect the world leaders to sit in a post war action table to draw a new order. May be a new UN and other world organisations to promote democracy and transparency in Governance. There is no better time than the present one to believe and adopt Vasudaiva Kutumbakam

KPM Das
April 15, 2020

A spotlight on a structural issue related to Indian health infrastructure , well summarized along the two pillars of a Unified Governance Framework and PPP. A few thoughts here. -as indicated here, there is a case to bring in / amend legislation to treat private healthcare assets as "extended" public sector assets. Associated partnership, regulatory and compliance models will need to be innovated with a belief that dual-role models can work with investment from the Govt and pay by citizens who can afford, co-pay by the employed across all classes and zero-pay by BPL citizens. -Additional FSR and low cost land and infrastructure support to hospitals with associated commitment of setting aside beds, intensive care assets and specialist resources may be viable. -While this may already be the case, a state and nation-wide inventory of healthcare resources and oversight of buffers mandatorily kept side for emergencies may be a possible option towards capacity assurance -Over the next two FYs, a definite and measurable Clause 135 CSR from industry may be directed towards incremental build of emergency healthcare assets and capacities