“People-centred and integrated health services are critical for reaching universal health coverage,” asserts the World Health Organization (WHO). Indeed, if the COVID-19 pandemic has taught us anything, it is the importance of robust healthcare delivery systems – and how existing weaknesses have, in many respects, exacerbated and amplified the pandemic’s effects.
As lockdown procedures were eased in many parts of the country, the question loomed as to whether the country’s healthcare system would be able to cope. “Unlike other countries that are lifting the lockdown, India has been unable to effectively utilise the lockdown period to prepare for exiting the lockdown,” Professor Sarang Deo and Hemanshu Das wrote in an IndiaSpend piece published at the beginning of June as relaxations came into force. This, their analysis said, applies “both in terms of curbing the epidemic and increasing the testing rate, when compared to other countries that are opening the lockdown.”
To elaborate on these points, I interviewed Professor Deo recently on the importance of healthcare delivery systems during the COVID-19 pandemic and how.
Our conversation has been edited for length and clarity.
- Thank you for agreeing to speak with me, Professor Deo. First of all, could you introduce yourself to our readers?
I’m the professor of Operations Management at the Indian School of Business and I also serve as the executive director of the Max Institute of Healthcare Management at the Indian School of Business. I am trained in operations management; I have a PhD from the University of California, Los Angeles (UCLA) Anderson School of Management and my research interests are in developing quantitative models of healthcare delivery systems, understanding how operational decisions in these systems impact on health outcomes.
I have been at the Indian School of Business for almost nine years now. Before that, I was faculty at the Kellogg School of Management at Northwestern University.
- We’re going to be talking about healthcare delivery systems. For the benefit of our readers who may not know what this refers to, could you explain what is meant by the term ‘healthcare delivery systems’?
I don’t want to go for a textbook definition, but in simple terms healthcare delivery systems refers to an interconnected set of resources, organisations, institutions and healthcare facilities that, together, are responsible for the eventual health outcomes of patients. This is a scalable definition.
If you think about the National Health Service (NHS) in the UK, the whole NHS could be thought of as a healthcare delivery system because it consists of hospitals, primary care centres, ambulance services, doctors, nurses, etc. At the other end, you can think about just one hospital itself as a healthcare delivery system because it has within it departments and facilities, such as the intensive care unit (ICU) and operating theatres, which are all interconnected and determine the outcome of patients.
- COVID-19 is an unprecedented public health challenge and one that has had a significant impact on public health. Could you explain how healthcare delivery systems in India have been affected by the pandemic?
I think like any other country, India’s healthcare delivery systems have been affected in at least two or more ways due to COVID. There is obviously the direct impact of COVID. Some of the patients who are infected have to be admitted into the hospitals, a fraction of whom end up in the ICU and need ventilators. That puts a burden on resources, and in the cases where these resources are constrained, that’s going to make things difficult. ICUs are going to get filled up and ventilators are going to be in short supply. The second effect is that the human resources – doctors, nurses, etc. – who are involved in delivering healthcare services are put at risk. If they get infected, that brings down the capacity of the healthcare delivery system further.
If you are trying to minimise that impact, then you may end up reducing the routine services provided, at either the primary, secondary or tertiary care levels. That is the third impact. There is enough data to show that during lockdown, immunisation numbers were down dramatically. Similarly, provision of essential services such as tuberculosis testing and treatment and HIV programmes were adversely impacted because of COVID. We also hear a lot of anecdotal evidence about private sector clinics and hospitals either shutting down or operating at significantly lower capacity as a prevention measure.
- Do you think healthcare delivery systems in India were prepared for a crisis of this magnitude?
Again, I don’t think there was any country that would have been fully prepared – least of all a developing country like India, where doctors are in short supply, hospital beds in ICUs are in short supply. From a sheer quantum of capacity of any resource, even good health systems were not prepared.
The nature of India’s healthcare delivery system is fairly fragmented and disjointed. We’ve got a mixed health system, involving both public and private sector. The public health system consists of district hospitals, community health centres, primary health centres and sub-centres at the community level. The private health system is really a motley crew of large chains of private hospitals at one end and, at the other, small, relatively unorganised nursing homes and clinics and solo practitioners that operate out of a small room. This is a healthcare system that inherently is not structured to put up a concerted response to COVID. We’ve been caught off-guard to some extent.
- To what extent do you think the pandemic has exposed pre-existing flaws in India’s healthcare delivery systems?
Any crisis, be it COVID or climate change, affects people differently. The more privileged ones are affected less and the less privileged ones moreso. Vulnerabilities are accentuated. In the case of COVID in India, if you come from a low-income household and you develop a cough or a fever or other symptoms, my guess would be that your ability to get a COVID test would be much lower than if you were well-to-do and had the money. The test is still relatively expensive in the private sector. In the public sector you can get it for free. But there are only a few facilities in the public sector where you can be tested.
I think the same applies in terms of information about the pandemic and prevention measures. Where there are already disparities, a crisis like this would just exacerbate and amplify them – and I’m just talking about the impact on health. There are the secondary impacts such as food and nutrition. You see the fault lines being exposed.
- To control the pandemic, India entered a state of lockdown for a considerable length of time. Has this been an effective step?
We can debate this until the cows come home. You need a very clear counterfactual: what would have happened if there was no lockdown?
The Indian Council of Medical Research (ICMR) has released model-based estimates concerning the policies and guidelines around COVID. They came up with a study recently that showed several thousands of lives were saved because of the lockdown. By several measures, our lockdown was enacted earlier and much more stringently compared to many other countries. Its implementation was much stricter than in many other countries. The initial narrative was that we wanted to flatten the curve and, as the curve flattens, build resources and capacity.
It is debatable whether we did that, especially given what is happening in the large metros like Delhi and Mumbai where ICUs are overwhelmed and doctors are getting infected. Possibly more could have been done. And I think that’s where the fragmented nature of the healthcare system comes into play. You don’t have a central orchestrator that can rapidly expand capacity. A lot of that is left to the private sector or the state and union territory (UT) governments. I think that makes things more difficult.
- The relaxation of lockdown restrictions in many parts of the country has been rolled out. Is this a premature step and what is the potential impact upon healthcare delivery systems – will they be overwhelmed even further?
I think we are seeing that. I think there is an argument that the economy needed to be reopened and that people were suffering with the lockdown but the testing capacity and lab capacity were not adequately expanded. What many other countries have done is ramp up testing capacity significantly, to be able to keep a tab on the pandemic so to speak. Contact tracing capacities too. These are still weak points in our system, partly because a lot of the on-ground activities are left to district administrators. There is significant heterogeneity across districts on how well some of the policies are implemented.
It’s Sophie’s Choice, really. I mean, you had to probably unlock at some point in time, but I don’t think we had the wherewithal to replace the blunt instrument of the lockdown with a more fine-grained chisel, so to speak.
- Different states and union territories have had varying levels of success in addressing the pandemic. How have the differences between healthcare delivery systems in different states influenced this?
A lot has been talked about and will be talked about the differences between states because health is a state subject, so the states are a natural unit of analysis for most people. Kerala is usually touted as the success story, with a very strong public health primary care system. They were very quick to pounce on the pandemic and act with great force and a well-organised effort. On the other hand, states that are suffering the most are suffering primarily because they are home to the large metros. I think the pandemic is largely an urban phenomenon in India because they have the living conditions that make for very easy transmission of the virus, unlike rural areas.
As to the differences across states, we see that in the amount of testing done in the amount of beds available, and I’m not an expert on this, but I’m sure part of that also has to do with the politics of the state and the priorities of the state governments. It’s a mix of clinical, technical and political factors, like any country.
What is not talked about enough is the differences between districts. Everyone has data for states but, within states, there is likely to be large disparities across districts. The response varies quite a bit.
- Do you believe that rural areas may suffer higher mortality rates due to COVID-19 because of a lack of access to healthcare delivery systems?
I am very concerned. I’ve done a lot of research on tuberculosis and other airborne respiratory infections and there are problems in rural areas for patients who are infected. Now the counterargument to that is the likelihood of transmission is actually somewhat lower in rural areas because people live in open space. Population density is lower compared to cities. So there is some hope. But I think that the difficulty and the fear is if people are infected to whatever extent the access to healthcare services is going to be much lower.
In the beginning, I was of the opinion that instead of locking down cities, it would have been wise to lock down villages or clusters of villages. In the initial days, the rural areas were very safe. For many weeks I think we had zero cases in a large number of districts. One of the strategies would have been to isolate those smaller districts and smaller towns and villages surrounding them and keep them away from the large urban centres. Of course, with the migrant situation, it was not possible. And so we are now seeing in some states are reshaping as an example, the large fraction of migrants or large fraction of cases in that state are coming from migrants.
It is a concern for sure because, if Mumbai and Delhi are getting overwhelmed with their ICUs, in rural villages, there is no ICU. It’s going to be much worse if it gets to that scale.
- Do you think the pandemic will lead to more attention being paid to the importance of robust healthcare delivery systems?
There is always hope. Even without COVID, there were glimmers of hope, where important entities in the country related to the health sector have been thinking in terms of systems. I was part of a few brainstorming sessions and planning sessions around development of a health systems platform consortium in the country. And there is movement. I mean, there is now the national National Health Authority, which is the agency that implements the Pradhan Mantri Jan Arogya Yojana (PMJAY).
But I am a bit skeptical because everything is so sort of exceptional in this situation. So once you will address a crisis, it is possible that people fall back into old ways. This may be a controversial statement, but we’re not very good at learning lessons from big crises in India. I don’t think we start immediately thinking in terms of systems to prevent such things from happening in the future.
I would be happy if that happened, but I’m skeptical about it.
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