As Coronavirus cases are surging up in India, everyone must be aware of Top 10 challenges in Covid-19 Treatment issues in India.
Introduction:
India’s battle against Covid19 is gradually slowing down due to the collapsed public health system. India’s Covid19 figure has crossed 2.84 crore with death toll stands at 3.38 lakh. Each day 400 to 500 people are dying from corona. The Covid19 treatment crisis in India’s top cities Maharashtra, Delhi, and Tamil Nadu has created a deep tension in the nation. Common citizen are not only fighting with corona disease but also struggling to get a bed in Government hospitals. The exorbitant charge in private hospitals has also become a worry factor for every civilian. Unhurriedly, the Covid19 treatment crisis is catching the middle class family as it is really difficult for them to bear the high end billings demanded by the private hospitals. After repeated complains, many state governments has now exercised some rules upon private hospitals under National Disaster Management Act 2005. But still people’s fight to find a bed and proper treatment in hospital has not come to an end. Recently many newspapers have published the reports how people are dying due to lack of bed in Public hospitals and denial of treatment in private hospitals due to paucity of fund.
In the dark shadow of Covid19 treatment crisis, let’s discuss some of the major points behind Covid19 treatment catastrophe and what challenges will the commoner face in the present and post corona pandemic situation.
1. Lack of effective Public Health Management:
The major point behind Covid19 treatment crisis is the lack of effective Public Health Management. Public health is concerned with disease prevention and control at the population level, through organized efforts and informed choices of society, organizations, public and private communities and individuals. However, the role of government is crucial for addressing these challenges and achieving health equity. The Ministry of Health and Family Welfare (MOHFW) plays a key role in guiding India's public health system.
In a recent study, the Center for Disease Dynamics, Economics & Policy (India) and Princeton University said the country currently has 713,986 beds, including 35,699 in intensive care units, and 17,850 ventilators for 1.3 billion people.
According to data from the Organization for Economic Co-operation and Development (OECD) available for India for 2017, India has 0.53 beds for 1,000 people compared with 0.87 in Bangladesh, 1.1 in Indonesia, 2.11 in Chile, 2.73 in Turkey, 1.38 in Mexico, 4.34 in China and 8.05 in Russia. The numbers have not changed in the last four years of available data, showing India’s stagnant allocation to the public health care budget.
India’s public expenditure on health as percentage of the GDP is far lower than countries classified as the “poorest” in the world, the Union Ministry of Health and Family Welfare has conceded in the month of November. India’s public expenditure on health in year 2019 stands at 1.28 per cent of the GDP which is lower when compared with other South-East Asian countries like Nepal, Sri Lanka, Bhutan, Indonesia, Thailand and the tiny island country of Timor-Leste.
India’s low investment in the health sector is now making it vulnerable to COVID-19. It contrasts with other developing countries such as Brazil, which spends 7.5% of its annual GDP on health, Bhutan, which has allocated 3.6%, and Bangladesh, which dedicates 2.2%. Among developed nations, South Korea has kept its healthcare expenditure at a whopping 8.1%, Japan 10.9%, and the US at 8.5%.
Upon comparing state populations with the number of available beds, Kerala with a population of only 3.5 crore (2018) has over 22,300 available beds in public hospitals/government medical colleges. Whereas, bigger states like Gujarat and Maharashtra with populations of over 6.82 crore and 12.22 crore (2018) respectively, have only 16,375 and 6,970 beds respectively. These differences across states also speak for the differing capacities to contain the virus at a sub national level wherein Kerala has emerged as a successful model.
With the onset of Corona pandemic in our country, it was the foremost duty of the Government to rapidly strengthen the public health system to fight the deadly Coronavirus. As this is a time of national crisis, Government should have proactively regulated the public healthcare system in all the states to fight the Covid 19 situation. But here it has been observed that administration emphasized more on lockdown and at the same time neglected the planning of essential health approach to combat Covid 19. Lockdown period was an opportunity for both the centre and state to properly estimate the Covid counts which will rise post lockdown and arrange the dedicated Covid19 healthcare units. But it has been noticed that administrations are waking up late for setting Covid19 hospitals when cases hugely raised and people are dying due to lack of bed.
2. High Covid19 Treatment Cost in Private Hospital:
Due to the over flooded Corona patients in Public hospitals in Maharashtra, Delhi, Gujarat and Tamil Nadu, Government has tied up with some private hospitals for Covid19 treatment. Families of several Covid-19 patients have accused private hospitals of charging excessive amounts for treatment of the disease. In many cases, families do not have medical insurance, making treatment out of reach for a large section of the population.
While charges vary from one hospital to another, some hospitals were charging up to Rs 25,000 per day for a bed in the general ward, Rs 30,000 for a private room, and Rs 72,000 for a bed in the ICU. In some instances, the treatment cost for a Covid patient would touch Rs 1 lakh a day.
Despite many states has capped the cost in private hospital but in ground level many reports are coming how private hospitals are exploiting common man. A virtual loot is going on," says Brinelle D'souza, faculty at Tata Institute of Social Sciences, Mumbai. At Bethany hospital in Thane West, Dsouza's friend was asked to pay Rs 91,000 for one and a half days, his father spent in the hospital's ICU and to add to it, they paid a whopping Rs 10,000 for the ambulance service for barely a distance of 3km from Bethany hospital to Sapphirre hospital in Thane.
Jolly Antony, a resident of Andheri narrates the experience of one of his friends who had to spend 12 days in a well-known, posh, private hospital in Andheri. "They were charged Rs 18 lakh, which included Rs 8,000 per day only for the PPE kits worn by the staff.
The Telangana government may have set a price cap on the treatment for Covid-19 in private hospitals, but with the non-coverage of basic consumables like PPE kits, ICU drugs, oxygen cylinders, and lab work, the cost is still too high for the common man. Many were shocked after coming to know that the 'hidden costs' would come up to Rs 50,000 to Rs 80,000 per day.
In one such case, a COVID-19 patient who is presently undergoing treatment at a private hospital in the city has been asked to pay 10 times the Rs 9,000 slab for ICU with ventilator. "Verbally, we have been told to keep Rs 14 lakh ready for 14 days of treatment. We are not sure what it would be for, because she (patient) was tested positive only a day ago. Prior to the G.O, on June 14th and 15th alone we spent over Rs 3 lakh for doctor’s fee, nurse’s fee, CT scans, X-rays, etc, before the COVID-19 test results came in," said the patient’s kin.
3. National Disaster Act and Acquisition of Private Hospital:
The Disaster Management Act, 2005 gives the Central government powers to take quick policy decisions and impose restrictions on people to manage a disaster. DMA is a national law that empowers the Central government to declare the entire country or part of it as affected by a disaster and to make plans for mitigation to reduce “risks, impacts and affects” of the disaster. The Epidemic Disease Act, 1897 does not provide such powers. DMA covers all man-made and natural disasters which are beyond the coping capacity of a community. It also provides powers to the government to act against anyone not abiding by government orders and regulations.
[The disaster management set up was structured at three levels viz. national, state and district. The NDMA was set up as the apex bodies at the national level, while at the state level State Disaster Management Authorities (SDMA) were set up. These were headed by the Chief Ministers. At the district level District Disaster Management Authorities (DDMA) were set up. These were headed by the District Collectors and co-chaired by elected representatives of the local authorities. All these authorities were charged with the responsibility of formulating holistic and integrated plans for disaster management and ensuring the implementation of these plans when required.]
The National Disaster Management Act, in fact, has provisions for the state to requisition required services to handle precisely such emergencies. In the case of the COVID-19 pandemic, private hospitals should play an important role in dealing with the moderate and severe cases that require hospitalization, making their ICU facilities and isolation wards available. Some state governments have in fact requisitioned private hospitals to supplement the public sector. However, the experience so far has been mixed.
On March 25, the Chhattisgarh government invoked the state’s Public Health Act and the Chhattisgarh Epidemic Disease Covid-19 Rules, 2020, to take over the privately run Raipur Institute of Medical Sciences. That would mean over 300 beds for Covid-19 patients, estimated Dharmendra Gahwai, state surveillance officer at the department of health and family welfare.
On March 26, the administration in Rajasthan’s Bhilwara district, one of the worst hit by the pandemic so far, invoked the Rajasthan Epidemic Diseases Act of 1957 to take over five private hospitals for the treatment of Covid-19 patients. Hotels in Ajmer and Hanumangarh were also requisitioned for quarantine camps in separate orders.
On the same day, the Madhya Pradesh government announced that private hospitals might be requisitioned in the near future to meet the demands of treating Covid-19 patients. Such hospitals were to send requests for protective equipment to the Madhya Pradesh Public Health Supplies Corporation in time.
Later, the Indore administration issued orders to take over Vishesh and Gokuldas Hospitals for Covid-19 treatment. On March 23, the state government had formulated rules for the treatment of Covid-19 cases under the Epidemic Diseases Act of 1897. Its provisions empower district magistrates to requisition any staff or institution needed to fight the pandemic.
Andhra Pradesh Government has also taken over facilities and manpower of Private hospital under the Disaster Mgmt Act to tackle Covid19 Pandemic. The government has taken over 58 private hospitals across the State to cope with the eventuality of further spread of COVID-19. Construing the situation as a “nation wide public health emergency”, the state government said it is the Government responsibility to ensure that the private sector carries out its activities in an equitable and non discriminating manner.
Now it is a great concern, that in national emergency time, while the centre and state had the proven authority to take over the private hospitals, many states would have implemented and arranged dedicated Covid-care centre. And with the separate Covid Care centre there would have no chances of infection to other comorbid patients. But it is a deep worry subject that while lockdown was imposed nationwide under the National Disaster Act but at the same time centre is clueless and silent in acquisitioning private hospitals for the treatment of its own citizen.
As countries across the world struggle to deal with the pandemic, the private sector has been commandeered in several places. Spain has nationalized all hospitals and healthcare providers. In Ireland, all private hospitals will be part of the public healthcare system so long as the pandemic lasts.
In the time of national crisis Private hospitals should also come up with suo motu approach to make partnership with Government to save the life of people in the pandemic rather than exploiting vulnerable people.
4. Oxygen Deprivation causing death of COVID-19 Patients:
Oxygen is vital for patients of COVID-19--a respiratory disease that mainly attacks the lungs and leads to dangerously low levels of oxygen in the body. About 15% of all COVID-19 patients with “severe infection” will require oxygen while 5% with “critical infection” will need a ventilator, the World Health Organization (WHO) has said.
“Many of the patients can be saved by giving just one treatment that is by giving them oxygen” said Randeep Guleria, director of the All India Institute of Medical Sciences, at a government press conference on April 23, 2020. “Therefore a strategy of having more oxygen-beds is based on this,” he said, adding that when oxygen levels in blood fall, it can trigger cardiac and neurological problems.
Many reports have come that how patients are dying due to lack of oxygen in hospital. Doctor’s mental health is also being affected when they are seeing that patients are dying in front of them in oxygen deprivation.
Doctors at Jogeshwari Trauma Centre write to medical superintendent “This has now begun to impact our mental wellbeing” Don’t blame us if patients die due to lack of oxygen, say doctors; A BMC-run hospital in Jogeshwari has not been able to supply adequate oxygen to Covid patients, leading to the death of at least 12 people in just two weeks, according to doctors at the facility.
Another resident doctor recalled the harrowing situation he witnessed last week when he was on duty in the ICU. “Two patients were gasping for breath and needed 8 to 10 litres of oxygen per minute. However, the supply was so slow the screen was continuously giving an alert of low pressure O2, and by the time I tried to fix the pressure with the hospital technician, both patients had died.
However, a lot of asymptomatic patients also suffer from extraordinarily low blood-oxygen levels or hypoxia without even realizing. Doctors are reporting an unusual phenomenon in COVID-19, where patients have critically low levels of blood oxygen, but no breathlessness. This has been described as ‘silent hypoxia’ or ‘hypoxia’ – meaning low blood oxygen. It could be because, in the early stages of the disease, low oxygen saturation doesn’t have any obvious respiratory problems. This silent depletion of oxygen levels in the body of asymptomatic patients may ultimately lead to cardiac arrest.
5. Struggle of Senior Citizen in Covid19 treatment:
The elderly, who constitute 10 percentage of India’s population, accounted for over 50% of the country’s Covid19 deaths. Besides, 73% of Covid-19 deaths were among those with comorbidities who are suffered from other critical cases such as diabetes, kidney problem, heart diseases. Their situation is becoming worst in case of Covid infection. They need ventilators for their survival. But due to lack of ventilator in Government hospitals and denial of treatment in private hospitals many elders are dying. And the number of death in our country is also exponentially rising up.
“The private hospitals refuse to take the old patients in critical condition because they fear their reputation will be spoiled if something happens to the patients during the treatment.” However, the government hospital has now asked the family to look for a private hospital for further treatment of the 84-year-old male, who is critical, as they have enough beds but lack ventilators.
“Now the question arises where the senior citizens who must be prioritized for Covid19 treatment are most neglected in this critical situation. Administration and hospital authority both must have been fixed up facilities for the old persons on the supremacy basis as we all aware of the fact that Covid19 affects elders very badly. But due to lack of proper provision, the country’s most needy persons are striving very hard during the Corona pandemic.”
6. Complexity of Other Critical Patients in Covid19 situation:
Other Critical Patients are also hugely suffering in this Covid19 situation as most of the public hospitals are loaded with Covid19 patients. Doctors are also packed with shifts. Private hospital those who shared their hospital bed for Covid treatment have also put other patients into risk of infection. Other patients are catching corona infection from the hospital premises.
Goyal’s son Anil (52), who runs a cycle repair shop in Nand Nagri, said his father fell sick on May 25 and was taken to a private hospital, where the family was informed that “he had suffered a paralytic attack, and was referred to a neuro centre”.
“We took him to Jain Neuro Centre in Jagriti Enclave, where… he showed improvement within a day. His condition deteriorated when a Covid-19 patient was admitted next to his bed,” Anil told The Indian Express.
Cancer patients have also been suffering a lot right from the lockdown because they are having higher risk towards Covid infection and also need regular chemo therapy for their survival. But as there is nationwide health crisis many cancer patients are also deprived of treatment.
Arun Gupta, a cancer patient himself and founder of NGO Win over Cancer, said that the immunity of patients undergoing chemotherapy is compromised, their body is weak and they already face a lot of issues. Chemo itself has a lot of side-effects and if a patient gets infected with COVID-19, it can be a life threatening condition.
On one hand, cancer patients are scared of contacting the virus in hospitals, so they forgo their treatments; on the other hand, hospitals have been forced to cancel appointments, as a majority of their healthcare staff has shifted to other wards to assist in COVID-19 emergencies.
“Looking at the Global catastrophe and the situation in developed countries, our administration must have been allocated dedicated Covid care unit where only Covid patients are treated with dedicated doctors and healthcare workers. And separate health care facilities must have been scheduled for other critical conditions patients so that there would have been no chances of infection from Corona patients to other patients.”
7. Increased cost of hospitalization for Non-Covid patients
Medical charges are becoming higher for general patients in the present Covid 19 situation. In Bengaluru, since most private hospitals are considering every patient as a suspected Covid-19 case and with doctors and nurses are using personal protective equipment, the cost of hospitalization has increased by staggering 25-30%.
The cost of one PPE alone is between Rs 1,800 and Rs 2,000 and hospitals say cost escalations are inevitable. “If a patient is treated in ICU or an isolation ward, the cost would go up by about 30%,” said Dr Naresh Shetty, president, MS Ramaiah Hospital who is also the president, Association of Healthcare Providers of India (AHPI), Karnataka chapter.
Shetty said the measures will be necessary until “every patient is tested for Covid-19 and safety is ensured”. A 69-year-old man, who was suspected for Covid-19, had to be in isolation for three days in a private hospital in Bengaluru in March until he tested negative. “The isolation ward charge per day was Rs 10,500. In the total bill there was a mention of 5 PPEs used, each priced at Rs 2,000. The family had to pay Rs 1.4 lakh for six days of hospitalization. The cost would have been minimum 30% less in pre-Covid times, the family says.
A woman from Kumaraswamy Layout, who recently consulted an orthopaedician, said she was asked to pay Rs 600 instead of the regular Rs 400 consultation charge. “The doctor wore a face shield, gloves and a mask,” she said.
“Now such circumstances arrived where patient with normal cold and fevers also have to go through Covid test. People with other respiratory disease also have to face the suspicion of isolation and Covid test. Pregnant Woman and delivered child also have to test for Covid19. Likewise the expenditure of common man for his health will increase. Now each and every person has to spend extra budget for their health care. “
As we all aware of the fact that how private hospitals make money by exploiting common people. Now we can easily imagine what is going to happen in Post Coronavirus Condition! To check this situation Government has to necessarily implement a common solution to save its people from being exploited in name of Coronavirus. It should fix a nominal cost for Covid19 test and its treatment in post Coronavirus period.”It also should try to draw a fine line of treatment distinction between Covid and Non-Covid patients.
8. Covid19 treatment and Insurance:
With metros seeing an increasing number of Covid-19 patients availing treatment in private facilities, insurers and hospitals are wrangling over bills. The average bill of a Covid-19 package in India is Rs 1.56 lakh so far, as per IRDAI data. Insurers say that claims range from Rs 2 lakh to Rs 8 lakh, but pay only what has been agreed upon in insurance contracts, with the rest borne by the insured.
"Normal treatment cost of Rs 50,000-1 lakh has now surged to Rs 1-2 lakh for Covid-19 treatment (due to increase in cost of consumables, patient distancing in hospitals, etc.) and to Rs 6-7 lakh or more where comorbidities are involved or treated in expensive hospitals," said Chandan D S Dang, Executive Director, Securenow.in, a Delhi based insurance broker.
Consumables in health insurance parlance refer to single-use items that are frequently used in medical treatments or procedures. These are considered non-medical items and hence, are not payable under most health insurance covers.
A single PPE kit includes a pair of nitrile gloves, a single use coverall, goggles with transparent glasses, an N-95 mask, shoe covers, and a face shield. Since each of these items is separately considered consumables, there is a significant increase in the number of consumables used in the treatment of Covid-19 infection. It is not just the cost of PPE kits but the cost of other consumables is also included in the hospital bill. These consumables are normally surgical accessories like tissue paper, crepe bandage, gown, foot covers, slippers, disposable gloves, sheets, syringes, gowns, masks etc. Toiletries and cosmetics are also considered as consumables.
The cost of treatment of Covid-19 has increased in hospitals, due to the use of personal protective equipment (PPE) a kit which is unavoidable to contain the spread of the coronavirus. None of this is covered under a health insurance policy, even though they are included in the hospital bill.
Delhi resident Surender Gaur claims his brother’s bill of Rs 4.08 lakh had Rs 70,900 earmarked just for PPE kits. He also alleges that his brother was billed for 22 visits by a specialist doctor as against seven visits. Chennai resident B Manikandan alleges that his father was billed Rs 4.8 lakh for Covid treatment of which Rs 75,000 was charged for a ventilator, which was never used. Insurers are also disputing add-on charges to the Covid test.
For the insurance industry, the cost of covid-19 treatment is a cause for worry for two reasons: hospital costs are not regulated and covid-19 costs could vary hugely depending on the complications. “Currently there is no uniform practice on how costs on account of defence protocols can be built into the bills. So in some cases, while a PPE kit is worn by a doctor who visits many patients in the same hospital, all of these patients are billed for these PPE kits individually," said Sushma Anupam, deputy general manager, New India Assurance Co. Ltd.
Elevated costs are not a problem only in the case of covid-19 patients, said Shreeraj Deshpande, chief operating officer, Future Generali India Insurance Co. Ltd. Hospitals are exorbitantly billing certain non-medical expenses, which are general in nature, such as protective gears for their staff to individual insured patients. “Even non-covid patients may have to pay for increased safety protocols given that a large segment of patients are asymptomatic," said Bhabatosh Mishra, director, underwriting, products and claims, Max Bupa Health Insurance Co. Ltd. Specific government protocols for covid-19 treatment should be followed and corresponding charges should be standardized," said Deshpande.
9. Crisis of Doctors and Health Care Workers:
The Ministry of Health and Family Welfare (MoHFW) has told the Supreme Court that it is ultimately a doctor's own responsibility to protect himself from COVID-19. The Ministry of Health has submitted that it is ultimately the healthcare workers who need to protect themselves from exposure to infections by training themselves and taking all precautions to prevent infection.
The statement was made while replying to a plea questioning the Centre's new guidelines for frontline COVID-19 healthcare workers by which it has ended the 14-day mandatory quarantine for them, reports legal news website BarandBench.com.
The Centre has further stated that the petitioner has given no "empirical evidence" suggesting doctors were testing positive for COVID-19 in spite of wearing PPE and that the conclusions drawn were merely a "hypothesis".
Predictably, this order was not well received by healthcare workers who are putting their lives at risk on the frontlines of this virus. Notably, the Residents Doctors Association (RDA) Delhi’s Ram Manohar Lohia Hospital (RML) requested some clarity in a tweet on 18 May. The reiterated the same in another tweet on 21 May which detailed a press release which is mentioned below.
“The recent change of Quarantine Guideline for HCW in Covid duties by MOHFW (dated 15/5/2020) is unfair, illogical and unacceptable. We can’t go back to normal routine of living with our families immediately after the Covid posting as we could be asymptomatic careers.”
As due to shortage of medical staff in this terrible position, Government has withdrawn the 14 days mandatory quarantine for doctors. Now doctors who are coming in contact with Covid patients are also normally going to their home. They might be treating other patients. But there are chances that they might be asymptomatic careers.
Doctors filed a plea and questioned the Centre’s new standard operating procedure for front line COVID-19 healthcare workers, by which it has ended the 14-day mandatory quarantine for them. But Government rejected the plea and told who are wearing proper PPE kit would have not a single chance of corona infection.
But this is the time we should specially care about doctors. In India the ratio of doctors is very less as compared to the whole population. In this corona pandemic they are working as soldiers. If wearing only PPE would have lessen the risk of corona transmission then doctors in London and Washington are not dying from corona during the corona fight!
10. Covid19 & Untouchability:
As in leprosy the mentality of people is that if we touch one leprosy patient then we will get the disease. Unfortunately in case of Covid19 patients’ similar trend has already acquired the mind of people that if we touch the Covid patient then we will get the disease. In one of the public hospital of Maharashtra, one old aged woman has also become a victim of untouchability. That nobody went near her and her dead body found after two days in a toilet.
Similarly in Bantwal taluk of Dakshina Kannada district, local residents heavily opposed the cremation of a 75-year-old woman who died of Covid-19. The minister asked people to behave humanely.
“People vehemently opposed the cremation of the deceased assuming that it would cause them infection. This behavior of treating families of Covid19 victims like untouchables is not acceptable,” he said.
Covid 19 is not the case of that if we will touch one Covid 19 patient then we will get the disease but it’s all depends on our immunity system. As many asymptomatic careers are moving but all will not catch the disease but those who have underlying chronic health issue they will easily catch the disease. And in fact the most important thing is that Covid 19 is an air borne disease. Mainly the virus spread through aerosol from the coughing and sneezing of an infected person in a close proximity. Its viruses are already circulating in the air but those with low immunity and co-morbid condition they will show the symptom.
But as fear and unawareness has spread among the people, so it has become a mindset of people which will hamper all of us in the future where many people will be discriminated and harassed if they found Covid 19 positive. Family people will not take care of them and society will discriminate their family. Also read a special coverage on Covid19 and untouchability in an article “Coronavirus Pandemic Will Foster Horizontal Untouchability As Opposed To Vertical One Of Caste.”
Conclusion:
Now it’s the turning point of our nation where Government and citizen both have to aware of the weak points in our system and will set quick resolution to fix those points. May be our country has a strong defense system but if another Corona pandemic situation will occur then it will hit our country more badly than a war. We might be ready for a nuclear war but as many scientist suspects that Corona is a biowar then how far we are ready to battle such situation. It’s the time that Government and citizen both have to think for a strong public health infrastructure in our country. Every citizen must first demand for universal health care in which all residents of a particular country or region are assured access to healthcare. If a country will not have a concrete public health infrastructure then it will be far to reach the dream of developed nation.
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