As India braces for the next stage of the coronavirus pandemic, state governments are marshalling resources to deal with a flood of cases. With the public health sector already under strain, unable to provide sufficient beds, ventilators or intensive care units, several state governments have pressed private hospitals into service.
Isolation wards had already been set up in some private hospitals. On March 24, the Uttarakhand government announced private hospitals with 100 or more beds would have to reserve 25% of these for Covid-19 patients. Covid-19 is the disease caused by the newly discovered coronavirus.
At least three states – Chhattisgarh, Rajasthan and Madhya Pradesh – have gone further, issuing orders announcing that entire private hospitals would be temporarily taken over by the government for the treatment of Covid-19 patients.
Healthcare for Covid-19 patients treated at these hospitals would be free, government officials in all three states said. But governments and private healthcare providers are still ironing out the details of the partnership.
Invoking the Epidemic Act
The states issued orders under rules flowing from the Epidemic Diseases Act of 1897 or state-specific variations of the Act. The colonial-era law empowers the state to enforce temporary regulations to fight the “outbreak of any dangerous epidemic disease”.
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. The state administration issued an order to take over all private hospitals the next day but withdrew it within hours.
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.
In all three states, staff at the private hospitals will also be dedicated to treating such patients. The public and private sectors will be working in tandem in these states. Romel Singh, coordinating Covid-19 preparations in Bhilwara district, said the state government would provide support with management and supplies. The five hospitals had enough ventilators for prospective patients, he said.
In Chhattisgarh, Gahwai said, financial support to the private hospital would flow from the state disaster management funds. Other private hospitals and staff had also been roped in for help. They could supply ventilators, multipurpose monitors and infusion pumps, as well as staff to monitor and supervise wards. “Our infection protocol is taken from private hospitals,” said Gahwai. “Trained doctors from AIIMS (the All India Institute of Medical Sciences), RIMS as well as senior doctors from private hospitals will also supervise infection [management].” Several private doctors had already volunteered to help, he said.
In Madhya Pradesh, government orders mention intensive care units, ventilators and staff of private hospitals will be devoted to the care of Covid-19 patients. Sapna Lovanshi, Madhya Pradesh executive officer for Ayushman Bharat, said the state government would reimburse the private hospitals as per the rates for pneumonia treatment under the national health insurance scheme which is part of the Ayushman Bharat programme.
The National Health Authority has recommended the inclusion of Covid-19 tests and treatment under the health insurance scheme across India. The proposal is still awaiting clearance. But Madhya Pradesh has decided to extend this to even hospitals that are not empanelled with Ayushman Bharat, Lovanshi said.
As countries across the world struggle to deal with the pandemic, the private sector has been commandeered in several places. Spain has nationalised all hospitals and healthcare providers. In Ireland, all private hospitals will be part of the public healthcare system so long as the pandemic lasts.
Governments, public health activists and private practitioners are united on the need to rope in the private sector to deal with the epidemic. “I don’t think there is a choice,” said Sanjay Nagral, a surgeon at a private hospital in Mumbai. “The private sector is involved in the majority of healthcare interventions. The public sector can’t take the burden. It is like a war situation and the government will have to push for it.”
According to Amulya Nidhi, a public health activist and national co-convenor of Jan Swasthya Abhiyaan, public hospitals in Indore, which accounts for nearly half of Madhya Pradesh’s Covid-19 cases, were already “overloaded and under-staffed”, with not enough infrastructure.
But Siddharth Bhattacharya, secretary general of the Healthcare Federation of India, an industry body for private healthcare providers, was ambivalent about the acquisition of private hospitals for Covid-19 patients. “You have to keep in mind there are a large number of non-Covid patients and a large section of that healthcare is provided by the private sector,” he said.
Nagral thought space would not be a problem in private hospitals. “Since they have stopped elective surgeries, hospital occupancies are down anyway,” he said. “The majority are elective patients so it is not a big issue unless the epidemic explodes and there are lakhs of cases.”
However, opinions vary on how the public-private partnership could be implemented. Bhattacharya felt dedicated facilities should be created for Covid-19 patients but not necessarily by taking over private hospitals. “A better model would be to take a facility that is available but not yet commissioned – a medical college or a stadium,” he said. “And then you can pool in doctors from private and public facilities. It is a question of how you create additional facilities, not who operates it. With the Rajasthan example, my question is, how are you creating new capacities?”
With just days left to prepare for an onslaught of cases, Nagral felt there was not enough time to create additional facilities. If need be, a percentage of beds could be set aside in private hospitals, even though infection was a concern. Covid-19 treatment centres could be set up in separate buildings on hospital campuses, he suggested.
Amulya Nidhi also saw no alternative to the takeover of private hospitals and resources: “You can create isolation wards in hotels and stadiums but you can’t create ventilators.”
The other question was costing. So far, private laboratories allowed to carry out tests for coronavirus have charged Rs 4,500 per test. But government officials, activists and doctors agreed that public-private partnerships should provide free healthcare to Covid-19 patients. Nagral urged that Covid-19 officially be covered by the government’s Ayushman Bharat scheme, especially for those who are critically ill.
What of general patients?
The diversion of healthcare for Covid-19 patients, however, has raised concerns about the treatment of general patients. A statement issued by the Jan Swasthya Abhiyan and the All India People’s Science Network flags the problem. “We have received reports of closure of regular out-patient services in some of the leading tertiary care hospitals under both state and central governments, or planned reductions of on-going hospitalisation care to accommodate an expected increase in the number of COVID-19 cases,” the statement said.
“It is not clear why hospitals should stop all elective or on-going and outpatient care before serious COVID-19 cases arrive,” the statement continued. “Nor is it clear as to why instead of organising a separate isolated stream for suspected COVID-19 cases to protect the spread to other patients, denial of essential healthcare becomes the preferred strategy – even at primary healthcare level. We have reports of disruptions in HIV, TB and NCD control programs and child and maternal health services that we would urgently draw the attention of authorities to.”
The strain has already shown in public hospitals and healthcare schemes and there is fear that it would spread to private hospitals as well.
Government officials, however, said the existing orders would not encroach on space for non-Covid patients. In Bhilwara, Singh said, all non-emergency hospital services had closed down. The five private hospitals taken over had already been closed. The state government was also taking care of non-Covid patients, he claimed.
In Chhattisgarh, Gahwai said, there were under 50 patients at the Raipur Institute for Medical Sciences. They would be shifted to the Raipur medical college. As of March 27, he said, the state had six Covid-19 patients, four of whom were already at the Raipur Institute for Medical Sciences. “If we keep patients at the medical college or different district hospitals, there is a chance of infection spreading,” he explained. “So we decided to have one dedicated Covid hospital.”
Lovanshi said wards for Covid-19 had been earmarked in government medical colleges and district hospitals. Only after they were filled to capacity would the government consider requisitioning more private hospitals. Madhav Hasani, a medical officer with the Madhya Pradesh government, said no patients had been transferred out of Vishesh and Gokul Das Hospitals. “They have been told not to admit new patients, he said. “Existing patients will not be discharged before their treatment is complete.” Only after the hospital had emptied out would it be used for Covid-19 patients.
Said Nagral: “What one needs to see – and is really not seeing – is a central command which makes policies taking into consideration everything.”. While this could be initiated by government, it could incorporate expertise from the private sector.
But in the end, Amulya Nidhi felt, there was no alternative to an expansion of public healthcare services, even if there was no choice but to involve the private sector for now. “There is no rationale for not taking over private hospitals,” he said. “But the government should invest money in expanding ICUs in their own hospitals. They should invest in district hospitals rather than in urban areas.”
This was especially true of rural districts. He cited the example of migrant workers who had gone back home, potentially carrying the virus with them to villages. District hospitals there had to be equipped with proper testing facilities, staff and equipment. That was the government’s job.