The first wave of COVID - 19
started receding around Oct 2020, in India, & Health Minister, Harshvardhan,
in the 1st week of Mar 2021, declared, “We are in the
end game of the COVID – 19” – a premature victory announcement revealed in hindsight. Complacency could partially explain why the National Covid Task Force went
into hibernation then but woken from its stupor, now, is warning of a likely 3rd wave. Preparations
for tackling a 2nd wave, apparently, were non-existent & the
lowering of guard was visible vide violation of social distancing norms during
the just concluded “super spreader” events - state elections & preponed Kumbh
Mela celebrations. No wonder the respected international Medical Journal, The
Lancet, called it a “self-inflicted national catastrophe”. Regrettably, the 4th
Estate, was busy peddling the narrative of either “Vaccine Nationalism” or
“Vaccine Diplomacy” & the whatsapp university played amplifier, instead of
warning the powers of the impending crisis
History often repeats itself first
as a tragedy & then as a farce. Lessons ought to have been drawn from the Spanish
flu, of 1918, that boasted of a more virulent 2nd wave & a
milder 3rd wave; similarly, assuming that India shall remain
untouched even as western nations were hit by a 2nd & 3rd
wave, a few months back, is nothing short of delusion.
As expected, the blame game has
begun with supporters of the Central govt. blaming the states for reneging on
their responsibility on “Health” - a
“state subject” while those supporting states blaming the Centre for not accelerating
“vaccine production”- & opacity on the usage of the PM Cares fund. The
loser, in either case, unfortunately, is the Indian citizen.
What Should Have Been The Indian Strategy?
The Global average is about 3 hospital beds per 1000 population while India, with a population of 138 crores (Cr.) about 16 Lakh beds, against 41 Lakh beds as per Sumeet Aggarwal, in a 2017 ET Healthworld interview. About 60% of these are contributed by private hospitals. Assuming an average of Rs 1 cr. investment, per hospital bed, requires an outlay of Rs 25 Lakh cr. (~ 13 % of GDP), impossible to achieve during a pandemic year, as this is about 70% of the combined state budgets of about 35 lakh cr. per annum. Even if states did divert resources towards healthcare, clogging of hospitals, as witnessed in many western countries, with impeccable infra, during the peak of the pandemic, was inevitable as hospital bed capacity is not designed for peak load; states cannot be condoned, though, for failing to put up oxygen plants, at each public hospital, when the cost is about Rs 1 cr. per unit only. The solution thus lay in fast vaccination of the 94 cr. adult (>18 years old) population, costing about Rs 28400 cr. (94 cr. x Rs. 150 per dose x 2 doses) or about 0.15 % of GDP. Paying double the price at Rs 300 per dose too was cheap at 0.3% of GDP.
India could have wisely learned
from Israel which secured Pfizer vaccines at $30 apiece, double the, prices
paid by its western counterparts, for early delivery, which its Prime Minister
Benjamin Netanyahu, reasoned was cheaper than the economic losses accrued due
to lockdowns; of course, this was linked to sweeten his re-election bid too. Western
Nations, including the US, UK etc. paid & blocked vaccine supplies, from
multiple vendors - Pfizer, Moderna, J&J, Astra Zeneca etc.- enough to vaccinate their population many
times over, inviting criticism of “Vaccine Hoarding” & hence
discrimination by the Global South. Obviously, India, a Middle Income country, with
high population, cannot afford to block supplies, of
costlier vaccines like Pfizer, costing $15-30 apiece, which requires a robust
cold chain infra too, to store vaccines at -70 degrees, which India lacks; but
blocking supplies of Covishied & Covaxin costing $2 apiece was always
possible. Furthermore, this crisis presented an opportunity for India to buttress
its claims as the “pharmacy capital of the world” by helping the global South.
India, therefore, should have decided
on vaccinating 94 cr. (>18 age) population, in 6 months, needing 188 cr.
doses. Funding capacity expansion could have happened either vide a subsidy, higher
price of procurement or paying an advance for the entire supply, in 3-4 tranches –
the last option, obviously, was the cheapest & hence recommended. It should
have paid advances for procuring Serum Institute’s Covishield & Bharat
Biotech’s Covaxin, to up capacity to 30 – 40 cr. per month. Post domestic
inoculation, supplies should have been made to the rest of the world, to
enhance its soft power. Instead, we are now at the mercy of other countries
begging for supplies.
Why Is the Private Sector Loath to Invest?
Return on Investment (ROI) for
private hospitals is in low single digits - since it faces a nutcracker case of
rising costs, courtesy inflation & war for talent & greater govt.
controls on prices of consumables - drugs, stents, implants - which bring 2/3rd of their profit
margins apart from treatment procedures & medical devises; paradoxically,
increased insurance penetration & hence greater bargaining power gained by
institutional customers – insured patients, corporates & govt. funded
patients – has also capped healthcare prices. While the govt. is right in
creating a regulatory framework of “affordable healthcare” it must accelerate
public investments into healthcare in the light of waning private investments – inferred vide many promoter sell offs in corporate
hospitals.
Against this background, policy
wonks would have expected a joint declaration last year, by the Centre & State
governments, to spend 2 lakh cr. each, in capital investments yearly,
for the next 5 years, to improve health infra. Meanwhile the Private sector
could adopt digital models of faster & cheaper service delivery & tap
more international business – to attract cash patients to achieve cross subsidy
– & enhance margins.
Way Forward:
(1)Increase investment in healthcare: History of Nipah Virus, in
Kerala, in May 2018, or the multiple waves of Corona, since Mar 2020, proposes
the likelihood of similar pandemic waves, in the years to come,either due to virus transmission across species or due to bio-warfare. Increasing hospital beds to WHO
norms, along with the attendant increase in manpower – doctors, nurses & paramedics
- & a proportionate increase in primary & secondary healthcare centres is
thus essential, all under the regulatory norm of “affordable healthcare”. While
the public: private sector contribution, in tertiary healthcare can be 50:50, heavy lifting of primary healthcare has to be predominantly led by the
govt.
Standardization of protocols is also essential to ensure speedy response, in the light of shortage of trained manpower.
(2)Replicate the successful template of Dr Rajendra Bharud, IAS, District Collector, Nandurbar, a tribal district of Maharashtra
·
Instead of dismantling temporary COVID - 19
facilities, post decline in cases, at the end of the first wave, Bharud, took
signals from the surging case load in Brazil & America & prepared for
the 2nd wave by strengthening infra, creatively, putting to use
district planning & development funds, state disaster relief funds &
CSR (Corporate Social Responsibility).
·
Schools & community halls were converted
into COVID - 19 centres – creating 7000 beds for isolation & 1300 ICU beds
with ventilators; 27 ambulances were procured to bring patients to the hospital & 2 to
move dead bodies. Today despite the 2nd wave the district boasts of
spare capacity of beds providing succour even to patients from neighbouring
states.
·
Learning from the 1st wave experience
of shortage of frontline doctors & experts due to lack of medical colleges
in the region, he roped in all local doctors & trained them to perform all
vital procedures like intubation & monitoring of oxygen levels.
·
As a preventive measure, he initiated rapid
vaccination of the 3 lakh, above 45 years old people, of the 16 lakh population,
of the district. 1 lakh people have already received the 1st dose, administered
vide 16 vehicles, to avoid citizens travelling in the hilly terrains, using
teachers & sarpanches as "influencers", to spread word regarding the
seriousness of the situation.
·
In Sept 2020, he installed the first oxygen
plant in the district, with a capacity of 600 litres per min, even though the
highest single day spike was 190 cases only. In Mar 2021 he installed the 2nd
Oxygen plant & in April, when cases started touching 1200, he started
preparing to install a 3rd plant, with a combined capacity of 3000 litres per
min. Thus while the rest of the country is gasping for oxygen, now transported,
in cryogenic containers, from the steel plants, largely concentrated in
India’s East, Nandurbar is self sufficient. He reasoned that directly extracting oxygen, from the air, is a
cheaper alternative, to shifting oxygen from elsewhere, considering
that cylinders are manufactured only in certain states.
·
Oxygen pipes were given as soon as saturation
levels start dropping, instead of waiting for the critical stage, as patients
use only 30% of oxygen in the first case against 90% in the latter case; it also
directly affects the brain & kidney making it harder for patients to
recover fast.
·
He created a website & control room to help
control panic & guide the citizens to avoid citizens running from pillar to
post in search of beds.
(3)Handle Manpower shortage: Dr Devi Shetty, Founder Narayana
Health, has highlighted the likelihood of shortage of nurses & doctors, in
ICUs, being the next headline, post shortage of Oxygen & Remdesivir is
addressed & suggested the following interventions to tide over the crisis:
·
Statistically per every patient tested positive,
there are 5 patients positive but untested. Thus 3 lakh per day of positives
implies 15 lakh actual positive cases.
·
Assuming 5% of them to need ICU beds means an additional
requirement of 75000 beds per day; each patient needs to stay in the hospital for about
10 days. Total ICU beds in India are 75000 -95000 & hence already full. Any
bed in a hospital with central oxygen can be converted into an ICU with a few
accessories which can be easily procured; doctors, nurses & paramedics are
in short supply though.
·
Frontline workers who did a phenomenal job
during the first wave are tired & exhausted.
·
Therefore
o
Exemption to the 2.2 lakh nursing students who
finished GNM or BSc Training from appearing for the examinations & given
preference in a future govt. jobs provided they work in a COVID - 19 ICU for 1
year.
o
NBE & NSE to exempt 25000 specialist doctors
& offer a degree if they work in a COVID - 19 ICU for 1 year
o
NMC to recognize medical diplomas in intensive
care cardiology or emergency medicine currently unrecognized by the Medical
Council to gain access to a few thousand additional resources
o
1.3 lakh doctors are preparing for the 35000
seat NEET examination; attract the 1 lakh unsuccessful ones by offering grace
marks for the exam next year provided they work in the COVID - 19 ICU for 1
year
(4)Accelerate Vaccine production:
The US has announced support for “temporary
waiver” of Intellectual Property (IP) Rights, for COVID -19 vaccines – not
diagnostic kits, therapeutics like Remdesivir & related technologies –
unlike the resolution proposed by India & South Africa, in Oct 2020, at the
World Trade Organization (WTO), that enjoys the support of over 100 countries. EU,
UK, Japan & Switzerland oppose the move though. While this “limited waiver’
is a step forward, the “consensus based” approach, of all 164 members, at the
WTO, shall delay the conclusion of the text based negotiations. India &
other nations can break the patents anyway under the “compulsory License’
rules. But waiver of IP alone is insufficient, if technology is not transferred to
accelerate production; problems of trade barriers & shortages of ingredients
remain. “Voluntary licensing” by pharmaceutical majors, of the Serum Institute
of India (SII) - Astra Zeneca kind – hopefully at reduced charges– is perhaps
the compromise formula that shall be agreed. Since negotiations shall take
time, India shall be better advised in accelerating production of SII’s
Covishield & Bharat Biotech’s Covaxin.
The govt. has announced Rs 3000
cr. to The Serum Institute & Rs 1500 cr. to Bharat Biotech as a credit
advance.
Covishield is expanding capacity
from about 7 cr. per month to 10 cr. per month (120 cr. per annum) by July 2021. SII shall also produce 100 cr of Novovax per annum.
Covaxin has expanded capacity
from 0.5 lakhs per month to 1.2 cr. per month (14.4 cr. per annum) with plans
to expand it further. Since Indian Council of Medical Research (ICMR) holds
patent rights along with Bharat Biotech, for Covaxin, the process should be
shared with other vaccine manufacturers, in the country to ramp up production.
India has a vaccine capacity of 8.2 billion per annum & ideally 50% of the
capacity could be diverted to produce Covaxin.
Dr Reddy shall import 12.5 cr.
vaccines starting May 2021 while Gland Pharma, Hetero Biopharma, Panacea
Biotech, Stelis Biopharma & Virchow Biotech shall produce 85 cr doses per
annum starting Q2 21(June-Sept 2021)
Biological E shall produce 60 cr.
of Johnson & Johnson’s vaccine as part of a QUAD deal - vaccine funded by the US & Japan, produced in India & distributed by Australia. However, India's aspiration to be a lynchpin of the Quad, stands diminished, struggling as it is to produce vaccines for its own citizens. China, meanwhile, is making inroads into South Asia & beyond at India's expense.
While Pfizer & Moderna have
been approved & imports are likely, they shall be constrained by the lack
of a cold storage chain & high prices (~$20) & could serve only
the creamy layer of the population. Sputnik is sold uniformly at $10 across the
world & would have found few takers when Covaxin & Covishield were
being sold for $2 apiece; that could explain the govt. allowing Covaxin & Covishied
to up prices.
Prudent however for the Central
govt. to book 188 cr. Covaxin & Covishield upfront, issue credit for stock
to ramp up capacity & continue to offer the jabs at Rs 150 to continue gaining
goodwill of the population.
Conclusion:
Lack of commensurate investments
in healthcare, over the last 70 years, is now coming home to roost; focusing
on an insurance led model & expecting the private sector to carry the
entire burden of upping investments, in tertiary care, is unfair &
unattractive when price controls restrict ROI to single digits. Govt. should
continue with price controls under the “affordable care” regulatory framework
& up public investments, into tertiary care, to be at least an equal partner to the private sector from current 40%. State governments should take the entire
load on setting up Primary Health Centres (PHCs) & share burden with the
private sector in strengthening Secondary Health care.
