Covid-19 and the way forward for healthcare

Jagat Ram, Rakesh Kochhar

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Jagat Ram
Director, PGIMER

Rakesh Kochhar
Sub-dean, Research

We are into the sixth month of Covid-19 in India. The number of cases is still rising and the peak is yet to come. The healthcare system has been stretched to the limit, burdened with the onslaught of Covid-19 at the expense of treatment for non-Covid diseases.

The pandemic has affected patients suffering from other diseases. Figures suggest that in March and April, one lakh less cancer patients reached hospitals, 4.5 lakh fewer children received vaccination and 30% fewer obstetric emergencies reached hospitals. The government-supervised treatment of TB, having been interjected, will result in at least 1.5 lakh additional deaths in the next five years. Similarly, with more than two lakh new patients of chronic renal failure added every year, and interruption in dialysis facilities, we are likely to see increased fatalities. The same holds true for patients with coronary heart disease who are facing problems in getting interventional procedures. Data suggests hospitalisation under the PMJAY/Ayushman Bharat Scheme during the 10 weeks of lockdown dropped by 51%. Cancer treatment fell by 64% and institutional childbirth by 26%.

In most states, government hospitals are bearing the brunt as these have been dedicated as Covid-19 hospitals. These hospitals are facing a shortage of isolation beds, ICU facilities, ventilators and manpower. With high cost of treatment in private hospitals and their reluctance to treat Covid-19 patients, there is pressure on a tertiary care centre like the PGI.

Last year, the PGI had seen nearly 30 lakh patients in the OPD and more than one lakh were admitted, with over 2.5 lakh undergoing surgical procedures. Every day, close to 350 patients used to approach the emergency OPDs with 40% of them requiring hospitalisation. For the northern states, the PGI is the only government facility offering robotic surgery, liver transplantation, bone marrow transplantation, advanced cardiac procedures and PET-CT besides non-surgical specialised interventions. While Punjab accounts for nearly 40% of admissions, patients from UP, Uttarakhand and Bihar also seek treatment at the PGI.

The pandemic has exposed inadequacies in the public sector healthcare system, especially at the secondary and tertiary care levels. It should be a wake-up call for Punjab, Haryana, Himachal Pradesh and Jammu & Kashmir to augment infrastructure in their medical colleges.

The PGI started the tele-consultation facility about four weeks ago. Of the close to 1,000 patients from medical OPD available for analysis, about 40% were consulting a doctor for the first time, suggesting they should have ideally been seen locally first. One-third needed easily available investigations like blood tests, x-rays or ultrasound before going further. Had these patients come to the PGI, they would have had to come again with test reports. Only 12% of the patients needed immediate attention.

Data suggests that most patients at the PGI tax the facility unnecessarily. To optimise tertiary care at the PGI, patients should first be seen at the primary or secondary healthcare facilities and referred only for difficult-to-diagnose conditions or for specialised treatment not available elsewhere. If the district hospitals and medical colleges can provide coronary angiography, management of stroke, hepato-biliary surgery or neurosurgery, then the PGI expertise can be used for complex interventional procedures, robotic surgery or advanced retinal procedures.

Non-Covid patients are denied ready access to medical facilities. Delay in diagnosis can lead to progression of the disease, making treatment difficult. A patient of liver cirrhosis or early cancer may become untreatable. A patient in early stage of coronary artery disease may develop heart failure or a simple patient of gallstone may develop complications. Covid-19 has also generated problems like joblessness, depression, and increase in domestic violence or alcoholism. A recent report said there is 60% increase in cases of suicide in one of the northern states.

The crisis has also given us an opportunity to assess deficiencies and overcome them. Health infrastructure must be improved and specialised manpower generated or augmented in district hospitals and medical colleges in the region. We need super-specialists like cardiologists, gastroenterologists, neurosurgeons and urologists with corresponding upgrade of equipment and facilities. There is no point in having ventilators and not having critical care specialists to manage the patients or vice versa. Secondly, a referral system should be there in each state. Only cases requiring specialised treatment should be referred to the PGI; all others should be managed by the district hospitals or medical colleges.

Each district can have a nodal officer to evaluate the need for referral. The patients could then be referred to the PGI after a tele-consultation with super-specialists. Availability of ICU beds should be checked to avoid inconvenience.

Though the OPDs are functional through tele-consultation and telemedicine facilities, to help non-Covid patients at the PGI, plans are afoot to review resumption of physical OPD services in specialties. While ante-natal care and chemotherapy services are already available, along with emergency facilities for trauma, head injuries and medical conditions, there is a need to restart other services. It has been proposed that the OPDs should be started in a staggered manner, beginning from Chandigarh itself and then to the neighbouring states. Patients from Chandigarh should be routed through GMSH-16 and GMCH-32, and from Panchkula and Mohali through their district hospitals. Each patient could carry a slip with the indication for referral clearly defined. The second way of intake into the PGI could be booking an appointment through tele-consultation.

Experience with telemedicine in the past two months has shown that it is a win-win situation. With a defined number of patients coming to the PGI, they will get better care. Patients can be allotted a specific time. Patients referred could be given priority in tele-booking appointments. A provision has also been suggested under which patients can be sent back to the referring facility after the diagnosis is established, treatment outlined and the acute phase over.

We should utilise the current crisis to streamline the public healthcare system so that resource utilisation is optimised.

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