– Oliver D’Souza
While in most countries institutions have gone out of their way to pitch in as much as they can to help handle the covid-19 pandemic and save lives, it is national shame that India’s private hospitals and nursing homes true to their character, see the pandemic as yet another opportunity to ruthlessly enrich their coffers, requiring the immediate formulation of a detailed national policy to ensure that every person infected with the virus is provided adequate and impartial medical care.
For weeks, the government of India was patting itself on the back, helped along by an ignorant WHO, for what it claimed are low number of infections in the country compared to the population size and compared to other nations, citing the poorly planned lock-down as the reason for the low numbers. The WHO officials, who have no clue about what is going on in the country were quick to believe the government’s claims and applaud it.
But the fact is that the claims of the government were far from the truth. To begin with, the figures are low because India is not testing enough. The correlation between testing and increased detection of infections was adequately demonstrated in Mumbai where when the testing levels were boosted, far more cases were detected, with a large and sustained spike in number of cases.
Globally too, it is seen that higher testing shows a clearer picture of the extent of the pandemic in a given nation. Nations that have detected high numbers of infection cases are those whose testing rates are very high as in the case of, among others, US, UK, Spain and Russia who conducted 75,948, 101,170, 103,232 and 103,892 test per million detecting 2,182,950, 296,857, 291,189 and 545,458 infections respectively.
Alternately, increased testing has also relievingly shown a low number of cases in, among other nations, Gibraltar, Monaco, Cayman Islands and Faeroe Islands whose testing figures are 300,288, 412,949, 262,263 and 225917 tests per million respectively detecting 176, 99, 187 and 187 infections respectively..
With a population of 1.3 billion people we are currently conducting 4316 tests per million, ranked at 138th out of 215 nations for the number of tests being done per million. The lack of high testing levels and hence lower number of total cases is not evidence of low infection numbers.
Secondly, in many states instead of the infection curve leveling out, testing itself has reached a plateau, with these states failing to increase the number of tests as a matter of unofficial policy to artificially keep the infection numbers low in order to avoid the political fall-out. This is not limited to BJP-ruled states, which have pathetic governance records.
Thirdly, there is extensive misreporting. The media is awash with reports of people with covid symptoms being treated and let go without testing them. Throughout the country, numerous people have also gone through 28 days quarantine but not tested for the virus. Why would anyone be quarantined for 28 days if there were no symptoms of infection?
To top it all, state governments have been exposed of misreporting even death counts. The Delhi Municipal Corporation (DMC) reported twice the number of cremations done with covid-19 protocols as compared to the state government’s official death count. The MCD in a release said that it had cremated 2098 corpses with covid cremation protocols while the state government claimed only 984 deaths.
Similarly, Tamilnadu recently admitted that many deaths due to covid were not categorized as such. Here co-morbidity were cited as the cause of death even when the person who died tested positive for covid. Same story is being played out across the nation, with covid positive patients who had other co-morbidity and who died after testing positive for the virus not being categorized as covid deaths.
It is also state policy not to test people who have died, so no one really knows how many of the people who are dying of respiratory problems – cardinal sign of covid death – died due to covid or that their co-morbidity was aggravated due to the virus leading to their death. And respiratory failure is not the only covid related cause of death. There are reports of heart-attack, brain stroke and other cardio-vascular related deaths in covid patients who were stable before the virus hit them.
Such advertent or inadvertent mis-categorization of deaths is not India specific. It is also happening in other countries as well. Among other nations, US, Italy and Spain have revised their death count, with New York City revising its covid death toll by 3,778 increasing the overall fatality to over 55 per cent in a one day. The US government said these deaths were linked to Covid-19 but previously not been counted under the head of corona virus pandemic. Many corona virus-hit countries have seen a rise in death rates outside the hospital deaths recorded as Covid-19 cases. Most of the people dying at home in these countries are untested for novel corona virus. Likewise, the UK has said the true number of those dying due to covid in the country could be 15 per cent higher than official figures.
Dr Balram Bhargava, Director General of Indian Council of Medical Research (ICMR), however, called the government’s bluff and put things in perspective while telling the press on June 11 that “0.73 per cent of the general population has been infected by the virus”. The 0.73% in a population of 1.3 billion people is roughly 9.9 million.
The ICMR conducted a survey in the third week of May, using a sample of 26,400 individuals and 28,595 households spread across 83 districts to ascertain the infection spread in the general population. The survey tested for IgG antibodies. The results showed 0.73 per cent of the population in these districts was found IgG positive, meaning that in the past they were infected with SARS CoV-2 or covid-19 as we commonly know it.
The ICMR survey in effect affirms that the only conceivable reasons why 9.9 million cases did not become the government’s official figure is because of lack of testing and due to misreporting. Disturbingly, if the percentage incongruence between the ICMR figures of 9.9 million infections and government figure of 3, 44,000 today is applied to the official death count, the actual number of death counts due to covid too could be much larger than reported by the government.
More alarmingly, after the ICMR did its survey in May, in early June, a test of 853 migrant workers who returned to Bihar after the lock-down was partially lifted showed that 26% of them were infected. There is no reason to not believe that an alarming number of the migrant workers who were lock-down in infected urban areas have now carried the virus to the rural areas nationwide. The official figures of interstate migrant workers is put around 200 million while unofficial the figure is put at twice that, which includes both interstate and intrastate migrant workers, most of whom have returned to their rural villages. Between the ICMR survey, the test of migrant workers in Bihar and the lifting of the lock-down, the indication is that India is close to a massive explosion in the number of covid infections.
This looming spectre of covid infection does not augur well for a overwhelming majority of the people in the country who get infected, requiring hospitalization. Until now, most covid patients have been treated free, in state owned or temporarily acquired hospitals meeting all the costs, but soon the state infrastructure will be insufficient.
The Center For Disease Dynamics, Economics & Policy (CDDEP) has estimated that India has a total of 1.9 million hospital beds, 95,000 ICU beds, and 48,000 ventilators. Of these 700,000 are government hospital beds while the rest are in private hospitals. Most of the beds and ventilators in India are concentrated in seven states – Uttar Pradesh (14.8%), Karnataka (13.8%), Maharashtra (12.2%), Tamil Nadu (8.1%), West Bengal (5.9%), Telangana (5.2%) and Kerala (5.2%). The rest have abysmally low government and private health infrastructure.
With increasing number of patients turning up everyday, the government hospital beds in most affected states are bound to run out fast, leaving the masses at the mercy of private hospitals and nursing homes, with reports of exorbitant charges for covid treatment in private hospitals revealing that these entities ruthlessly intend to make most of the situation.
The Max hospital in Delhi, for instance, charges Rs 25,090 a day for general ward admissions, Rs 27,190 for twin sharing and Rs 30, 490 for private ward (isolation). This is over and above the ICU charges of Rs 53,050 without ventilator and Rs 72, 550 for ICU with ventilator. In Mumbai, the Lilavati Hospital was charging Rs 2.5 Lakh per covid patient before government intervention. In Hyderabad, the Hindu reports, a 53-year-old man who got admitted to a corporate hospital in the city for COVID-19 treatment was charged nearly Rs 20 lakh for 23 days of treatment.
The exorbitant rates being charged for covid treatment by the hospitals are not unilateral actions taken by the hospitals and nursing homes. Rather, they are a collective move originating with the Association of Healthcare Providers (AHP) which itself suggested that for patients in general wards the fee should be fixed at Rs 15,000 per day, in wards with oxygen it should be Rs 20,000 per day and isolation ICUs can cost Rs 25,000 every day. The AHP has also proposed that rate per day for isolation ICUs with ventilator support can be fixed at Rs 35,000.
The private hospitals, as reported by Business Today, justify the exorbitant charges arguing that treatments are all patient-specific and so are the costs. They also argue that “providing COVID-19 treatment is an expensive for hospitals as additional costs had to be incurred, along with higher financial compensation to the medical staff attending to corona virus cases, and cost of providing transport facility, separate accommodation and meals to them within the hospital during the period of lock down.”
While there will certainly be some additional costs for expanding facilities and adding equipment and needed accessories, these cannot account for Rs 4000 a day merely for admission and a bed in a general ward, excluding costs of drugs, procedures and needed tests.
The costs of higher financial compensation that the hospitals claim they are giving their medical staff too is mostly an eyewash. Dr HM Prasanna, member of the committee and president elect of Private Hospitals and Nursing Homes Associations is on record telling the Hindu “preliminary discussions are going on among private healthcare providers and we are waiting to see if there is an economic stimulus. If not, we will have to resort to cutting salaries or laying off employees. Those earning below Rs 15000 will not see cuts but nurses earning below Rs 30,000 might see a 10-20 percent cut. Doctors earning above Rs 50,000 can expect higher cuts. However, we have not decided on it. We will reinstate the original salaries once the economic situation becomes better,” said.
Already numerous reports have come in of doctors and nurses and other healthcare workers in private hospitals suffering salary cuts, some of them even losing jobs. May have also not been paid full salaries. And it is not as though private hospitals do not have sufficient funds. Private hospitals, as reported by Indian Express, have been making profits of upto 1700% for a long time.
“Country’s drug pricing regulator, released detailed analysis to show excessive profit margins made by hospitals from sales of medicines, consumables and other services and highlight nexus between doctors and industry that leads to prescription of drugs that are largely outside price control,” said the report. The analysis showed that profit margins made by some consumables went over staggering 1700 per cent in some cases.
Rather, instead of facing any real financial issues, the exorbitant rates by the hospitals is nothing but pure racketeering. Insiders say that the rates being charged by the hospitals is as much as three-four times the actual costs. After the start of the lock-down and the continuing restrictions after lifting it which have together resulted in a deteriorated economic situation, the hospitals are losing revenue due to low number of OPD patients from whom they usually make a substantial profit. The hospitals are now recouping these losses and more by ruthlessly hiking charges for covid treatment. They are following their age old philosophy of privatizing profits and passing on the losses to the general public.
Receiving complaints of exorbitant charges Telangana, Maharashtra and Tamilnadu have capped the maximum that can be charged by the hospitals.
In Mumbai, as per a government notification, charges for a Covid-19 patient in isolation ward cannot be more than Rs 4,000 per day, Rs 7500 for intensive care unit (ICU) and charges for ICU with ventilator is fixed at Rs 9,000.
In Tamlinadu, patients in general wards in Grade A1 and A2 hospitals cannot be charged more than Rs 7,500 per day and in Grade A3 and A4 hospitals, the amount for general ward is Rs 5,000.
In Telangana, Health Minister E. Rajender announced “Treatment in general isolation ward will cost Rs 4,000 a day and in the intensive care unit (ICU) without ventilator Rs 7,500. Those on ventilator can be charged Rs 9,000 per day.”
Delhi, which said that it would fix a cap on charges to make it affordable but has just added a Taj Hotel as a covid treatment centre with a room rent of Rs 5,000. Most other states have ignored the issue.
However, even the relatively low Rs 4000 per day fixed by the Telangana government even if applied nationally is unaffordable for a majority of the population. At Rs 4000 a day, admission into a general ward for covid that entails a minimum of 14 days in hospital, works out to Rs 56,000, excluding all other medical expenses.
To be able to pay that kind of money, one will have to have substantial savings or insurance, which unfortunately is not the case with most people in the country. India’s per capita income in 2019-2020 was Rs 11, 254, or Rs 1, 35, 048 per annum. With an average household size of 4.9, broadly speaking, how many households with this level of income could have saved money for a rainy day? How can a family with an income of Rs 11,254 afford over half its annual income for 14 days of treatment?
The picture becomes even more disturbing when one takes a closer look at the breakdown of household incomes in India.
According to Statistica.com, in 2016, 7 million Indian households categorized as Elite, earned over 21,56,000 per annum (@ Rs 70 per dollar), 17 million households categorized as affluent, earned between Rs 10, 78,000 per annum and 21,56,000, 40 million households called ‘aspirers’ earned between 5,39,000 and 21,56,000, 121 million households called the ‘next billion’ earned between Rs 1,61,000 and Rs 5, 39,000 and 82 million ‘struggler’ households earned less than Rs 1,61,000 per annum.
As per this breakdown, even if you assume that the elite, the affluent and the aspirers – a total of 64 million households – are able to afford the exorbitant charges of getting treated in private hospital, we have 203 million households that earns less than Rs 13,416 per month and not all of them earn the same. According to the Rangarajan report, in 2016, 29.5% of the population lived below the poverty line which is defined as less than Rs 43 per person per day expenditure in the urban areas and Rs 32 in rural areas. Over 30% of the population earns below Rs 1,333 per month.
Insurance is not something that the entire population can count on to cover covid treatment costs. In fiscal 2019, Statistica.com reports, “over 472 million people across India were covered under health insurance schemes. Of these, the highest number of people were insured under government-sponsored health insurance schemes, while individual insurance plans had the lowest number of people. Overall, the penetration of health insurance in India stood at just around 35 percent in financial year 2018.” This effectively means that 65% of the population has no health insurance of any kind. Over 64% of medical expenses in the country during 2016 was out-of-pocket expenses.
The only silver lining in the health insurance scenario is the Ayushman Bharat Scheme, which has now been extended to covid testing and treatment. But even here, the pre-conditions which defy logic, among others, include not owning a two-wheeler and not earning over Rs 10,000 per month, leave a large part of the needy population out of the scheme, particularly in urban and semi-urban areas.
On their part, private insurance companies too have not been forthcoming in fulfilling their legal obligations. In the case of the 53-year-old-man from Hyderabad who paid Rs 20 Lakh for 23 days of admission, only 7.2 Lakhs was covered by insurance. On the contrary, you now have insurance companies like Bajaj now offering loans for covid-19 treatment!
With a covid explosion at out door, it is high-time the Union government formulated a national policy for treatment of covid patients in private hospitals, fixing prices that are affordable. The government cannot wait to act after people start dying on the streets because no hospital admitted them due to paucity of funds.
The government also has to extend the reach of the Ayushman Bharat to a larger number of people. It has to get rid of some of the silly criteria it employs to make one eligible for Ayushman Bharat, while also moving forward and implementing the scheme it has touted for those not covered by Ayushman Bharat.
Additionally, it needs to pump more funds into these schemes by curtailing all unnecessary expenditures including the Rs 26,000 crore vista parliament project, buying new jets for the PM and the vain bullet train project and instead use the funds the treatment of covid patients. Its obligation to the populace is much greater because the pandemic could have been efficiently controlled if in the first place it had acted and started shutting down all airports in the country the day the first case was reported in Kerala on January 31. Instead, right up to March 15, it kept pandering to its political interests.
At the same time, the PMCares fund, which has reportedly collected over Rs 25,000 crore in contributions in the name of the pandemic needs to be used to fund covid treatment. To date the government has refused to explain where this money is being used and the fund that has no accountability. The allegations are that the money has been diverted for political purposes.