How can India involve the private sector in fighting coronavirus without creating an unequal system?

On Tuesday, India reported its third coronavirus death, as a 64-year-old man in Mumbai succumbed to the infection. The total number of positive cases in the country rose to 137.

With the case load expected to rise in the coming days, there is a growing demand that the government involve the private health sector in fighting the pandemic. But opinion is divided on how exactly this should be done.

Should the private sector be allowed to charge for the services? What safeguards are necessary to ensure the infection does not spread and that cases handled by the private sector can be traced and monitored by the government?

Responding to the infection typically involves several stages. First is testing suspected cases, a process that involves quarantine to limit contact with uninfected people and prevent the spread of the disease. Next comes hospitalisation for severe cases.

Private sector involvement at each stage poses tricky questions.

Scroll.in spoke to private labs, hospitals, state government officials and public health activists to understand the concerns.

Testing guidelines

So far, coronavirus tests have been largely restricted to those who with travel history to coronavirus-affected countries or those who came in contact with confirmed cases locally. These tests – 6,500 samples of 5,900 people until March 13 – have taken place in 52 government-run labs across the country.

But in a statement on Tuesday, the Indian Council of Medical Research indicated testing could finally expand to private labs. “ICMR is also engaging with high-quality private laboratories that includes NABL [National Accreditation Board for Testing and Calibration Laboratories] accredited labs,” the statement said.

The statement also carried guidelines for private labs “intending to test” for coronavirus and steps to be followed. “ICMR strongly appeals that private laboratories should offer COVID19 diagnosis at no cost,” the statement said.

The ICMR claims India is yet to experience community transmission, a stage of the outbreak where it would not be possible to pin down the specific source of the infection for a large number of cases. But the trajectory of the disease in other affected countries suggests that community transmission is inevitable. In countries like China, Italy and Iran, cases exploded once this process began, putting heavy pressure on the public health infrastructure.

GSK Velu, the chairman of Trivitron-Neuberg Diagnostics, which runs a network of diagnostic labs across the country, told Scroll.in that no clear guidelines have come from the government for private labs to start testing. “The approval actually has to come from the state governments,” he said. “We are also in touch with the Union Ministry of Health. But still no definitive guidelines are out. We saw media reports that this has already been approved. But this is only media approval.”

On the ICMR’s appeal to private labs to offer the tests for free, Velu said he was not aware of the statement. However, offering the tests for free at the moment may not be viable, as testing one sample could cost anywhere between Rs 4,500 to Rs 5,000, he claimed. The ICMR statement pegged the cost at Rs 1,500 for the first test and Rs 3,000 for the confirmatory test.

“We have to import these kits from Germany and USA,” Velu said. The company is trying to develop a kit at a lower cost of about Rs 500 per test, but this would require the government’s approval for use, he added.

In China, when the cases exploded in numbers, the government created a green channel for import of the diagnostic equipment and kits, Velu claimed. Such policies are yet to be framed in India.

“The capacity of the private labs will be limited even if allowed to test. There are less than 100 labs in the country that could do this,” he stated, claiming that the technology used for the testing is quite high-end.

Velu said it does not make sense to offer the tests for free even for the rich. “The government could tell the labs that such category of people, like the poor, have to be given the tests for free. But we are waiting for directions.”

A senior public health official in South India said there has been no communication from the Centre on allowing private labs to test. The official noted that there are several problems in allowing private sector to starting testing, the first of which is traceability: private labs would need to report all positive cases to the government to ensure that the patients and the people they have come in contact with can be traced and monitored.

“We need to ensure a foolproof method of reporting,” the official said. “Once profit motive comes in, we have to ensure cases do not go unreported.”

Experience of involving the private sector in testing has shown that unethical business methods were rampant. For example, during the swine flu outbreak in 2015, private labs charged exorbitant rates of up to Rs 10,000 per sample, an amount impossible for the poor to pay. “We need clear price control and protocols for this to work,” the official added.

Quarantine facilities

Unlike testing where the role of the private sector is still unclear, governments have started using private infrastructure to quarantine potential patients. Last week, the Delhi government booked over 180 rooms in three hotels near the Delhi airport to house passengers who come to India from abroad.

According to IBIS, one of the hotels providing the quarantine facility, 92 rooms on an entire floor have been set aside for this purpose. The government has fixed the price of the room at Rs 3,100 a day, which includes all three meals. This is paid by the occupant, not by the government.

A spokesperson of IBIS told Scroll.in that as on Tuesday that 45 people were occupying these rooms. “These people are brought by the government staff in their own vehicle,” the spokesperson said.

Hospitalisation challenges

On Tuesday, the government issued guidelines mandating that private hospitals and doctors report suspected Covid-19 patients to the district authorities. Apart from those who have travelled to coronavirus-affected countries or have come in contact with confirmed cases, suspect cases include those with severe acute respiratory illnesses who need hospitalisation, with no other cause fully explaining their condition.

But there are a lot of concerns about the role of the private sector in treatment once hospitalisation for a large number of people becomes necessary.

According to the chairman of private hospital in Chennai, when people talk about private hospitals, the imagination is one of large corporate hospital with hundreds of beds. While there are many of these in the big cities, the districts even in richer states like Tamil Nadu and Karnataka lack them.

“I would say 80% private hospitals are very small, like nursing homes,” he said, requesting anonymity. One of the necessities in the case of large coronavirus outbreak is the availability of ventilators in intensive care units. “Susceptible groups like the elderly will need ventilator support for pneumonia symptoms,” he said. “But how many hospitals in the districts have this?”

Having said this, the hospital owner argued the private sector should be seen as capacity addition rather than being the major line of defence. “The idea now should be to increase manifold the public health capacity,” he said.

On whether it would be viable for private hospitals to provide these facilities for free, the hospital owner said the bills would be prohibitively costly for hospitals, especially smaller ones, to fund out of their own pocket. “Even if the government says we will waive the amount spent from your corporate social responsibility funds, we will invariably depend on public funding,” he said.

Experts’ concerns

Public health experts warn that India is on the precipice of a major disaster if the coronavirus infection follows the trend seen in countries like Italy, Iran and China.

According to Sulakshana Nandi, the national joint convener of Jan Swasthya Abhiyan, it is worrying that the Ministry of Health and Family Welfare, the agency that should coordinate the fight against the virus with the states, has not provided a clear action plan for a large outbreak.

If the government’s claim that community transmission of the disease is yet to start is taken at face value, the focus in the interim should be on increasing public health capacity manifold.

“This planning has to be done at the district level in every state,” she said. “It is not enough if you improve the capacity in cities and make people from rural areas travel long distances.”

The government is yet to offer basic information on the capacity of government hospitals and how much more is required. “It is only after this assessment is done will come the question of the extent of the private sector’s involvement,” Nandi said.

Even if the government decides to involve the private sector by taking over beds and intensive care units, for example, the question of funding looms large. At the moment, Nandi said, the Centre seems to be happy with letting the states use funds already allocated to the health sector in general to fight the coronavirus. But this will be inadequate when the outbreak intensifies. “We do not understand why the government has not allocated a large sum exclusively for this purpose,” she said.

While taking over private infrastructure is possible in a a small area when the case load is low, like the Kerala government did in Ernakulam with private paramedics, such measures would require greater funds to replicate on a larger scale.

Nandi added that any service, whether by the government or by the private sector being roped in, should be consistent for all classes of people. The private hotel rooms where the customer pays thousands for quarantine is not affordable to the poor and the middle class. “You cannot say let the rich get the good facilities by paying,” she said. “Ideally, the treatment in an emergency situation like this should be free for all.”

Former Union Health Secretary Sujatha Rao said no private hospital can should refuse to treat coronavirus patients. “The virus has been isolated so a treatment protocol could be established,” she pointed out.

As far as the cost is concerned, she said the government should ensure that insurance, both private and its own, covers this treatment. “They have to establish a protocol for the private sector and clearly state what they could charge,” she said. “Then the insurance should cover it.” The government could also supply testing kits and drugs to reduce the burden on the private sector.

For those who do not have insurance, the government could consider providing subsidies.

The former bureaucrat said this current crisis should bring to the fore the neglect of the public health sector. “The lesson here is you cannot ignore public health in normal times. Health has been low priority for too long.”