Lack of testing kits, understaffed hospitals: COVID exposes India’s crumbling healthcare system

With just over a hundred cases of COVID-19, India’s healthcare system is already showing its fragility. Sameer Sehgal/Hindustan Times/Getty Images
16 March, 2020

On 15 March, the Indian Council of Medical Research convened a meeting with national health experts about the rising cases of COVID-19 in the country, and the way forward for the healthcare system to address the growing crisis. “I know for a fact that India does not have testing kits,” a public-health expert who attended the meeting told me, on the condition of anonymity. “They are delaying expanding testing criteria because if they include patients who have no travel  history, they will very quickly run out of tests.” The union health ministry has limited testing in central government hospitals to international travellers or those who have come in contact with them, and only at the government-accredited centres. Yet, with just over a hundred cases, India’s healthcare system is already showing its fragility.

This was evident in the circumstances surrounding India’s first death from COVID-19. On 11 March, in the southern city of Kalaburagi, in Karnataka, a 76-year-old man who had returned from Saudi Arabia on 29 February, died after being turned away from two private hospitals. The tests results confirming the COVID-19 infection came a day after his death. India’s first casualty from COVID-19, public health experts told me, is a peek at the grim and impending health crisis staring at us: government hospitals are ill-equipped, and the private hospitals are not accountable to anyone.

These fears were confirmed the next day. Troubled by the inordinate delay in testing people showing symptoms of COVID-19, TS Deo, the Chhattisgarh health minister, wrote to Harsh Vardhan, the union health minister, imploring him to expand testing facilities. In the letter, he wrote, “The current testing criteria is too restrictive … In Chhattisgarh, like many other states, only one centre is carrying our testing currently. We are concerned whether Government of India will provide us the adequate number of kits if we allow wider testing.” Kerala, too, has expanded its guidelines for testing. Now, patients with severe symptoms or with underlying conditions of the lungs, heart, liver and kidney, pregnant women, and those older than 60 years will be tested for the virus even if they have no travel history. The revised guidelines are for testing, quarantine and hospital admission of COVID-19 patients based on a risk assessment.

The centre’s failure to competently deal with the ongoing crisis has reached a point where not just the state governments, but even government doctors have publicly expressed their concerns about the situation. On 14 March, Dr SP Kalantri, a professor of medicine and medical superintendent at the Kasturba Hospital—a government-run facility in Sevagram, Maharashtra—aired his frustration at not being able to care for his patients on Twitter. He tweeted, “Caring for a patient with severe pneumonia and multi-organ failure in an ICU. Unable to figure out who the villain is: bacteria or viruses. The regional lab refused to test his sample for #COVID2019 because he lacked a travel history. Aren’t testing criteria too restrictive?” The following evening, he tweeted once again, “If only 10% of the lab capacity for testing #COVID19 has been used so far, why should government labs refused to test seriously ill patients with #Pneumonia simply because they lack travel history?”

According to Dr Yogesh Jain, a community doctor and activist, who runs a rural clinic in Chhattisgarh, the patient from Karnataka “died because the hospitals gave up on him and his family.” Jain continued, “There has so far been no reasonable explanation as to why the patient was allowed to leave after his samples were taken. Clearly, the government suspected something to take the samples, but did not ensure the patient would get care, leaving the family to go from hospital to hospital.” The patient’s daughter, too, subsequently tested positive for COVID-19. Jain was one of the founding members of Jan Swasthya Sahyog—People’s Health Movement—an NGO that provides health care in rural Chhattisgarh.

Doctor like Jain have been warning for decades of scenarios exactly the kind we are facing now: a pandemic is upon us, and the country has precious little resources in terms of bed capacity, ventilators, doctors, nurses, and laboratory strength. According to the 2019 National Health Profile, which is a compilation of all the resources that the union health ministry has at its disposal, India has a total of 11,54,686 registered allopathic doctors. Of this, the government sector—which is where the current testing and treatment of the novel coronavirus is limited to—has 1,16,756 doctors. That amounts to one government doctor for every 10,926 person. The World Health Organisation recommends a doctor-to-patient ratio of one doctor for 1000 patients. A 2016 Reuters report noted that India needed more than 50,000 critical-care specialists, but has just 8,350.

In short, India’s hospitals are in intensive care, and in no position to cope with an avalanche of patients with a contagious respiratory infection in the manner that China and Italy have been doing. By 15 March, the number of novel coronavirus cases in the country rose to 107, with 12 fresh cases in Maharashtra reported in the preceding 24 hours. Yet, the testing criteria continues to be restricted only to international travellers, and their immediate contacts. Testing is crucial as it allows an infected person to avoid infecting others and quickly receive the care they need. It is also crucial for everyone to understand the prevalence of the disease. According to Our World In Data—a statistical research initiative that charts progress on issues of global concern—India, as of now, is performing the least number of tests per million among countries with confirmed cases of COVID across the world—at three tests per million people.

A government official who attended the ICMR meeting told me, on the condition of anonymity, that the experts discussed the possibility to asymptomatic testing—testing universally, including individuals who have not shown symptoms of the virus or been in contact with international travellers, as has been done in South Korea—and rejected the idea. “We discussed whether we should start testing asymptomatic people and it was clearly said that we cannot test asymptomatic,” the official said. “It was not considered efficient. We will encourage private hospitals to start testing provided they follow our norms, but without a price cap.” he added. The official added that the health ministry and ICMR is likely to decide whether there should be a price cap of COVID-19 testing kits on 16 March. The current cost of testing each sample is upward of Rs 5,000. When asked if India should prepare for an exponential outbreak as witnessed in Italy, the official said, “Yes, it can happen.”

Scientists at ICMR have isolated the virus strain from Indian patients and found that it was “99.99% similar to the Wuhan strain,” according to Dr Balram Bhargava, the director general of ICMR. According to Our World in Data, in Europe, which has become the current epicentre of the pandemic, the cases are doubling every three or four days. In India, they are doubling every five days right now—but without testing, and isolating infected patients, the disease has the capacity to quickly saturate and overwhelm the number of available hospital beds, doctors, nurses, and India’s other precious resources in health sector.

Even if testing is quickly expanded, there is an additional rub: errant private sector hospitals will turn away all pneumonia patients—COVID-19 or not, because they cannot test for the virus and they cannot risk infecting other patients. “I feel pretty certain pneumonia patients, even those without COVID-19, are going to suffer in the coming days,” Jain said. “The government can keep denying the extent of transmission but that’s not going to save the patients. Private hospitals will turn them away, just as they did with the Kalaburagi patient.”

By all indications, the coronavirus pandemic will be Indian health sector’s come-to-Jesus moment, and force a fundamental reassessment of how the country has dealt with healthcare so far.