India’s healthcare system has for a long time been a mirror image of the country’s many contradictions. With a health budget of about 1.3% of GDP, it has a woefully inadequate and underfunded public health infrastructure, and worse social indicators than some of its economically weaker neighbours. And yet, India’s private healthcare sector—which got a boost with economic reforms—boasts of advanced medical infrastructure, state-of-the-art equipment, well-trained medical staff, options like “deluxe” hospital beds, and a rapidly expanding medical tourism industry. India’s middle class, who would access public hospitals in the post-independence period, have gradually abandoned public hospitals to seek care in private hospitals. After all, who wouldn’t want to avoid long queues, a lack of quality time with overworked doctors, and the poor hygiene and comfort in the wards and washrooms of most public hospitals? The impact of the second wave of covid-19 in India was however an eye-opening equalizer for most, putting the rich in the poor man’s shoes.
India’s first covid-19 wave predominantly affected the lower socioeconomic classes and brought the state of public health infrastructure to the limelight, with grim viral videos showing patients on beds on hospital floors and delays in moving dead bodies to the mortuary. The second Covid wave however turned the table. The middle and upper classes were predominantly affected, and it was the private medical infrastructure which got overburdened this time round. Everyone’s sanitized views of the private healthcare system burst as the differences between public and private healthcare narrowed on many fronts. Videos from prominent private hospitals showed overcrowded patients being accommodated in elevator lobbies, while hospitals in the national capital of Delhi were reduced to desperately tweeting or even going to court to secure oxygen supply. Patients had to be on a waitlist for a few days before being able to secure even a regular hospital bed (the waitlist for ICU beds sometimes even surpassed 100) and there was a shortage of drugs to treat covid-19. This affected citizens across socioeconomic divides. Money was no longer the key differentiator; the middle and upper class couldn’t simply buy their way out of the situation, something they had taken for granted over the years.
The city of Mumbai, where we work, witnessed some unique phenomena in its healthcare infrastructure during the pandemic. The Mumbai Municipal Corporation temporarily took over 80% of private hospital beds to ensure a common admission route with strict triaging and capped rates. The elite who normally avoid engagement with public hospitals, and were always guaranteed a bed in private hospitals on the basis of expensive deposits, had to call municipal telephone lines and wait to secure a hospital bed. This transient centralisation and regulation of healthcare facilities, routine in many countries, demonstrated visible results and was commended as the “Mumbai model.”
A deeper look into the reasons for the success of the Mumbai model also demonstrates a more longstanding systematic investment to create a more robust public healthcare infrastructure compared to many other cities in India. Apart from its large private medical infrastructure, Mumbai boasts of five central academic teaching hospitals, and over 20 peripheral municipal hospitals, attracting top medical trainees from across the country. During the pandemic, medical interns and post-graduate trainees became its strongest workforce. Importantly, unlike the central budget, health has been a relative priority in the municipal budget, accounting for 12% of the overall budget. This partly ensures no shortage of funds in procuring medicines or equipment for creation of larger covid care facilities. The Municipal Commissioner, Iqbal Chahal, led from the front, including an overnight transfer of 168 patients from hospitals running out of oxygen to others with adequate oxygen without a single death. However, probably the biggest strength of the model was allowing decentralized management at the local ward level (Mumbai is divided into 24 administrative divisions called wards), with each having individual “control rooms” for the management of covid patients, right from testing, sanitization, home isolation, contact tracing and quarantining, and hospital admission. One unique policy was that the RT-PCR test reports were not directly communicated to the patients from private laboratories, as this was found to increase panic and jam the covid helplines. Instead, they were channeled via the control rooms, who were then better prepared to systematically discuss the course of action with the covid patient. This happened without significant public backlash proving that people accept such regulation even if it involves delaying communication of the diagnosis as long as the intention behind this was perceived to be for the greater good and was transparently communicated.
The dramatic load on private healthcare in the second wave led to the middle class experiencing first-hand what it means to face a dysfunctional healthcare infrastructure and perhaps even grasp its tragic consequences, besides also understanding the crucial role of public healthcare for overall national wellbeing. This may translate into sustained public pressure for bringing healthcare into the mainstream political agenda. This will soon be tested in the local Mumbai Municipal elections due early next year, along with elections in a few states. In New Delhi, a local political party which has placed health and education at the centre stage for some time has managed in the past to upstage national parties and win the elections, with support both from the working class and substantial sections of the middle class. Will Mumbai’s poorer and the middle and upper classes come together in the aftermath of covid to force permanent changes in its public healthcare infrastructure, by altering the usual identity politics on which elections are won? This is a question that only time will answer. But if it does happen, it could also be another Mumbai model for the rest of the country to follow.
Akshay D Baheti, Department of Radiodiagnosis, Tata Memorial Hospital, TMC, Mumbai, India; and Homi Bhabha National Institute, Mumbai, India
Trupti I Gilada, Infectious Disease Physician, Unison Medicare and Research Center, Mumbai, India.
Sanjay Nagral, Department of Surgical Gastroenterology, Jaslok Hospital and Research Center, Mumbai, India.
Competing interests: none declared.
Competing interests: none declared