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 Table of Contents  
PERSPECTIVE
Year : 2020  |  Volume : 9  |  Issue : 5  |  Page : 77-80

Novel Coronavirus – 19 pandemic impact on private health-care services with special focus on factors determining its utilization: Indian scenario


1 Department of Hospital Administration, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
2 Department of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
3 Department of Community Medicine, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka, India

Date of Submission29-Apr-2020
Date of Decision02-May-2020
Date of Acceptance12-May-2020
Date of Web Publication04-Jun-2020

Correspondence Address:
Dr. Amogha Shree
Department of Community Medicine, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_69_20

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  Abstract 


The novel coronavirus disease (COVID-19) outbreak, caused by severe acute respiratory syndrome coronavirus 2, has rapidly escalated into a global pandemic which leads to declaration of national health emergency in several countries and is having a profound impact on private health-care systems globally including India in unprecedented manner. However, the impacts are very serious, especially on global economics and health care due to COVID-19 pandemic. During this pandemic, private hospitals and clinics are experiencing a reduction of in patient footfalls due to nationwide lockdown and several other factors as well which are leading to inadequate utilization of health-care services by the patients and decrease in medical services volumes which resulted in acute economic crisis. In this article, various factors that caused a significant reduction in utilization rates of private health-care systems such as hospitals and clinics were outlined and discussed.

Keywords: COVID-19, novel coronavirus, pandemic, private health-care systems


How to cite this article:
Nilakantam SR, Kishor M, Dayananda M, Shree A. Novel Coronavirus – 19 pandemic impact on private health-care services with special focus on factors determining its utilization: Indian scenario. Int J Health Allied Sci 2020;9, Suppl S1:77-80

How to cite this URL:
Nilakantam SR, Kishor M, Dayananda M, Shree A. Novel Coronavirus – 19 pandemic impact on private health-care services with special focus on factors determining its utilization: Indian scenario. Int J Health Allied Sci [serial online] 2020 [cited 2020 Jul 15];9, Suppl S1:77-80. Available from: http://www.ijhas.in/text.asp?2020/9/5/77/285965




  Introduction Top


The World Health Organization declared COVID-19 infection as a global pandemic which is presently engulfing 213 countries affecting over 2 million people and 157,970 deaths as of April 20, 2020.[1] It is expected that the number will grow in the next few weeks. India is also suffering with over 17,000 cases and nearly 550 deaths as of April 20, 2020.[2] Being one of the developing countries, India is suffering with humanitarian crisis with severe restriction on people's movement like complete lockdown that predominantly affected millions of migrant workers and daily wage workers.[3]

This worldwide COVID-19 infection has also affected the day-to-day life of the people, their businesses, and problem in getting their essentials and even the health-care sector largely. COVID-19 has affected the entire departments in the hospital where they are unable to concentrate on their regular patients.

The central and the state governments across the nation enlisted almost all district government hospitals for the identification and management of COVID-19 in the initial phase. The private health-care systems consist of 58% of the hospitals in the country, 29% of beds in hospitals, and 81% of doctors, which account for 82% of outpatient visits, 58% of inpatient expenditure, and 40% of births in institutions.[4] Hence, it is important to understand the determinants of hospital service utilization during COVID-19 specifically for the private hospitals not only because they are major contributors to the health-care delivery system in India but also due to a fact that some private hospitals continued to serve in the middle of COVID-19 crisis for non-COVID-19 patients.

Few private hospitals were also shut down during the pandemic times, due to the high rate of infections in those hospitals. The probable reason could be due to the early phases of pandemic, where hospitals were not prepared to identify and manage effectively and also due to lack of experience of hospital staffs in dealing with such a novel agent and with such a degree of infectivity. According to the National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas.

The health-care sector is at the epicenter of this unprecedented global pandemic challenge, and the private health sector has risen to the occasion, by offering to the government all the support it needs, be it testing support, preparing isolation beds for the treatment of COVID-19-positive patients, or deploying equipment and staff in identified nodal hospitals.

As the lockdown began, the government at all levels repeatedly highlighted the fact that health-care services come under essential services and hence shall be exempted. However, there was a complete collapse of the public transport system which acts as one of the important means for patients to reach the hospital. In this period, the utilization of private hospital services was evaluated. The tertiary care teaching hospital in Mysuru, which is 1800 bedded, attached to medical college received 42,096 outpatients in March 2020 and 28,221 outpatients in April 2020 against 54,976 outpatients in March 2019 and 53,271 outpatients in April 2019 in the same period of the last year and these accounts to almost 60% drop in the footfalls of patients to the hospital, which directly or indirectly impacted the utilization hospital and health-care services.

Although it is easily assumed that lockdown, lack of public transport, fear of contracting COVID-19 infection might have played a role in underutilization of hospital services, it is important to explore the perspectives of patients who are the end users of services. The Government of India has, on March 21, 2020, released guidelines for the hospitals to prepare for the coronavirus outbreak. Among other things, hospitals are required to reserve beds, create isolation wards, and mobilize additional workforce and train staff, in addition to arranging for adequate high-oxygen masks and ventilators. This resulted in sharp drop in footfalls of private hospital services such as utilization of outpatient departments (OPDs), diagnostic testing, prioritizing only urgent and emergency cases which resulted in canceling of many medical appointments, and cancellation or postponement of elective surgeries until there is clarity on infection prevalence in the region and means to control it. In the tertiary care teaching hospital in Mysuru, a survey of 60 patients who utilized services during the lockdown and 60 patients who did not utilize despite the scheduled appointments revealed many factors that help us to understand the factors contributing to significant reductions of health-care utilization in ongoing COVID19 crisis. At the time of writing this article,, the information obtained from the survey has not been analyzed, but few important factors have been outlined here to discuss their impact on private hospitals and health-care systems.


  The Following Are the Factors That Affected the Utilization Rates of Private Health Care Services Top


Nationwide lockdown

Since March 24, 2020, India has been under a nationwide lockdown, now extended by the Central Government till May 17, 2020, to curb the spread of the coronavirus. This lockdown has been causing huge disruption, and distress, to the lives around the world and also achieved modest reductions in overall hospital admissions and substantial reductions in the use of daily OPDs and elective services.

Lack of public transport

As a part of nationwide lockdown, the closure of public transportation has exacerbated challenges for patients in accessing health-care services, especially those living in rural areas and economically underserved settings, as rural populations are more likely to have to travel long distances to access health-care services, particularly subspecialist services. In urban areas, public transit is also generally an option for patients to get to medical appointments. Rural communities often have more elderly residents who have chronic conditions requiring multiple visits to outpatient health-care facilities. This becomes challenging without availability of transportation whether it is public or private.
Figure 1: Reasons for decline in footfall of patients in private health-care facilities

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Postponement of elective surgical/diagnostic procedures

Measures like restrictions on the non-urgent use of hospitals were imposed, which impacted the private hospitals performance on surgical services. [5] These restrictions resulted in shrinkage in the rate of admissions for elective procedures; however, subject to the restrictions, majority private hospitals continued to allow few essential elective admissions. Because, higher priority should be given to the patients, who are clinically unstable or if the intervention is predicted to end in substantial overall survival gain or improvement of quality of life. Postponement of elective surgeries and procedures could have an adverse impact on the quality of life while the patients wait for the right time to get the treatment they need. Surgeries have been reduced by approximately 50% nationwide.

Telemedicine

As patients under lockdown and health workers at the risk of infection, health-care system is adopting virtualized treatment approaches that reduced the physical meeting between patients and health providers. Digital health technologies are being adopted at a huge rate now without any technological barriers in the adoption of virtual health care.[6] As a result of this, most of the outpatient visits have been shifted from hospitals toward telehealth visits.

Fear of contact

Patients' fear of seeking hospital-based care may have been an important determinant of hospital services utilization during the SARS COVID-19 outbreak. Although it was concluded at an early stage that the infection spreads by droplets and it was not immediately recognized that the virus was so tenacious that it could survive outside the body on surfaces for long periods. The estimates of the time that the virus could survive on various surfaces grew longer and longer – from hours to days throughout the outbreak – as an understanding of the virus increased. The fears of SARS COVID-19 significantly influenced people's health-care-seeking behavior and that this fear seriously compromised their access to quality care. It is not just a problem of common people, even nearly 70% of the medical students were reluctant to attend clinics from fear of getting infected or passing on to others during the outbreak[7] because of initial lack of awareness of the mode of spread of the virus.

Closure of private clinics

Many of the private medical practitioners across various cities, especially on the fringes, have stopped opening their clinics during the lockdown fearing close contact with coronavirus-infected patients. With no option left, many patients despite having minor illness are forced to rush to crowded hospitals, defeating the purpose of social distancing.

Homemade medicines/self-medications

Many patients have started self-medication, risking health. Since the commencement of lockdown, there is a lot of usage and preparation of homemade medicines by patients. Many families have fallen back to traditional ayurvedic and herbal medicines that can be easily prepared at home. This practice of using homemade medicines has also picked up in villages and towns as they do not have transportation facilities to reach the hospitals and clinics. This concept has gained more importance when the AYUSH ministry brought measures for enhancing the body's natural defense system (immunity) which also included homemade remedies for illnesses such as dry cough and sore throat.[8]

Over-the-counter medicines

Due to this lockdown because of the COVID-19 pandemic, people who are suffering from non-COVID illness are unable to reach the hospital on time which resulted in further deterioration of their health condition. Only those with the knowledge and smartphone could access virtual treatment, whereas the poorer are still devoid of these facilities which made them take the over-the-counter medications including many with little evidence to support their safe use.[9] Thus, both virtual treatment and over-the-counter medicines indirectly resulted in less utilization of hospital services.


  Expected Changes in Post Covid 19 Phase Top


Once the lockdown is lifted, people may rush to hospitals with new diseases or with the complications of existing disease. As the lockdown was for a very long period (already completed 28 days of lockdown as on April 20, 2020), we can expect the surge in new cases related to mental health among who suffered from COVID-19 and their immediate family due to nonacceptance of them and among daily wage workers and migrant laborers due to economic instability and suicidal tendency among alcoholics, etc. Another challenge is an epidemiological shift toward noncommunicable diseases where lack of physical activity plays an important role. Furthermore, elective surgical procedures, checkups, and other treatments that have been postponed will likely now be jammed into the second half of this year in order to comply with insurance plans. Patients of chronic disease, being wary of going out, or facing difficulties in movement due to lockdown restrictions might miss on treatment, ending up with long-term sequelae. These can eventually increase the possibility of complications and worsening of the disease, raising the overall burden of diseases of the country to a certain extent. Hence, private health sectors should also be ready to tackle the other side of the footfall. It is also expected that patient visits to psychiatry will be increased not only due to fear of isolation and stigma attached to those who are being quarantined and isolated but also because of psychosocial and socioeconomic impacts. The health-care community will begin to prepare for life after COVID-19, and the gradual re-opening of hospitals and practices of health-care providers will turn their attention to addressing their equipment purchases that were delayed or deprioritized. In addition, new equipment needs will emerge in order to protect patients such as testing devices, telemedicine, and safe waiting areas for patients.

Health care will continue to take center stage as we continue to battle this pandemic and the anticipated return of viruses. There will be more robust discussions of universal health care and basic universal income. Regardless of the outcome of these debates and the passage of various new policies, the strengthening of our health-care system and the preparation for future pandemic risks will be widely supported by our politicians and our citizens. There will be mounting pressure to ensure each state, and its health-care providers to have adequate access to necessary equipments and supplies, as well as tighter control of the supply chain by the government.


  Conclusion Top


During COVID-19 pandemic, health-care utilization and medical services decreased significantly which resulted in significant loss of revenue and increased use of resources. The immediate shutdown of elective surgeries, dramatic decreases in patient volumes, and the measures taken to prepare for a potential surge in hospitalizations have created immediate and long-term financial impacts on the system. The private hospitals and laboratories, which were already facing multiple challenges, will witness an acute crisis due to COVID-19 and the subsequent lockdown, which has resulted in occupancy levels to fall to a mere 40% by late March and April vis-a-vis pre-COVID occupancy levels of 65%–70%. This is expected to reduce even further. Hence, to conclude, SARS COVID-19 pandemic brought about not only relatively discernable economic losses but also observable damage to health-care organizations, and this has resulted in a lower health-care utilization rate.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Coronavirus; 2020. Available from: https://www.who.int/emergencies/disea ses/novel-coronavirus-2019. [Last accessed on 2020 Apr 18].  Back to cited text no. 1
    
2.
WHO COVID-19 Dashboard; 2020. Available from: https://covid19.who.int/region/sea ro/country/in. [Last accessed on 2020 Apr 18].  Back to cited text no. 2
    
3.
Andrade C. COVID-19: Humanitarian and health care crisis in a third world country. J Clin Psychiatry 2020;81:20com13383.  Back to cited text no. 3
    
4.
Thayyil J, Jeeja MC. Issues of creating a new cadre of doctors for rural India. Int J Med Public Health 2013;3:8.  Back to cited text no. 4
  [Full text]  
5.
Schull MJ, Stukel TA, Vermeulen MJ, Zwarenstein M, Alter DA, Manuel DG, et al. Effect of widespread restrictions on the use of hospital services during an outbreak of severe acute respiratory syndrome. CMAJ 2007;176:1827-32.  Back to cited text no. 5
    
6.
2020. Available from: https://www.thelancet.com/action/show Pdf?pii=S0140-6736(20)30818-7. [Last accessed on 2020 Apr 28].  Back to cited text no. 6
    
7.
Gupta L, Agarwal V, Davalbhakta S, Agarwal V, Misra D. A Survey-Based Study on the Knowledge, Attitude, and the Practices Pertaining to the 2019 Novel Corona Virus Infection amongst Undergraduate Medical Students in India; 2020.  Back to cited text no. 7
    
8.
Available from: https://www.ayush.gov.in/docs/123.pdf. [Last accessed on 2020 Apr 28].  Back to cited text no. 8
    
9.
Porter G, Grills N. Medication misuse in India: A major public health issue in India. J Public Health (Oxf) 2016;38:e150-7.  Back to cited text no. 9
    


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