PHM-Exch> Novel health approaches emerging from the COVID epidemic in India

Mon Jul 25 04:25:29 PDT 2022

From: Abhay Shukla <abhayshukla1 at gmail.com>

 I have recently written an article for the journal Economic and Political
Weekly, outlining certain new or less recognised pro-people approaches to
health systems, which have emerged during the COVID epidemic. This is based
on experiences from Maharashtra state, though these are relevant for India
as a whole and many other countries. Key approaches which emerged and have
been described include Co-production of Health care, Interventionist
regulation of private healthcare rates, and Social accountability of
private hospitals. These can be bound together by the larger approach of
enhancing 'Publicness' in the health sector.

Do see the article here, also pasted below:

*www.epw.in/journal/2022/30/commentary/novel-health-approaches%C2%A0emerging-covid-19-crisis.html
<http://www.epw.in/journal/2022/30/commentary/novel-health-approaches%C2%A0emerging-covid-19-crisis.html>*

_________________________________________________________________________________________________________________________
Novel Health Approaches Emerging from the Covid-19 Crisis
<https://www.epw.in/journal/2022/30/commentary/novel-health-approaches%C2%A0emerging-covid-19-crisis.html>

*Novel public health experiments from Maharashtra in the pandemic times,
involving co-production of healthcare, interventionist regulation of
private hospital rates and popular initiatives to ensure social
accountability of private hospitals, demonstrate significant potentials to
advance people-centred health system changes.*

The COVID-19 pandemic exacerbated and highlighted the deep contradictions
in our health systems, like never before. This was especially true in the
case of Maharashtra—the Indian state that was worst-affected by COVID-19 in
terms of the number of cases and deaths. Despite massive distress caused
to ordinary people due to health system inadequacies, this crisis also
generated certain novel public responses. As we move into a post-COVID-19
situation, drawing upon experiences from Maharashtra, we will attempt to
identify some approaches that demonstrate significant potentials to advance
people-centred health system changes in the coming period.

*Co-production of Healthcare*

One of the critical interfaces during the pandemic was between public
health systems and people. Here, the dominant dynamic was, of course,
centrally directed procedures such as lockdowns, testing, tracing,
isolation and quarantine measures, and vaccination drives. Largely framed
in a ‘‘militarised’’ public health discourse, these measures were designed
and implemented by the national and state governments in highly
centralised manner, requiring strict compliance by populations, and were
complied with in varying degrees by ordinary people.

At the same time, less visible but important participatory initiatives
came up in many areas, which emerged not through central directives but
parallel to them. These involved panchayats, frontline health workers,
grassroots activists, and civil society groups, occupying the interstices
that emerged on the ground during the crisis. While many of these were
short-lived, such participatory efforts (forms of ‘‘public–public
partnership’’) provided much-needed support to patients, migrant workers,
and various groups of affected people during the pandemic.1

One common form of such initiatives in rural areas of Maharashtra was
numerous actions taken by panchayats and village-level *dakshata
samitis* (vigilance
committees) to set up local isolation and quarantine centres while
providing essential support to the occupants in terms of food and other
arrangements. In some instances, local groups and village health
committees actively supported front-line health workers like accredited
social health activists (ASHAs) and anganwadi workers, enabling them to
reach out to people more effectively for health measures and also
arranging essential supplies.

One remarkable form of civil society–state cooperation was the running of
patient support desks in rural public hospitals, with 40 such help desks
across various talukas of Maharashtra operated during the second wave. Help
desk volunteers in dozens of blocks came forward and assisted patients and
caregivers in the face of considerable personal risk. Not waiting for
state-level official endorsement, block and district health officials
enabled this initiative to be rapidly replicated in each block where it was
proposed. As a result, during July 2020 to August 2021, over 80,000
patients and caregivers were provided information and guidance related to
accessing COVID-19-related care and general health services through such
civil society-run help desks working in public hospitals across the state
(Patil 2021).

Within Maharashtra, Pune has been the most affected district in terms of
COVID-19 cases and mortality. Within this setting, a broad-based coalition
of civil society organisations and community groups in Pune catalysed the
formation of a joint task force on social action for COVID-19 control in
August 2020, in collaboration with the divisional commissioner and
local officials.
This joint task force worked at the health system–people interface by
launching campaigns for mass awareness, supporting outreach measures in
communities, and enabling community feedback to the health system
(Mascarenhas 2020). A notable spin-off of this initiative emerged in the
Velhe block of Pune district, where a similar block-level joint task force
on social action took several collaborative initiatives on healthcare and
nutrition, including provision of nutritious food for malnourished
children in large number of villages during the lockdown situation.

One aspect needing emphasis here is the autonomous agency of front-line
health workers who often acted beyond the call of duty and struck up wider
social collaborations during peak periods of the pandemic. This includes
primary healthcare staff and semi-formally employed ASHAs working under
considerable constraints with inadequate honorariums. These front-line
workers often reached out to panchayats and local social groups with the
recognition that collaborative action was essential in this situation.

Similar ground-level initiatives emerged during the COVID-19 pandemic in
many states, notably in Kerala where the state government actively promoted
the engagement of panchayats, womens’ groups, social organisations, and
local volunteers in pandemic control efforts. Such initiatives that
involved close collaboration between public functionaries and
community-based actors on the ground can be regarded as examples of
co-production of healthcare. Historically, the co-production of health
approach has been developed in clinical settings, advocating for close,
continued partnerships between health professionals and patients to
improve health outcomes (Hart 2010). More broadly applied, the
co-production approach recognises that healthcare cannot be optimally
produced either by health services alone or by communities on their own.
Only an equitable, reciprocal, and democratic collaboration involving
public health systems (including front-line health workers) and communities
can create optimal conditions for provisioning of healthcare towards
enhancing people’s health status. This involves configuring a major,
equity-oriented shift in the power relations between health systems and
people and provides an alternative to dominant top-down, militarised, and
bureaucratic public health approaches. Co-production of healthcare does not
imply any abdication or dilution in the essential role of the state to
provide health services to the entire population. While the state remains
fully accountable to fulfil its range of roles in service provisioning,
community-based actors and groups and ordinary people would be treated as
equitable partners in planning and implementation. Co-production would be
focused at the primary healthcare level, linked with complementary
participatory processes at higher levels.

*Regulation of Private Hospital Rates*

A second important front of interaction during COVID-19 has been between
public systems and private healthcare providers. The backdrop of
large-scale privatisation of healthcare in India, especially in states
like Maharashtra, is well known. Inadequate capacities of public health
services to deal with the spiralling number of COVID-19 patients presented
the spectre of large-scale exploitation of people by commercialised
hospitals, a potential “market disaster.” Given this context, Maharashtra
was the first state in India where regulatory measures to standardise rates
for treatment of COVID-19 as well as non-COVID-19 patients were decreed by
the state government through orders issued in April and May 2020.2 All
private hospitals were required to implement specified rates concerning 80%
of their beds, covering treatment of both COVID-19 and non-COVID-19
patients. This was the highest proportion of rate-regulated hospital beds
among all Indian states during the COVID-19 pandemic.

These measures were notable and unprecedented, since during the previous
decade until COVID-19, various state governments in Maharashtra had not
managed to take forward legal regulation of private healthcare. Maharashtra
has neither adopted the national Clinical Establishments (Registration and
Regulation) Act, 2010 nor has it enacted an equivalent, updated state
regulatory act to govern private healthcare providers.3 Yet, during
the COVID-19 pandemic, the state moved rapidly and decisively to regulate
rates in private hospitals across the board, and official auditors were
appointed to scrutinise private hospital bills especially in larger
cities, in attempts to keep COVID-19-related hospital bills within
specified limits.

The results of these regulatory directives were mixed due to multiple
reasons. Sections of the private healthcare lobby challenged the validity
of regulatory orders, which had been hastily stitched together based on
laws, such as the Epidemic Diseases Act, 1897 and Disaster Management Act,
2005.

These laws provide certain general powers to the state in emergencies, but
their jurisdiction in the area of hospital rates was not clear. Responding
to a public interest litigation filed by a private doctor with the Nagpur
bench of Bombay High Court, the state government orders to regulate rates
for non-COVID-19 patients were declared invalid by the high court, and this
stipulation was subsequently upheld by the Supreme Court (Ganjapure 2021).
Concerning the regulation of rates for the care of COVID-19 patients, the
orders were continued and did have an impact in larger cities like Mumbai
where the government was able to effectively deploy a number of special
auditors who reduced crores of rupees from COVID-19-related hospital
bills, providing some relief to patients (Parab-Pandit 2022).

However, inadequate public regulatory capacity, especially in smaller
cities and towns, combined with multiple stratagems used by many commercial
private hospitals to circumvent these regulations limited the
effectiveness of these regulatory orders in many parts of the state.

While these regulatory measures were temporary in nature and had mixed
effectiveness, this shift from “minimalist regulation” prior to COVID-19
to the “hands-on regulation” of private healthcare during the pandemic was
potentially significant. Ongoing compulsions of the Indian state to promote
capital accumulation in the healthcare sector are reflected in the usual
minimalist regulation approach even in states where the Clinical
Establishments (Registration and Regulation) Act, 2010-type legislations
are operative. Such regulations so far have tended to mostly focus on
registration and the fulfilment of some infrastructural standards by
private hospitals, thus streamlining the healthcare market, rather than
reshaping the market towards public goals. Maharashtra government’s
decision to regulate rates for vast majority of beds in private hospitals,
covering non-COVID-19 as well as COVID-19 patients (only the latter getting
operationalised due to legal constraints), highlighted the potential for an
alternative approach of interventionist regulation of private healthcare.
Fourteen other Indian states also adopted similar rate regulation measures
during the pandemic, though these orders were limited to COVID-19 treatment
and covered small proportions of hospital beds in these states. We need to
learn lessons from the attempted interventionist regulatory approach,
including analysing the reasons for ultimately limited effectiveness of
rate-regulation measures. Based on this, an expanded, legally
strengthened, and sustained version of interventionist regulation,
including standardisation of rates, could help check the widespread
market failures and commercial exploitation of patients by the private
healthcare sector. This could be an important component of a larger
process for reshaping healthcare in a pro-public direction.

*Ensuring Social Accountability*

A third significant interaction highlighted during the pandemic in
Maharashtra was between private hospitals and people. The mentioned
rate-regulation orders did have some impact, but numerous commercial
private hospitals found ways of circumventing these and massively
overcharged patients for COVID-19 care while violating various patients’
rights.4 Major evidence for such overcharging emerged from the
participatory survey covering 2,579 COVID-19 cases, with respondents being
women who had lost their husbands to COVID-19 and other family members of
patients who had been treated for COVID-19. This rapid survey conducted in
September 2021 across 34 districts of Maharashtra by the social networks
Corona Ekal Mahila Punarvasan Samiti and Jan Arogya Abhiyan, demonstrated
overcharging by private hospitals in 75% of the covered COVID-19 cases,
taking state-mandated rates as the benchmark.5

While such overcharging, especially by larger private hospitals, was
widespread, there was also a unique social response to the situation from
below. This started with organisation of ‘‘Santap Sabhas’’ (anger
assemblies) by Jan Arogya Abhiyan and Corona Ekal Mahila Punarvasan Samiti,
involving women who had lost their husbands to COVID-19, and other family
members of COVID-19 patients. These assemblies were organised in Nashik
and Pune during September–October 2021 where striking testimonies
of COVID-19-related overcharging by private hospitals were presented, and
the demand was voiced that huge excess charged amounts must be refunded.
This expression of social outrage was taken forward through dialogue with
the state health minister, leading to official audits of private hospital
bills for 480 complaints across Maharashtra related to COVID-19 treatment
overcharging (Shukla 2022). This audit process (currently underway) is
rather unique, since, though the auditing is anchored by public officials,
the mentioned civil society networks are playing a major role in
collectivising affected patient families, analysing the often complex and
cleverly inflated hospital bills, and even technically supporting local
officials for effective conduction of these audits.

This public–public collaboration for private healthcare accountability has
led to major and unprecedented refunds to patients from various private
hospitals, significantly benefiting over 60 COVID-19 patients across the
state until now, with the average refund amount in each case being
over `25,000. It may be argued that public regulatory efforts from above
remain inadequate unless accompanied by such enforcing of social
accountability of private hospitals from below. These processes can be
located within a wider framework of ‘‘social embeddedness’’ of private
healthcare providers*. *The COVID-19 pandemic punctured the corporate
mantra that ‘‘healthcare should be treated like any other industry’’ (with
minimal social obligations), reminding both people and providers that even
private hospitals must function as social institutions, having definite
public responsibilities. Today, powerful tendencies promoting
corporatisation of healthcare seek to completely subjugate healthcare
providers to market forces, wrenching them away from all social moorings.
In this context, experiences like the overcharging audit in campaign mode
strengthen the counter-discourse that even private healthcare providers
must be held socially accountable.

*Shaping Post-covid-19 Health Systems*

The mind, once stretched by a new idea, never returns to its original
dimensions.

—Ralph Waldo Emerson

We have seen how during the COVID-19 crisis certain novel public health
responses emerged in Maharashtra. These related to interactions between
each of the components of the ‘‘health system triangle’’ consisting of the
public health system, the private healthcare sector, and people.
Co-production of healthcare emerged through interactive processes between
public health systems and people; interventionist regulation dealt with the
interface of public systems with private healthcare providers; and social
accountability processes sprung from interactions between private
healthcare providers and people. Obviously during COVID-19, the dominant
dynamics along each of these axes reinforced pre-existing power inequities,
reproducing hierarchies and commercialised behaviour. However, the
unprecedented COVID-19 crisis also shook up the system, created new spaces,
and generated novel interactions, though these were on smaller scale and
have been nascent in character. As we move towards post-COVID-19 health
systems in India, each of these emergent directions need to be carefully
studied, since these form precedents that deserve upscaling as part of the
crucial processes for health system change.

Probably the most important health system lesson from COVID-19 has been to
heavily underline the importance of robust public health systems. While
demands are made for the strengthening of public health services, we
should be cognisant of the dominant direction that is being currently
rolled out for public health systems in the form of securitisation and
digitalisation. While public provisioning remains underfunded, highly
centralised mechanisms of health sector control and surveillance are being
prioritised, further marginalising front-line providers and communities,
and excluding participatory processes. There is apprehension that the new
public health act being formulated at the national level might reinforce
such tendencies.

In this context, the experiences and vision of co-production of healthcare
can provide a powerful counterbalance, emphasising the irreducible role
played by communities and ordinary people in public health processes, who
must be equitably involved and consulted as active subjects, rather than
being reduced to objects of top-down directives and surveillance. We need
further discussion about how components of co-production can be integrated
within the larger, essential process of public health strengthening in the
post-COVID-19 situation. Such an approach can point the direction for
reconfiguring relationships between various health authorities, front-line
healthcare staff, panchayats, and communities in a democratic framework,
countering autocratic designs in the health sector.

Concerning the private healthcare sector, the dominant discourse supported
by influential bodies like Niti Aayog is to accelerate transnational and
domestic investment, fuelling further private sector growth.
The Niti Aayog’s document “Investment opportunities in India’s healthcare
sector’’6 rolls out the red carpet for multinational capital to further
marketise India’s already hyper-privatised health system but does not even
mention the need for regulation of private healthcare. In this context, the
lessons from interventionist regulation of private healthcare during COVID-19
need to be built upon, strengthening the argument that reining in
commercialisation of healthcare through public action is not only necessary
but is also feasible as an option, provided there is political will to do
so.

At the same time, challenging unbridled commercialisation of healthcare
will not be effective if limited to demanding top-down regulation of the
private sector by historically weakened public systems. Here, initiatives
for social accountability of private hospitals show us how ordinary
citizens and grassroots civil society organisations can confront
commercialised private hospitals and demand accountability, overcoming huge
asymmetries of power and knowledge. In this process, new allies are
emerging such as middle-class sections who have been maltreated by private
and corporate hospitals. While the trajectory of regulatory action from
above remains uncertain, options for social action from below will continue
to remain relevant for pushing back exploitative processes linked with
commercialisation of healthcare.

Crises inevitably throw up major challenges, but often they also provide
glimpses of novel paths to transcend these challenges. While we chalk out
directions for a post-COVID-19 health system in an increasingly contentious
political environment, let us not lose sight of these promising
experiences and resultant hard-earned insights. Each of these directions
represents a concrete dimension of strengthening ‘‘publicness’’7 of
healthcare (an approach encompassing the public system, as well as
public–private interactions in the health sector). The approach of
promoting publicness offers a comprehensive alternative to bureaucratic
capture, privatisation, and corporatisation of health systems. Today, as we
challenge the constriction of democratic spaces and critique the dominant
framework in healthcare, we also need to pose action-oriented
alternatives that embody real democracy based on people’s initiatives.
These provide us grounded hope in difficult times and ensure that while
moving beyond the COVID-19 crisis, its most valuable lessons are not left
behind.

*Notes*

1 For description of several such initiatives in Maharashtra, see “Vedh
Arogyacha” (www.sathicehat.org/vedh-arogyacha) and “Dakhal,”
www.kalpakhosting.co.in/Sathi/wp-content/uploads/2021/08/Dakhal-Covid-Yoddhyanchi.pdf
).

2 See https://fmesinstitute.org/wp-content/uploads/2020/05/Restriction-on-Charges-by-Hospital,
pdf
<https://fmesinstitute.org/wp-content/uploads/2020/05/Restriction-on-Charges-by-Hospital.pdf>
 and
https://www.maharashtra.gov.in/Site/Upload/Acts%20Rules/Marathi/Restriction%20of%20Charges%20by%20.Pvt%20Hospital%20RevisedFinal1%20(1).pdf
<https://www.maharashtra.gov.in/Site/Upload/Acts%20Rules/Marathi/Restriction%20of%20Charges%20by%20Pvt%20Hospital%20RevisedFinal1%20(1).pdf>
*.*

3 Private hospitals in Maharashtra are registered under the Maharashtra
Nursing Homes Registration Act, which is a slightly modified version of the
archaic Bombay Nursing Homes Registration Act, 1949.

4 For striking patients’ testimonies during COVID-19, see
www.sathicehat.org/wp-content/uploads/
2022/04/Compendium-Patients-voices-during-the-pandemic_email.pdf.

5
www.janarogya.org/wp-content/uploads/2021/10/English-report-on-overcharging-survey.pdf
.

6 https://www.niti.gov.in/sites/default/files/
2021-03/InvestmentOpportunities_HealthcareSector_0.pdf
<https://www.niti.gov.in/sites/default/files/2021-03/InvestmentOpportunities_HealthcareSector_0.pdf>
.

7 For discussion on the concept of “Publicness,” see Mcdonald and Ruiters
(2012).

*References*

Ganjapure, Vivek (2021): “Government Can Not Fix Rates for Non-covid
Patients in Private Hospitals: Supreme Court,” 20 July, *Times of India*,
https://timesofindia.indiatimes.com/city/nagpur/govt-cant-fix-rates-for-non-covid-patients-in-private-hospitals-sc/articleshow/84565884.cms
*.*

Hart, Julion Tudor (2010): *The Political Economy of Health Care*, Bristol:
The Policy Press.

Mascarenhas, Anuradha (2020): “Flash Mobs, Community Participation: Pune’s
‘People’s Campaign to Halt Covid’ to be Launched on 16 October,” *Indian
Express*, 13 October,
www.indianexpress.com/article/cities/pune/flash-mobs-community-participation-punes-peoples-campaign-to-halt-covid-to-be-launched-on-oct-16-
6722492*.*

McDonald, David and Greg Ruiters (2012): *Alternatives to Privatisation,* Cape
Town: HSRC Press.

Parab-Pandit, Shefali (2022): “Mumbai: BMC Axes `21 Crore from Overcharged
Private Hospital Bills to Covid Patients,” *Free Press Journal*, 24 April,
https://www.freepressjournal.in/mumbai/mumbai-bmc-axes-rs-21-crore-from-overcharged-pvt-hospital-bills-to-covid-patients
.

Patil, Hemraj (2021): “Aarogyaseveche Lokdoot,” *Loksatta*, 21 April,
www.loksatta.com/vishesh/article-on-health-service-envoy-abn-97-2449630/?utm_source=whatsapp_web&utm_medium=social&utm_campaign=socialsharebuttons
<http://www.loksatta.com/vishesh/article-on-health-service-envoy-abn-97-2449630/%0A?utm_source=whatsapp_web&utm_medium=social&utm_campaign=socialsharebuttons>
*.*

*Shukla, Abhay (2022): “Regulation of Private Hospitals during COVID Gets a
‘Booster’ of Social Accountability,” Leaflet, *
https://theleaflet.in/regulation-of-private-hospitals-during-covid-gets-a-booster-of-social-accountability
*.*
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