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Experiences from Maharashtra

Novel Health Approaches Emerging from the Covid-19 Crisis

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 providersThe 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 and https://www.maharashtra.gov.in/Site/Upload/Acts%20Rules/Marathi/Restriction%20of%20Charges%20by%20.Pvt%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
.

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

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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Updated On : 23rd Jul, 2022
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