India’s health infrastructure will benefit from pandemic legacy

01 Aug 2021 Long Read

More ICU beds, better hospital penetration at the district level across the country, focus on decentralised medical education, holistic views of supplies of oxygen, equipment and trained manpower, the Covid has pushed India to increase allocations by 137%. E Jayashree Kurup speaks to doctors across the country to assess the reality.

India entered the pandemic phase with a very low hospital bed density of 0.55 per thousand people, less than a third of the prescribed WHO norms of three beds per thousand people.

After wave 1, the 23,000 makeshift beds, 6,000 in ICUs, that were added to combat the increasing cases in late 2020, were removed. However, wave 2 showed how unprepared the entire system was in coping with the peak numbers.

Also read:

  • ‘Extension of Hospitals’ project begins in India to fight Covid 19
  • Oxygen demand: Govt undertakes multiple initiatives to enhance availability 
  • Currently, the Centre has requested the state governments to formulate a full plan relating to: bed capacities, ICU beds, identification of additional hospitals, preparation of field hospital facilities, ensuring sufficient oxygen supported beds and oxygen supplies.

    Kerala, with a hospital bed density of 1.05, stood out as an excellent example of early preparedness. Having evolved a contact tracing protocol to contain the Nipah virus in 2018, the state’s performance in tackling the pandemic during the first wave showed a much higher testing capacity and more random surveys. Epidemiologist Gagandeep Kang says even today the state turns up bigger numbers as the intent is to test for correction. Thus the state posts a high case load but with no overwhelming of the state health machinery.

    CONSTRUCTION WORLD spoke to several senior heads of departments and directors of state-run hospitals to understand what changes have come about in the country’s health infrastructure. A common reply was that ICU beds used to be in short supply, even in large hospitals. A 1,300 bed hospital would function with just 30 ICU beds, says a senior physician.

    Of the country’s 642 districts, 100 have been picked up as a pilot, says Dr (Ar) R Chandrashekhar, Advisor, Ministry of Health, GOI and states for Hospitals Design & Construction and Chairman IGBC Health Care Facilities Rating. “Where land and a 300-500-bed hospital is available, the effort is to attach a medical college to it. The idea was conceived in 2013-14. Implementation began about three years ago. The Kalpana Chawla Medical College in Haryana was the first off the ground.

    This way doctors in district hospitals who were languishing without promotions get a chance to become professors. And super specialities get added to district hospitals. Nursing and paramedics training institute added to it provides an upgrade chance for languishing professionals and enough trained manpower in the districts to man the medical facilities. Medical colleges also command a high degree of trust in the districts, among patients.”

    As more hospitals get added to the pool, there is a growing need for architects and engineers who understand hospital design and construction, says Chandrashekhar. A special course on Health Facility Planning and Engineering has been set up. The first batch has gone up. The second is in progress. The teaching is online and on ground training takes place at PGI Chandigarh once a year. The course has been designed in modules:

    Level 1 - Certification
    Level 2 - PG Diploma
    Level 3 - Masters Degree

    PGI Chandigarh was used as a lab to train the architects and engineers so that medicine and design could synergise.

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  • Post Pandemic Hospital Design 
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  • During Covid, most medical professionals have been exposed to ICU care. Earlier a very small percentage knew how to manage critical care. That has changed. Public healthcare doctors believe that high dependency units’ care will improve. “The need is for continuous medical education to improve staff knowledge that would now ensure that this does not go to waste,” says Chandrashekhar.

    Overall capability of public health will go up, experts believe. A public hospital did not have more than 30 ICU beds. Government had never invested in ICU care. Now 80-100 ICUs in 1200-1300 bed hospitals has become the norm. Some NRI NGOs have started an initiative to upgrade Indian healthcare with 10-bedded ICUs in every district hospital. Also neo-natal and paediatric ICUs have come up.

    The Indo UK Institute of Health plans to create the model of available, affordable and accountable healthcare for all in India with 11 hospitals of 100 beds each as hubs and spokes of 69 wellness centres. The wellness centres in the towns and villages would have the basics of ECG, ultrasound, blood test and X ray machines. “This takes care of the basics,” says Dr Chandrashekhar. This reduces the burden on the main hospitals. The first 1,000 bed hospital is starting in Nagpur. There would be a 250 bed 7-star facility and a 750 bed medical college hospital. Backward and forward integration with equipment and drug manufacturers given space close by in the medical SEZ facility will bring economies of scale and cross drive profits of premium healthcare into basic facilities for the masses.

    While distributed healthcare is the biggest benefit, the fate of non-Covid treatment is signalled by the medical fraternity as the biggest negative. First there were restrictions, then patient fear but now patients are slowly coming back. After the second wave, hospitals opened to non-Covid patients very fast. Now fully vaccinated hospital staff know the protocols and masking has become routine among staff and a large number of patients.

    In addition, hospital management has started to focus on issues like infrastructure, trained manpower, equipment, indoor air quality and emergency Covid protocol according to IGBC guidelines, explains Chandrashekhar. “The first round was all about infection control,” says V Suresh, Chairman IGBC. Now the designs are fine tuned to accommodate fresh air and indoor air quality, energy savings, planning for enhanced capacities and germicidal treatment to kill the germs within the filters.

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  • Combating COVID through PPP: Anil Swarup 
  • Resilience in Healthcare Design 
  • Distributed healthcare with planned facilities offering jobs, access to medicine and better treatment across the country, would be the biggest legacy benefit of the pandemic to India as a whole.

    The second legacy benefit is a holistic approach to preventive healthcare. Nutrition and wellness can help boost immunity. Many medical problems can be treated at the primary level. Asha workers have a huge role to play here. Just anemia is a huge challenge that can be tackled at their level. Doctors of district hospitals feel that the government cannot run away from the responsibility of providing primary health care. Just iron and folic acid can bring many back to health.

    Currently 65% medical expenses in India are out of pocket and the government takes care of only about a third of the expenses. The finance ministry has announced an increased health sector allocation by 137%, says Chandrashekhar. India spent 1.6% GDP on health. The US spends 8% GDP on health. In India this amounts to an average $75 per person, according to a specialist’s computation. Brazil has $915 per person and South Africa $570. Even Malaysia spends $450 per citizen.

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  • CW’s Open Letter to PM Modi 
  • India’s health step-up needs sanitation and potable water. Primary Health Centres have to be manned by medical personnel. Medicine availability has to go up. In rural areas lack of availability can lead to hostile situations. Medical staff need safety and services when posted to the hinterland like civil servants.

    The overall vaccination system has to be ramped up. Till now no importance has been given to adult vaccination above the age of 65. Most could not afford it. Adult vaccines were only for those who could afford it. We need a national policy for adult vaccines.

    Distributed heath infrastructure, a system of primary, secondary and tertiary facilities, contributed by altruistic corporate houses, cross subsidising premium and affordable facilities, managed locally is the direction. And the neighbourhood doctor is a person they know.

    Indoor air quality parameters
    1) Filtration (Hepa Filters etc)
    2) Pressurisation
    3) Air changes - ventilation
    4) Purification - trapping pathogens in filters
    5) Elimination - Using UV and germicidal methods to kill the trapped pathogens in the filters

    Research by Leena Karmakar

    The current status: where have we come till now?
    In a detailed affidavit filed in the Supreme Court by the Centre:

  • ICU beds up 45-fold from a baseline 2,500 to 1,13,035
  • Isolation beds (excluding ICU beds) climbed 42-fold from 41,000 to 17.17 lakh
  • The number of category one COVID-19 dedicated hospitals have increased 25-fold from 163 to 4,096,
  • The number of Category II dedicated COVID-19 health centres is 7,929 and Category III dedicated COVID-19 care centres are 9,954
  • Oxygen-supported beds have multiplied 7.5-fold from 50,583 to 3.81 lakh.
  • About 5,601 facilities in rural areas in isolated railway coaches which were commissioned as Covid treatment centres did not exist earlier
  • Testing capacity has increased with 2,621 labs active and working as compared to 10%-50% during the two waves.
  • Research by Leena Karmakar

    E Jayashree Kurup is Director, Wordmeister Editorial Services, Real Estate & Cities Write to her at

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