As the nation’s COVID vaccination program takes off in earnest, a most striking feature has been the near-flawless conduction of the program at government hospitals as well as outsourced COVID facilities. The government’s rollout has received a staggeringly high 97% positive rating by healthcare workers, who were the first to receive the vaccines in the country. This kind of positive feedback for a public healthcare program is unprecedented in our country. Film personalities have also been spotted availing vaccination at government facilities.

This is in sharp contrast to the consistently poor image of government hospitals and the widespread reluctance of patients to go to government and municipal hospitals for treatment. Overcrowded, dirty, stinking, rude staff, no feedback mechanism, poorly maintained equipment with frequent breakdowns, perennial shortage of consultants – these are common problems at virtually every government hospital across large parts of the country. I have addressed these issues in detail on earlier podcasts.

One may note that the same problems continue to plague patients being treated for COVID at municipal and government hospitals, but not at the temporary facilities set up by the government. Why is this so? Why do temporary and makeshift facilities have such high ratings but permanent structures fail the test? What has made the difference?

The answer probably lies in a successful PPP model. A successful treatment outsourcing service has been created with private-public partnership, wherein the patients pay nothing for their treatment and the government pays the private player a fixed remuneration per patient, with minimum occupancy guarantees. Several government COVID treatment centers have been outsourced to private players, including the Bandra-Kurla Complex jumbo facility which has treated over 11,000 in-patients till date. The feedback from patients hospitalized at these facilities has by and large been very good in spite of the temporary nature of the structures. This is probably the first time that paying patients are opting to take treatment at free government facilities by choice on a mass scale. In India this is unusual, but in other countries such as UK, this has been the norm. Treatment at NHS hospitals in UK is free, but waiting lists are long. As 70-90% of consultants are in the private sector in India, the problem of long waiting lists for treatment at government facilities too can be eliminated by bringing in a pay per patient policy of outsourcing.

But how do you ensure that frauds do not happen, and funds are not siphoned off by bringing in fake patients? Turns out that COVID care models in India have answered this question too, through the much-maligned Aadhar. Every admitted patient is authenticated via Aadhar. Treatment protocols and details of patients being treated at any point in time can be made available online to check the authenticity of patients. Note how the mass vaccination program is being run using CoWin, which gives real-time data on every patient being vaccinated across the country. This platform can be expanded and adapted across all government and municipal facilities to monitor patient care in real-time. Patients in waiting lounges post-vaccination at the BKC Covid facility are approached by tab-bearing staff to collect feedback on the entire process in real-time. Such models can easily be integrated and expanded across public hospitals to bring in quality improvements.

Other financial models for PPP have been tried that involve handing over government facilities to private players on promise of treating a certain number of patients free of cost in return for utilizing the majority of beds for paying patients. This does not work very well as free beds exist mainly on paper, and such commitments are often violated with impunity. I would venture to say that the only successful model that can bring quality standards to patient experience in public hospitals is the one in which the service provider is accountable and does not need to cross-subsidize with paying patients. And this is where most government and municipal hospitals falter: accountability to individual patients. The quality of patient interaction is bad enough at most places for poor and middle class people to go bankrupt in taking treatment at private hospitals rather than visit the government setup.

It is not my case at all that the medical treatment at public hospitals is bad: these hospitals by and large are extremely efficient and patient outcomes are good. I am proud to have done my MS (general surgery) from LTMGH, Mumbai, one of the most crowded and busy municipal hospitals, which has a policy of never turning back a patient that ensures that facilities are always stretched to the limits. The trauma and emergency care at LTMGH is stunningly efficient, and I know for sure that if I were to ever meet with an unfortunate accident, LTMGH would be the place where I would have the highest chance of survival. But where public hospitals lose out is the patient experience. Despite the extreme efficiency, patient interactions continue to be poor. Overcrowding is the norm: we may need twice the number of beds and five times the number of staff that exist presently to be able to efficiently manage the patient load. At municipal hospitals of Mumbai, capacities are slowly being upgraded and staff hiring has shifted to contractual models.This is fraught with its own share of dangers, as we saw a large number of contractual staff disappear from duty during the COVID pandemic from some of these hospitals. The sensitivity in dealing with patients is sorely lacking, and it is not because the staff does not care: this comes in large part from the stress of being unable to cope with the overload and the consequent desensitization that follows.

Public hospitals are not inefficient in treatment. They are inefficient in use of funds, maintenance, communication and other aspects that contribute to patient experience. In Maharashtra, there have been several incidents of fires in intensive care units of poorly maintained government hospitals. Far from rectifying the situation, the government has chosen to go after compliance in private hospitals while virtually giving their own hospitals a clean chit: a classic case of diversion of attention from where the problem really is. This quality of government officials can be utilized in a positive way: in an outsourced model, they can get private players to implement the standards that they fail to do when they have to run the show themselves.

Some states have shown how public healthcare can be done right. Kerala has a responsive and formidable public health system that the author has experienced first-hand while working with the Kerala government during the 2018 floods. Tamil Nadu has successfully filled out all vacancies of doctors in rural areas and now routinely has thousands of applications for a few hundred posts. This thread by a Tamil Nadu surgeon shows how public healthcare can be transformed if the state is willing to invest and puts the right people in charge, even without any outsourcing. The central government, on its part, has been trying to encourage a healthy competition between states by bringing in rankings. However, without adequate funding, things will not change. The sharp increase in expenditure on healthcare in the 2021 Budget is not likely to make any substantial impact on hiring of healthcare workers and additional facilities, as the areas of allocation of additional funding are mainly sanitation and water.

Ensuring healthcare of a certain standard for the poorest citizens of the country is as important in maintaining their dignity as toilets for women, and does not need to be the dehumanizing experience that it is in many states. The excellent way in which facilities have been created for COVID management and vaccination can potentially be considered a successful model for bringing in a sea change in quality of patient experience at our government and municipal hospitals.