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Planning for a pandemic

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While the virus and the pandemic have been erratic, certain trends are now visible

With an eye on preparing for the next wave of the COVID-19 pandemic, the recent launch of the Pradhan Mantri Ayushman Bharat Health Infrastructure Mission, also known as Pradhan Mantri Atmanirbhar Swasth Bharat Yojana (PMASBY) rightly starts at the grassroots. As per a PIB release, it aims to shore up India’s critical healthcare network from village to block, to the district to the regional and national level in the next 4-5 years.

While it is a long-overdue initiative, the government must also take care to plug any leaks fast. And the initiative must hopefully outlast political regimes, and not become another Centre versus States battle at implementation stage, to show long-lasting results.

Initiatives like the PMASBY are critical for the public health sector to match the infrastructure expansion already underway in the corporate healthcare sector, so that there are as many affordable care options as possible.

Given that we are in the midst of our biggest festivals, and after a year of masking and various degrees of social restrictions, public health officials are bracing for a third wave. Especially as COVID fatigue has set in. India’s vaccination drive continues, but there are still areas where coverage is poor. While the cover story in Express Healthcare’s November 2021 edition (https://www.expresshealthcare.in/digital-issue/express-healthcare-november-2021/431967/), with a special theme on sustainable healthcare infrastructure, showcases strategies to design and build smart and sustainable hospital infrastructure, a couple of recent reports throw up interesting insights on where India’s health ecosystem needs an infrastructure ramp up.

The FICCI-EY report, ‘Prevent, Plan and Prepare: Strategies to win against the pandemic’ makes the point that the virus and the pandemic have been erratic, and therefore it is difficult to predict where, when and how high the third peak will be.

As each region displays its own distinct wave pattern, the FICCI-EY report suggests that a highly localised plan, instead of a common nation-wide plan, may be critical to designing an effective pandemic response in case of a possible third wave.

The report considers three scenarios. Projecting a repeated peak of 4 lakh cases per day, the FICCI-EY report estimates it would call for 9 to 10 lakh beds to cater to moderate and severe cases, with shortages in over 200 under-served districts. The report recommends that Intermediate or Transition Care Centers can be an effective low-cost and scalable option to address surge capacity, specifically for management of moderate COVID cases. If the prevailing case load continues, existing infrastructure would be able to absorb the demand for COVID beds and requirement of surge capacity may not exist.

If, however the third wave turns out to have similar intensity as the second wave with a peak of ~4L daily cases, the FICCI-EY report predicts an estimated 9—10L COVID beds may be needed to cater to moderate and severe cases. With the existing infrastructure, demand for ~8L COVID beds can be met, leaving a shortfall of ~2L beds, of which 84 per cent is contributed by six states and 180—200 districts.

However, if the third wave has 50 per cent lower incidence (i.e., ~2L daily cases) and 50 per cent lower hospitalisations, an estimated 3—4L COVID beds would be required and hence ‘surge capacity’ requirement may be minimal to nil, as per the FICCI-EY report.

Even as India’s total vaccinations crossed the one crore mark, we are still far from safe. Let’s consider a second report, from Boston Consulting Group (BCG) aiming to understand vaccination trends and India’s vaccination hesitancy.

BCG conducted two surveys in March and May this year and recently released findings of a third survey titled, ‘COVID-19 vaccination – Citizen willingness: research insights’. The September survey has a study sample of over 3500+ participants, is representative of different states, city tiers, age, income and gender. Though the sample size is small, considering India’s 1.3 billion population, the findings are still valuable.

Regarding the unvaccinated participants, the BCG’s September survey shows that the high willingness seen in their May’21 survey has translated in high adoption in recent times. The current unvaccinated adult population is showing significantly lower vaccine willingness (v/s May’21 round). The willingness to get vaccinated varies by citizen cohorts, higher willingness to adopt in smaller town (38 per cent), rural (47 per cent) and <5 lakhs income population (40 per cent).

According to the BCG report, the key adoption barriers for those willing to be vaccinated are crowded vaccination sites, long waiting time and lack of nearby vaccination sites. The September survey also showed a higher proportion of fence sitters in urban – large towns (44 per cent) and older age groups (56 per cent). Hesitancy towards vaccine was driven by doubts over vaccine efficacy as well as fear of long-term irreversible effects. Unlike earlier, short-term side effects did not come up as a key hesitancy driver this time, except in rural areas, as they fear a loss of wages.

Among the vaccinated participants, those who have taken 1st dose but not 2nd dose, approximately 60 per cent of the population who are vaccinated with first dose have high willingness to take the 2nd dose. The willingness for 2nd dose shows no/ less variation by citizen cohorts. 35 per cent of this segment is indifferent, driven by lower COVID-19 cases, and belief of one shot being sufficient to protect against.

The BCG report concludes with two key policy implications/suggestions for demand generation and uptake of COVID-19 vaccinations. One, the demand generation strategy among unvaccinated needs to be different for urban v/s rural, given significant differences in underlying barriers (e.g., lack of nearby vaccination sites is more critical for rural).

In rural areas, the focus needs to be on converting willingness to actual vaccination – e.g., access innovations. There is also need to increase access by setting up residential camps, increasing sites especially in rural and small towns and improve perception of experience on safety measures, limited wait time, etc.

In urban areas, the focus should be on increasing vaccine willingness, given high hesitancy in unvaccinated. Therefore, vaccine efficacy has to be built up, via communication and influencers (e.g., PM, Doctors). Doctors/ experts need to be to allay perceived fears around long- term health implications.

The second recommendation from the BCG report is that willingness to receive the 2nd dose should be increased via a communication, outreach programme run by influencers to educate the masses on disease prevalence, hospitalisation/ mortality risk, as a single dose is not sufficient to prevent COVID-19 infection.

Policymakers and healthcare industry would do well to pay heed to these predictions as they plan their infrastructure investments.

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