Question

Create either a 5 Whys or a Fishbone diagram for each of the two short-term opportunities and the one long-term opportunity you identified during your Gemba Walk in the hospital during a pandemic. Work through each step of the 5 Whys or Fishbone processes to find the root cause(s) of each problem.

Answer 1

Gemba Walk during COVID-19 in AIIMS Hospital Delhi, INDIA

SHORT TERM OPPORTUNITIES

1. Visa cancellations and travel restrictions

The business coming from international patients is likely to dry up. International patients account for 12-14% of the aggregate revenues of the companies in ICRA’s sample set, going as high as 25% of the revenues of certain super specialty facilities located in the metros and tier-I cities. Revenue coming from international patients constitute high realisation and high margin business for hospitals.

2. Resource deployment/diversion

The resource deployment/diversion are likely to impact the near-term cash flows of the players. Nonetheless, in case the facilities see a jump in admissions on account of the virus attack, the volumes will receive a boost, although the ARPOB from the coronavirus treatment will be lower than the existing ARPOB of super specialty hospitals.

Further, the elective procedures include certain orthopaedic, cosmetic, and ophthalmological treatments. Additionally, across all disciplines, a certain percentage of procedures are not immediately required and can be postponed. In the wake of the coronavirus attack, the business from elective procedures is likely to be pushed back. As footfalls in hospitals have been impacted, the OPD revenues are also likely to be affected, which may in turn reduce admissions, as the OPD to IPD conversion rate for the industry is 10-12%.

3. Comfortable debt protection metrics

The debt protection metrics has remained comfortable- while the net debt/EBITDA stood at 3.0x in September 2019 as well as March 2019, the interest coverage ratio improving from 2.62x to 3.06x during this period. Given the above, ICRA continues to maintain a stable outlook on the sector.

LONG TERM OPPORTUNITES

1. Fast-tracking of implementation of targets for public health emergencies within National Disaster Management Plan
Guidelines for biological disasters have been in existence since 2008 and Biological & Public Health Emergencies (BPHE) was added as a part of the National Disaster Management Plan (NDMP) itself in the most current version updated in November 2019, with the objective of enhancing the resilience of health systems by integrating disaster risk reduction into all levels of healthcare. However, within two months of releasing these guidelines, it was clear that the planning and implementation was required as of yesterday.

Several Short term (ST, by 2022) Medium Term (MT, by 2027) and Long Term (LT, by 2030) objectives and responsibilities mentioned in the plan are all in the right direction and would have been a saviour had the outbreak waited another five to seven years for these to be implemented as per the plan, such as “Dovetail norms & regulations relevant for BPHE with DM act 2005” (MT), “Establishment of early warning system” (MT), “Establishing and maintaining community based network for sharing alerts” (MT), “Develop a clearly defined interagency emergency response plan with roles and information flows clearly marked out” (MT), “Partnering local institutions with national institutions/experts” (LT), “Stockpiling of essential medical supplies such as vaccines and antibiotics etc.” (LT), “Establishing adequate decontamination systems, critical care ICUs and isolation wards with pressure control and lamellar flow systems”(ST), “Adequate PPE for all the health workers associated with the responding to biological emergencies” (ST), “Upgradation of earmarked hospitals to cope with emergencies” (LT), “Mobile telehealth services & Mobile Hospitals” (LT), “Specialised healthcare and laboratory facilities to address biological emergencies/incidents” (MT), “Establishing and strengthening quarantine facilities” (LT).

While one can rue the fact that we recognised these requirements within a structured framework too late, the silver lining is that the crisis has made us implement some of these, in some manner or the other, immediately instead of waiting another five to ten years as planned in the NDMP. The best part is the lessons in managing this crisis at hand will help in a faster and more practical execution of several great initiatives identified in the NDMP just before the pandemic. We can also hope to see a legal framework for dealing with such emergencies come up much earlier than the targeted timeline of 2027, as also a policy on stockpiling and upgradation of certain facilities.

2. Community Awareness towards Hygiene will have positive impact in the long-term, though in the short-term likely to increase PHC burden significantly
Since the days leading to the full-blown pandemic, intensive campaigns are being run promoting hand hygiene to prevent transmission of infection. This has led to very high levels of awareness and compliance to this seemingly small routine of clean hands but one which in the long run can have far-reaching implications for transmission of various other infections as well. All signs point to a protracted period of contagion and perhaps seasonal returning peaks as well, which means reasonably long cycle of special emphasis on hand hygiene, face mask, hygienic social habits and disinfection. These long cycles of focus on hygiene combined with Swachh Bharat Abhiyan may have positive impact on improved health of the society, although extent of benefit will be difficult to measure tangibly. On the flipside, in the short-term, a tremendous increase in burden on primary care facilities and GPs can be anticipated as over-cautious people throng them even on mild symptoms.

3. Gaps in Care of patients of other ailments, especially chronic diseases in the short-term can lead to long-term burden on healthcare
As urgent takes precedence over important, the entire system focused on prevention, diagnosis, treatment and containment of COVID-19 infection is likely to miss opportunities for timely diagnosis and treatment of other diseases. Patients of chronic disease, being wary of going out, or facing difficulties in movement due to lockdown restriction might miss on treatment, ending up with long-term sequelae. These can eventually increase the possibility of complications and worsening of disease, raising the overall burden of diseases of the country to a certain extent. Recently we also read about BMC shifting some patients of cancer and other disease to makeshift arrangements under a flyover in Mumbai to accommodate rising number of COVID-19 patients in the city. Unavailability of several government set-ups that have been earmarked for COVID-19 has also limited the availability of emergency treatment of acute conditions for the less privileged whose only fall back for healthcare needs are public facilities. Postponement of Elective surgeries and procedures could have adverse impact on quality of life while the patients wait for the right time to get the treatment they need.

4. Strengthening of Government Infrastructure and Public Private Partnerships over next few years, but in the near-term, ongoing plans will see a major realignment
It is no secret that healthcare infrastructure in India is sub-par and highly inadequate to meet the needs of its large population. In terms of accessibility and quality of healthcare service the country ranks 145 among 195 countries globally. Countries that spend upwards of 8-10 per cent of GDP on healthcare are also crumbling under the huge burden of this pandemic, giving shivers to the governments across the developing world, including India., India spends a meagre 1.4 per cent of GDP as public expenditure on healthcare. Recognizing the inadequacy of this for serving such a huge population, the government had laid out ambition to increase the spending to 2.5 per cent of GDP in the next two to three years. While progress has been made in the recent past in augmenting the infrastructure and manpower through opening new tertiary institutes, increasing seats in medical colleges and implementing expansion of primary healthcare setup across the country under Ayushman Bharat, a lot still needs to be done. This need is acutely being felt now while we prepare for a scenario if the situation goes out of hand further, and this realization will hopefully accelerate implementation of healthcare infrastructure strengthening. At the same time, in the short-term since a huge spend is being utilized for managing the pandemic, budgetary allocations on current plans will get realigned.

5. Internalization of Pharma Supply Chain & Make-in-India focus for Medical Equipment
Over the last few decades India has emerged as the pharma hub of the world, being the largest suppliers of generic medicines all over the world with a 20 per cent share in global supply by volume and 50 per cent of global demand for vaccines. Currently over 80 per cent the antiretroviral drugs used to combat AIDS are supplied by Indian firms, which is a significant contribution to mankind as otherwise less developed countries would not have been able to afford therapy for this global crisis. COVID19 crisis has again highlighted the contribution of Indian pharma industry as India opened export of hydroxychloroquine to scores of countries that can help save thousands of lives.

Despite being the strongest player in pharma, a major lacuna that developed over years in the Indian industry is over-reliance on Chinese APIs (bulk drugs) especially the fermentation-based products like Penicillin-G and a lot of intermediates (KSMs or key starting materials for APIs). This was already recognized by Indian pharma players when the Chinese started winding down industries and/or increasing prices to comply with the stringent enforcement of environmental laws. It was then that Indian players had started planning alternate sources for Chinese material, but cost being a major driver in the end market, the progress remained slow. With China’s perceived role in not sharing information that could have prevented the COVID19 global pandemic, there is an increasing sentiment in various countries to move their manufacturing out of China. Japan is in fact paying its companies to move their manufacturing out of China. This can thus be a big opportunity for India to internalize the entire supply chain for our own good as well as present ourselves as an end-to-end giant in the pharma supply chain. A strong pharma industry has always been a pillar of affordable healthcare in India and one can expect this trend to further strengthen now.

Another area where India and almost the entire world is over-reliant on China is medical equipment. We have seen cases of ventilators, PPE, masks, diagnostic kits – almost all equipment for sailing through the current crisis coming for China, which is a problem in times like these. In India, several non-medical equipment companies have risen to the occasion and converted their manufacturing to make ventilators and other equipment currently needed. The pandemic will eventually go, but the equipment will stay. Using these equipment efficiently over long term to improve our healthcare delivery is an opportunity. A push through make-in-India for medical equipment can further strengthen this trend. Medical devices can be a natural area for expansion of pharma companies, because of synergies of end customers even though new manufacturing skills will need to be internalized.

6. Medical Tourism will continue to see a downtrend, at least in the short-term
India has become a hub for medical tourism, especially for neighbouring countries, middle east, central Asia and Africa. In 2015, India ranked as the third most popular destination for medical tourism, when the industry was worth $3 billion. The number of foreign tourists coming into the country on medical visas sat at nearly 234,000 that year. By 2017, the number of arrivals more than doubled to 495,056, government figures show. These medical tourists come not just for advanced modern medicine treatment available in the country but also for rejuvenation through traditional medical practice such as Ayurveda. With international travel being a major cause of the spread of COVID19 pandemic, the writing on the wall is clear. The influx of tourists, including medical tourists will remain slow at least for a good part of this year. One can expect picking up only next year, that too if recurrence of peak does not happen again globally in the winter months which is quite a probable scenario as per the latest research.

7. Increased use of Technology, Telemedicine, Training of primary health workers and Mobile hospitals
In the midst of the Pandemic, MoHW, in collaboration with Niti Aayog, released Telemedicine Practice Guidelines enabling Registered Medical Practitioners to provide healthcare in remote settings using telemedicine. These guidelines recognize telemedicine as an enabler of healthcare access and affordability through faster access to appropriate interventions and access to services that may not otherwise be available. There have also been frequent online training sessions for nurses, paramedic staff and primary health workers for protocol to be followed for detection, isolation and communication regarding suspected infections. Increased use of technology and opening up telemedicine through transparent guidelines will improve access to healthcare even in remote locations in geographically diverse country like India. Going by recent comments by Niti Aayog senior officials, there is a possibility of carving out some further roles as paramedic functions that may not require a full MBBS degree. This could be an innovative way to augment trained healthcare manpower, although practicality of such a decision will emerge with time.
Additionally, recognizing the increased need of hospitals across the country, several ingenious approaches are being explored, the most interesting of which is converting train coaches into isolation wards to make mobile hospitals which can be taken to locations throughout the country as per requirement. Although mobile hospitals were a target in the NDMP 2019, such an innovative approach arose out of necessity and has benefits of moving as much capacity as required to various locations and is much faster and more efficient than road transport. If retained and built upon, this flexible concept has the capability of supplementing the healthcare infrastructure substantially.
Thus, as we face this humongous challenge and focus on sailing through with minimum damage to human lives, there are opportunities to be unravelled for improvement in the healthcare scenario in the country.