Extending The Hospital Ward: How India’s COVID Surge Inspired a New Strategy to Improve Care and Equity | Deloitte US has been saved
By Punit Renjen, Global CEO Emeritus, Asif Dhar, M.D., vice chairman and US Life Sciences and Health Care (LSHC) Industry leader, Deloitte LLP, K. Srinath Reddy, M.D., DM, MSc, president, Public Health Foundation of India, and Dhruva Chaudhry, M.D., DNB, DM, professor & chair, Department of Pulmonary & Critical Care Medicine, Post Graduate Institute of Medical Sciences (PGIMS), University of Health Sciences Rohtak, Haryana, India.
The highly infectious delta variant caused a summer spike in COVID-19 infections, knocking many US health systems and local communities back on their heels.1 Over the past month, the average daily infection rate has been steadily ticking down. New daily cases have dropped by more than one-third since the beginning of September.2 What have we learned? Can our most recent experiences prepare us for future surges, new pandemics, or other health emergencies? Are our communities and health systems better prepared now than they were a few months ago?
We first learned about the delta variant last spring as it raged through India, leaving hundreds of thousands of people dead.3 This tragic and frightening event hit Deloitte particularly hard. Deloitte has more than 50,000 people based in India, and many of its US colleagues have family members or friends who live there. In India, as in many nations, access to curative health care is often determined by the ability to pay for services. People in poor and rural communities typically have limited or no access to a hospital, therapies, or vaccines.
Even in the US, health disparities could leave some communities particularly vulnerable to a health emergency. However, if quality health care is made available to people outside of hospitals, access to care could be easily expanded at much lower cost.
Bring the hospital to the patient
Last spring, as the virus surged in India, Punit (a co-author of this blog) learned that his mother in the northern India state of Haryana had been infected but was receiving monitored quality care in her home. This prompted the four of us to ask, ‘why can’t other people receive quality care in their home?’ This simple question inspired a project that—in collaboration with the Government of Haryana—became the Sanjeevani Pariyojana (in Hindi, this translates to The Life Project). The thought was to help create a supervised, virtual quality care-in-the-home initiative to help people with mild or moderate symptoms access care. Providing care in the patient’s home can help protect bed capacity for the most critically ill patients.
This public health initiative between Deloitte and the Haryana Karnal district authorities (one of 22 districts in Haryana) mobilized local health care practitioners to help provide early detection (through home test kits), and essential care for home-isolated COVID-19 patients. Patients who had more severe conditions were identified early and transferred to health facilities. Sanjeevani Pariyojana took advantage of Haryana’s existing technology infrastructure by adding or enhancing command-center capabilities, and augmenting the availability of telemedicine, virtual triage, and advanced life-support transportation services when patients required higher acuity care. The initiative also sourced oxygen concentrators and assembled mobile care kits that included pulse oximeters and thermometers.
Accredited social health activist (ASHA) workers were trained by licensed medical professionals to support care in the home and 200 third-year and final-year medical students provided physician-supervised virtual health services. ASHA workers—who are seen as trusted members of their communities—did the heroic work of knocking on doors, educating patients, and distributing the home health kits. Home-based services supported the collection of test samples, and medical students engaged in telemedicine to triage and care for patients at home. When patients required higher acuity care, Haryana’s command center managed transportation to either field hospitals or conventional hospitals and/or ICU beds. Remote command centers were enabled to manage scarce resources such as hospital beds, oxygen, ambulances, and medical professionals.
The project helped extend medical care to rural areas where people often weren’t aware of the new variant and didn’t know how to treat it. It also helped to reduce the strain on hospitals. Between May 24 (when the project began) and June 8, 200 medical students consulted with more than 7,000 patients who were receiving care at home. Dr. Yogesh Sharma M.S., Chief Medical Officer for the Karnal Administration, said the impact of the project was felt within a few days as fatalities decreased significantly. Death rates fell from 10 per day in Karnal at the start of the pilot to four per day during the second week.4 (It might be impossible to know how much of a direct impact our project had on those numbers.)
There is now interest from the central government and other states in India to expand this program to the most underserved areas to help prevent variants from taking hold. These underserved areas include India’s 117 aspirational districts. These areas are seen as having the most potential to improve India's ranking under the Human Development Index, improve living standards among residents, and help ensure inclusive growth. More than 250 million people reside in these districts, which are encouraged by the Indian government to transform themselves to provide better citizen services consistent with the best ranked districts.
Lessons learned
While Sanjeevani Pariyojana has been successful, it is an ongoing learning experience. Here are a few lessons we gleaned that could help improve the way communities and health care organizations respond to future health emergencies:
- A public health crisis triggered by a highly infectious virus can quickly overwhelm hospitals: Hospitals have historically been seen as the front-line of defense for public health disasters. The problem is that hospitals are expensive fixed assets. By having more scalable resources, such as community and telehealth resources, we were able to help move the frontline to where the battle starts—in the community and at home.
- Time and resources should be dedicated to training: The project team initially underestimated the impact ASHA workers would have. In retrospect, we should have mobilized more resources to better enable ASHA workers. We also should have developed apps to help streamline communications. This could have allowed information to be collected faster and expedited more scalable communication with telehealth workers and Haryana’s command center. We are building a communications app and mobilizing more extensive professional training into future efforts.
- People will usually stay home if they are satisfied with the care they receive: COVID-19 spreads when infected people come in contact with others. When people receive care in their homes, they can recover with less risk of spreading the virus to others in the community. When patients trust the level of care they receive at home, they are usually willing to stay there, which helps relieve pressure on scarce inpatient services. ASHA workers, who were supported by telehealth and Haryana’s command centers, were a trusted asset, particularly in rural settings. Designing them into the program was a key success factor.
- Care should be designed around health equity: When we launched the project, there were approximately 5,400 active cases within this district of 1.6 million people, but only about 1,000 hospital beds available to COVID-19 patients. If those beds were made available to only those with wealth or access, the result would be massive health inequities and overwhelmed facilities. As part of the project, field hospital beds were strategically placed throughout the district. The project also had 200 medical students support panels of 25-35 patients, and physicians were on call for complex consultations. As a result of these efforts, there was increased capacity to address the wave for residents irrespective of their financial means.
We have taken the lessons we learned in Karnal to underserved communities around the world. In the US and around the globe, the delta variant has been particularly aggressive in communities that have low vaccination rates. The US remains focused on vaccinations and is evaluating a wide array of measures to blunt further infection spread and to reduce mortality. However, when health care institutions are stretched to the limit, we believe innovative approaches to extend resources and provide virtual options could help relieve some of the strain. In addition to the known measures such as testing, vaccinations, and non-pharmacological interventions, we hope stakeholders continue to evaluate options to help extend resources in hard hit areas.
For our part, we will continue to study the impact of this effort, refine lessons learned, help expand open source command center software, and make playbooks available. It is possible that these and other approaches could have an impact beyond COVID-19 by creating more equitable access to health care and possibly making care more affordable, convenient, and effective.
The authors of this blog would like to credit the following people for their role in the Sanjeevani Pariyojana project: Hon. Manohar Lal Khattar, Chief Minister of Haryana and Rajeev Arora, Additional Chief Secretary to Government of Haryana, Health & Family Welfare, Devender Singh, Additional Chief Secretary to Government of Haryana, Nishant Yadav, Deputy Commissioner, Karnal and various officials in the State of Haryana who implemented the Sanjeevani Pariyojana project at Karnal, Haryana, India and N. Venkatram, CEO, Deloitte India, Romal Shetty, President, Consulting, Deloitte India, Rohan Lobo, Partner, Consulting, Deloitte India, who worked with them and are supporting in the enhancements while expanding the work to other regions around the world.
1COVID Data Tracker, Centers for Disease Control and Prevention
2COVID in retreat, New York Times, October 4, 2021
3India’s death toll tops 400,000 as delta variant gains ground worldwide, The Washington Post, July 2, 2021
4A pandemic silver lining: Building a better health care infrastructure and advancing health equity
