Getting India Back to Work: The Healthcare Agenda

Mumbai: Companies should stagger employee arrivals and attendance, and increase sanitation measures for months to come as COVID-19-related lockdown restrictions are eased, Sangita Reddy, president of the Federation of Indian Chambers of Commerce and Industries (FICCI), an industry body, says. FICCI has compiled detailed guidelines for individuals, owners and the management to follow in the months to come.

It is important to ensure people have money in their pockets--for immediate needs as well as to revive consumption demand--even as supply chains for non-essential items are reactivated, for the economy to recover, Reddy says.

Hospitals have had a “triple whammy”--loss of revenue in the early days as patients could not come to hospitals, continued operational costs (unlike other sectors which have downsized/implement pay-cuts), and an increase in costs due to the elaborate sanitation and precautionary measures, says Reddy, joint managing director of Apollo Hospitals.

Edited excerpts:

About a week ahead of further easing of lockdown restrictions, what does going back to work mean, or what should it mean?

I think it is not a single line. Everybody does not go back to work--let us be very clear about that. This is a calibrated, well-planned lifting of the lockdown. First is, as everybody has heard, the traffic light strategy: If you are in a red zone, you are not going to go back to work. Everyone who can effectively work from home is going to be requested to continue to work from home. The amber and the green zones are opening; public transport is opening, but with social distancing. Airlines will take a bit more time, but I expect in the next 10 days to two weeks, limited airline opening will also happen. FICCI has worked extensively with the industry; and Apollo Hospitals has also worked to bring out what we are calling, ‘Life after Lockdown’, a detailed guide to look at it from the point of view of an individual, an operator or owner, the CEO, and the responsibility, as well as the HR. This includes strategies like grouping people.

For example, last week when a factory in Muzaffarnagar opened up, one person tested positive three days later, and the collector said [they should] shut down the whole thing. That means 400 people [are] back without work again. Our recommendation is you do clusters of 20 people in a group. They sit together, they eat together, so that your potential containment zone or tracking zone is only 20 people.

Secondly, before people come back to work, let them know if their desk space has changed. Do [schedule people coming to work] on alternate days, so that you are reducing the number of people. Extend the working hours and definitely schedule the lunchroom. Create core cleaning facility, whether it is the tunnel or the handwash, and definitely the temperature control. Have a sick bay in each office. There are detailed guidelines, and these have to be followed--not just on day one, but consistently, rigorously, meticulously for the next many months to come.

The link between the economy and public health has never been so strong. How does that work and how do you view this?

Earlier, a red zone was a district, but now the zones are actually shrinking, in that the size of the zone is not related to the whole district but a 3-sq-km radius around the difficult spot. But there is still approximately 40-55% of economic activity in areas which are currently designated red zones. Over the next two weeks, those areas coming out clean and careful is a very important aspect of the whole strategy we need to look at.

The second aspect is the supply chain. There is an inter-dependency of commercial activity in the country. [For example], we grow cotton in the West, we make the yarn in the South, and the stitching happens in clusters all over the country. The transport was very effectively opened up for essential goods, and food; most of our supermarkets were able to get all kinds of supplies, and agricultural produce and vegetables moved. There is a lot of proactive work from the government, the transport, the police as well as business and the farmer who reached out. The big thing is, why will a manufacturing person open up his store if he does not have a retail outlet to display his product?

And the other aspect, like Sulaja [Firodia Motwani] who is on our FICCI committee, said is, “Who wakes up in the morning and decides to buy a vehicle?” How are we going to re-stimulate demand? And from that comes the base question, of how much can we ensure that people have jobs, people have money in their pockets--first to buy essential produce, and then to come back and stimulate demand--so that the demand and the supply engine of the economy, both of which have had a considerable shock, are both reactivated at the same time or as quickly as possible.

The healthcare sector has almost been as badly affected by COVID-19 as have patients or those on the frontlines of medicine, because economically this has been a very tough period for you. So how do you see yourself coming out of that--whether it is your chain or your peers in the industry?

Clearly, the sector has been significantly affected, and we are calling it a triple whammy: Number 1, in the early days, patients could not come. Therefore, there was no revenue, and healthcare is a daily operation. The second aspect is, like other sectors or industries did, we could not cut wages or salaries or tell people not to come to work, because we need those people--doctors, and nurses, etc. None of them were ever taken off the rolls. And the third thing is, in preparation, some of us who were treating COVID had to prepare and buy kits, buy PPEs [personal protective equipment], upgrade the number of ventilators, and all this is very expensive.

Now, as we begin to open--actually, at Apollo, we are pretty much open, and a lot is happening--we have to do it. The new normal in healthcare environment is not just everyone wearing masks, but the whole cleaning protocols have grown by a factor of 10x; any time you do a procedure or a protocol, everybody has to wear a PPE, and that adds a cost to the whole thing. You know, [for a] Rs 500 consultation, the doctor is wearing a Rs 1,000 PPE. This is the new dynamic and yet again, we cannot refuse people because. So, what we said is that in all our emergency rooms, any patient can come in and we will proactively treat [them] as if they are positive. Then, we will parallelly do the testing and make the next level of plan for the individual. And this is taking a cost for the hospital and the patient.

As the lockdown lifts in phases, the other crush you are going to see is of people who have been waiting for treatment, which perhaps they could not come earlier but desperately need to now. Are you going to see a surge of patient inflow, may not be COVID but even otherwise?

The underlying disease will remain and, naturally, people have to come. But I think the rate of individuals coming back to the hospitals is directly proportional to the mechanism of the fear lifting. It is not that the lockdown opens up and the next day you are going to see huge lines, because the public are still scared and there are a lot of misconceptions.

The only thing we can say is that, even while you are staying at home, please use tele-consulting. Use the delivery mechanism and make sure you are taking your medicines. If you need to have testing, we will send you people home to draw the blood, who are safe and screened people. Do not neglect your underlying disorders, not just from the long-term of your disorder but even now for COVID because the numbers and the statistics are showing that comorbidities increase mortality. So, it is very important to keep your diabetes under control, have your heart in good condition, keep your immunology and your entire fitness level to the highest possible, so that you can fight COVID well. For all these reasons, using whatever mechanisms possible, we request everyone to stay fit and to stay in touch with their healthcare and their doctor.

I know you started teleconsulting almost 20 years ago. Have you seen a dramatic increase in that number, and do you see that number rising further?

[There is an] unbelievable, fantastic adoption in tele-consults--both on the doctor’s side and the patient's side. Realistically, a doctor who is super busy in his consulting room is not going to take the trouble to do tele-consulting, unless he is specially motivated, or we have requested. So, everybody did. And you are right, we started 20 years ago. But today, we have millions of people on the app and are doing thousands of tele-consults every day.

The biggest satisfaction is our NPS levels on tele-consults are very high, and this is where our experience is showing. We are not just opening up WhatsApp windows and saying talk to your doctor. This is a platform that we built over the years. It has an appropriate capture of medical data, a proper scheduler, a payment gateway and then at the backend, when we are doing the GP [general practitioner] consults, we have a “clinical decision support engine”, which is proactively prompting to make sure that the doctor’s interaction is of the highest quality and capability. I actually feel one of the good things that have come out of COVID is really the digital.

And this is not just our app. [In] the areas where we support the government in our primary healthcare, we are using tele-consults. In a project that we created, called Stay I, where we partnered with hotel chains to create isolation rooms, we have put our tele-medicine on top of it, so that this minimises the number of times a medical person needs to go into the room. We are using digital and technology across the board. Our eICU, which is again a programme we have had for a very long time, we are now supporting nursing homes and some government hospitals in ICU.

And then there is the whole aspect of tele-learning. On our e-learning platform, the first course we created on update on COVID had 170,000 users globally. The next thing that we created in partnership with the Critical Care Society of India is a ventilator training project. We did the content, we did a fantastic simulator in partnership with an international group, and then we did a one-on-one connect using the Critical Care Society and the new learner. Today, you can buy ventilators, how do you buy expertise overnight? We are now using technology to train people on how to get up to speed on ventilator use, and how to do mentorship--because if the doctor is over 60 years old, he is probably staying at home and not coming in. But he can stay at home and mentor a young person, on using the ventilator and getting up to speed on this. So, these kinds of partnerships are also happening.

The people at the frontlines--doctors, ventilator care experts or nurses--need to stay motivated at this time, more so than anyone else. How are you, as a large chain of hospitals, ensuring that, and do you see any challenges there?

I think in the early days there was this initial fear; and people had seen these scary images from Italy and heard the numbers of the medical workers [affected]. Firstly, we said it is voluntary, [and asked] those who want to come [to] please come forward. Secondly, we assured them that we would do whatever we could in our capability to keep them safe. We invested in proper separate rooms. We never put a number of patients in a big general ward. We created the rooms, we created the negative pressure, we bought the right PPEs, gave them the training on how to wear them, and then we never over-worked them. We did staffing, we cut the shifts and we quarantined them separately, so that they were not mixing with other staff. So, if a nurse working in a COVID ward, she will not meet a nurse who is in a non-COVID hospital of ours, till the period she is working or the 14 days of quarantine. I wore the mask and everything, and went into the COVID ward to greet our teams and tell them that we are with them and we appreciate the kind of risk they are taking. And by God’s grace, so far, the staff has been very proactive; they are safe, and we have been able to really care for a lot of people.

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